information in order to inform that provider in order to make the best personalized decisions. he made the point yesterday you shouldn't be mandating to follow those guidelines and i agree i think that would be interfering, stepping between the provider and the patient, but you also simultaneously don't want to deny the provider the opportunity to have that access to that information without mandating the use it but in order to make sure they will have the access they need and i think what the compromise language as offered does in the sense it doesn't mandate that you use it but it doesn't prohibit in the sense from you having access to it and my fear would be by adopting the language as modified as opposed to the ones we talked about yesterday will end up doing that. not prohibit the dissemination of any information by the practice of medicine by the studies coming out of this. >> one compromise at a time.

>> that solves it. that solves your concern that we may not get to disseminate the information, but it puts a clear prohibition on the fact that cms isn't going to ration care. >> i hear your point on this. we were watching the insurance industry rationing care for a long time without a bureaucrat or insurance company steps in and tells your doctor you can't provide that benefit or procedure because we're not going to pay for it. an irony is in a sense to the extent that that will exist. you have the private bureaucrat stