prepared to accept enzi amendment number 10 for personalized medicine for specific scientific criteria. i'm also happy to accept enzi amendment number 11 which creates an expert advisory panel in the case of research studies for rare diseases. and that as we all know can often be falling by the wayside. that's excellent. also, i'm happy to accept enzi number 12 which inserts the practice of medicine as a criteria for participation in advisory counsels. i think that we can accept that. enzi 15 which relates to specialized advisory panels and last but not at all least, as

someone who's interested in epidemiology, enzi number 6 which says that the center may allow reports to assess whether treatments benefits sub populations. and as we have got feedback from our public health experts as well as the aarp they thought enzi number 96 was an excellent and outstanding amendment and so do i and i'm happy to accept it. we can accept all of those and it shows how we can find a center on the outcomes research. let me go to some others. senator murkowski has two -- five amendments that she had just in sin effois inserting th where they were. that's murkowski 3, 4, 5, 60 and

61. we are ready to accept one affected trauma programs, this was agreed to also by senator murray. thank you, senator murray. senator roberts, you have an amendment, hhs, you consider unique characteristics of rural hospitals and low volume hospitals when establishing reporting progress on hospital readmissions. again, i think that adds a great insight and dimension that my original framework was backing. i thank you for that. i'm happy to accept that. >> what number was that? >> that's roberts number two. we accept murkowski three, four and five related to indian health, 60 and 61 also on indian health, roberts number two on unique characteristics.

they're telling me how i should talk. i'm 72 years old. i did pretty good so far. roberts number two as modified. we're going to take the rural and low volume hospitals. so we've got those done. so that's two, four, six, eight, ten, we have cleared 11 amendments and we're going to be looking at a couple of others during the break related to hatch and murkowski. >> i actually counted, i have three, four, five, 60 and 61, roberts number two, and i have enzi number 10, 11, 12, 15, 6 and 96. did i miss one? >> 10, 11, 12, 15 and 96. >> and 96. but i was right on the other ones? three, four -- >> yes. >> that's one, two, three, four, five, six, seven, eight, nine, ten, 11. >> yes.

we have agreed. >> 96 is a good one, too. we'll talk about that some more. >> pardon me? >> number six is a good one, too. we'll talk about it. >> murkowski number six. enzi number six? i-25? just so we get to bingo, i'm fine, okay? but again, i want to thank our staffs for working through the lunch break and i think this was a great set of accomplishments and we thank you for them. it actually improves the bill. >> senator, we thank you. senator enzi, senator murkowski, senator roberts, who were involved in that and their staffs, respectively. what i'm going to do is a couple of these were as modified but i will ask consent that the amendments as identified by senator mikulski be considered. without objection, so ordered. the amendments are adopted. that includes the seven we did

this morning, so that's about 20 amendments. there were 59 introduced originally but we're moving on this. granted, it's not luke skywalker speed, senator roberts, as you mentioned earlier today, but we're moving here. pretty good pace. we have a vote that's just started and i will be -- in fact, i entertain another amendment to at least be offered and we can start for a few minutes the conversation, then come back after the vote. >> isakson number one. >> johnny? >> thank you, mr. chairman. i think there's a copy, everybody has a copy. >> good job. thank you. >> this amendment simply requires that upon signing up and becoming eligible for medicare, that every recipient will show proof of having exercised an advance directive legal in the state either by statute or by previous court

cases. an advance directive is basically a durable power of attorney that directs physicians, hospitals, care providers, what an individual would want to take place in the last days of life if they are incapacitated and cannot make a decision. >> i don't think we have this. i don't think it as an amendment. i don't have it as a description of the amendment. i don't mean to interrupt the senator -- >> that's okay. the lady's welcome to interrupt. >> you are so very courteous but i want us to have what you're going to have. >> i thought it was already up there. >> he's passing them out. i'm sorry they weren't already there. basically, i have had an interest in this for 30 years because as many of you -- >> would you repeat what it does? >> what it basically does, on page two, lines eight, nine and ten of the heart of the amendment which basically says that every enrollee will provide proof to the secretary that the individual has in effect an

advanced directive recognized under state law whether statutory or as recognized by the courts of the state an advance directive as the end of life directives that you would direct what care you would want to receive were you to be incapacitated or in a state where you could not make that decision. beginning in the '70s, this movement began around the country. i was in the legislature then, became very familiar with it and had personal experiences in my own family with people who had not executed an advance directive which can cause for some awful will painful situations to happen but most importantly on the cost side, an astronomical amount of costs spent that really would not have been spent had the beneficiary or had the patient actually had an advance directive. the department of medicare and medicaid services has determined that as the last year of life of each beneficiary, the average expense to medicare is $24,856,

which is 27.9% of everything medicare spends on the average patient in their lifetime. so if we are talking about savings, and we're talking about quality, and we talk about a system where 90 days prior to your 65th birthday you come in to sign up and begin the process of registration for medicare, i think if we require the advanced -- proof of the advanced directive to be part of the qualification, we would ensure that everybody's wishes were respected in those difficult times of life and that physicians, care providers, et cetera, would have legal direction as to what the patient would have had done. >> well, if i could just comment, first of all, i understand the objective that the senator from georgia seeks but this is legislation that would affect the eligibility for medicare and i believe it is

truly outside the scope of our committee. is there -- i don't want to sound like a parliamentary fussbudget here, but -- >> i think the senator, i think she's right, it's a finance committee matter. i must say, i like the direction you're going with this, because i think there's some validity in pursuing these ideas with people but i'm concerned about us -- we raise all the time with the finance committee when we begin to encroach on the jurisdiction of the committee, so i want to be careful about imposing ourselves on their jurisdiction which is the first concern i'd have, trying to deal -- i'm not sure what title this is even in. we're trying to do title two and it may be appropriately in this title but it doesn't seem to be a section 1899. i don't know where that is. >> mr. chairman, if i could say, perhaps we could look at this

during the vote. to see whether it is within the appropriate scope. if it is, we'll discuss it but i also have to connect with senator shelby on the floor. i really need to go participate in this vote. >> why don't we go and make the vote. >> let's come back and make sure we're within our appropriate parliamentary parameters. if we could have a read on that when we come back, then have further discussion. >> for your consideration, this is a copy of the underlying bill and each of these tabs represents the finance committee jurisdictional issue which is in the underlying body. so -- >> don't show that to them. >> it's not like we're plowing new ground. >> mr. chairman, could i also add for the people that are going to look at this, the base bill, the underlying bill, on page 203, 204 and 602, there are references to the social

security act. on pages 35, 101, 103, 107, 209 and possibly 210, the internal revenue code. clearly, these are areas that on the face would be the jurisdiction of the finance committee so if we're going to selectively choose which members get to participate in it, i think it's a little unfair to senator isakson. >> the lastx

we return to live coverage here on c-span 3. >> you get a three option check in the state of georgia as to what you want end of life done and in many places, it has been established through a court precedent which is why the language in there refers to whether statutory or as recognized by the courts of the state. so i certainly, i'm trying to save a cost burden on medicare and improve the quality of life to the individual, not put a cost burden on the individual.

>> that's exactly right. >> because of the 90 day -- i think i'm right. i stand to be corrected. but i think you're supposed to go in 90 days before your 65th birthday to register and that's at which time you get your package of information on part b and the other options, and then you enroll. >> but see, that takes me to my question. so you got your 90 day packet and then would medicare have a standard form then that you would be having a box to check or whatever, or do you have to not only consult with your physician and i hope your family and your chaplain or family, i mean, i've had to look at my own life in terms of the parameters of my own church and so on. would medicare have the form? >> no. this does not portend that medicare would have the form. it portends that medicare would provide the information of the

requirement when they come in to register and they would consult, recommend they consult with a family physician. i would suggest also that medicare makes it a requirement that they have it, people will respond in the health community, the faith community as well as other communities to have that information readily available because it's a great thing for everyone to have. >> i think it's a great thing to have and as i said -- >> it saves the will federal government a ton. >> but i'm also thinking about not only saving the federal government money, and as you know, end of life decisions are fraught with enormously complex medical and ethical considerations. many of this, in this room have been through it with their own family, someone who has practiced medicine, someone who has been a social worker. my concern is that requiring everyone to fill out an advance

directive would add an incredible burden to a 65-year-old to be able to come up with this medical directive. the way you would have to do a medical directive is at least probably consult with a lawyer. that's one issue. the other is where would you get these medical directives if you're not consulting with a lawyer and how would you -- so i'm concerned that it would become a deterrent for applying for medicare. i'm concerned that it is placing a tremendous mandatory requirement on a potential beneficiary and apart from whether we're in the appropriate section, i would be hesitant to endorse the bill, the amendment, even though i know what the gentleman from georgia is trying to achieve. i would sure like -- there has been no hearings on this. i would sure like to know what

aarp thought of this. in terms of from the beneficiary side, before we voted. have you come to a position on the parliamentary -- >> what i would like to suggest, if we might -- >> i understand both compassion and the cost constraints that this suggested. >> let me say to johnny, i think this is -- i like the concept. i think the reasons you have identified it have value. so i would not want to, if we could, this is one of these things we will be at this a number of days here and if we can ask people to go back and take a look at this thing. senator mikulski has a strong interest -- >> could we get aarp's take on this and also, could we get the cbo or gao to tell us the cost of implementation? >> i just would feel better if

we had a little more look at this thing. >> mr. chairman, if i could, one minute. >> we want to be clear. this isn't a blow-off. >> i know. i know. i have respect for the questions that you're asking. two or three points that we'll send to you. there's a web-based all 50 states directives are on the internet. this information is readily available. i've told my staff to give you that site. number one. number two, i don't want to be picky here but we rejected out of hand senator gregg's vote on his first amendment that he offered to check costs. we know without a shadow of a doubt that the cost this saves would be greater than whatever cost it is to implement. it's pretty obvious from the medicare numbers how much is spent at end of life. i would like to work with the gentle lady and the chairman during the course of the markup before we get to the end but i'm

pretty doggone serious about it. this is not a flippant, it's an opportunity for me just as the bill is an opportunity for a lot of other people to do things they have always wanted to do. i think this makes an awful lot of sense. i would appreciate the opportunity to continue to work with the lady. i will see she gets the information on the web access as well as the other and then mr. chairman, maybe you and i could figure -- >> i appreciate that. >> but again, let's think at it from the standpoint of being 64 years old and nine months, getting ready to apply for medicare. who are you, what is expected of you, what it is that you need to do and how then are you going to be able to do it. it's the how are you able to do it that gives me pause and concern in terms of making it a condition for eligibility, and as compared to a carrot which

says if you come with an advanced medical directive, you don't have to pay co-pays for three years. >> let me, if i can, i want to clarify one thing because i think this will come up off and on over the markup and it's a point that was raised by richard as well as by johnny. that is pointing out that in this bill we touch on jurisdictions and i asked the staff, i said tell me, that's a legitimate point and their counsel to me on this is, we do this in a number of places in the committee with jurisdiction in order to make our policy effective. what we're not trying to do is to change fundamental policy in these areas but rather to conforming to what existing law is. we're trying to be careful about it. not to say it's perfect but we are trying to be sensitive to the jurisdiction particularly of the finance committee. but you're right, there are matters where we touch on it but the purpose is not to create new policy that would be their jurisdiction but rather to make the policies we're improving forward. i wanted the record to reflect

that, we're not just trampling all over jurisdiction and the reason we are doing it is to touch in these areas. i'm grateful to our colleague from georgia. i'm grateful to my colleague from maryland for raising very legitimate points that we ought to be considering. but i for one as well have the directive. i think many of us do. it's a choice i made and having watched the case of my mother, go through a long time years and years ago, and i could almost hear at the time having no question in her mind where mary grace murphy was going and lie for 11 days in a coma, keeping her on life support at the time. it was the six children arguing and debating with each other about those moments. this was almost 40 years ago, long before people thought about a lot of these ideas. so it's a very legitimate -- the families wrestle with it all the time. i hope that my children and family have a pretty clear idea of what i have in mind or would like. i think -- >> do you have one? >> oh, yeah. absolutely. >> where did you get it? >> i got it in connecticut, the

lawyer did it for me, also represented the local hospital. so we were very conscious of what the hospital -- and hospitals get nervous about this stuff. >> did he charge you by the hour? >> i presume he did. >> mr. chairman, i cut off the doctor. could he speak for just a second? >> you all make this sound so terribly simple. the fact is i don't think half of the advanced directives are ignored today in this country because of the liability situation. how many physicians can really tell you it's end of life? and if we don't know, what do we do? today i had a phone conversation with the elderly father who had been on a ventilator for 13 days because they didn't know it was. so until you fix liability, until you address the tort situation that the providers in this country face, we can do all sorts of things but it's really not going to save money because

we have another thing we're considering besides an advanced directive. what if this isn't the end? what do we do? what if the family isn't there at the time we need to -- and one of the questions that goes through every doctor's mind is what is my exposure if i don't resuscitate, if i don't intubate, even if i have an advanced directive. therefore, we put people through all sorts of procedures and machines not because they didn't have an advanced directive. it's because we're worried about what our liability is when they do and we can't make a clear and convincing case that it's black and white. >> very good. thank you. >> mr. chairman? >> yes. >> can i just address three things? for the purposes of senator mikulski. there is nothing that precludes a 64-year-old who walks in for

that 90 day period and says i want you to do everything to keep me alive you possibly can. that is a medical directive. two, part d medicare, we have a requirement, you have to decide which plan you're going to be on. it's a decision that we're asking every person that's gone on medicare to make, and we go further. we say if you won't make a decision, we're going to put a 10% penalty on you. that's going to accrue for every year you don't pick a part d supplier. and to the chair's comments, i would only ask staff to look at page 101 of the base text. specifically, the small business verification. i don't believe that this is a technical conforming language to interweave this into something else. this is basically a new dictate and therefore, we do get into

finance committee's jurisdiction. >> all right. okay. senator hagan? >> thanks, mr. chairman. i used to serve on the ethics committee of a large vet hospital and we dealt quite often with decisions near the end of life. i actually used to teach courses in the advanced directive, and there are a lot of decisions that the individual and obviously in conjunction with their family and their faith need to be made. i think whatever we do to incentivize and encourage people to fill these out, it really helps, i think, the physicians that i have dealt with but you also have to remember, you have to be competent at the time that you actually execute one of these things. so that might preclude any sort of mandate of a requirement. so i think in looking at it, you certainly have to take that into consideration but i do think if you can be more instead of the stick, a carrot approach would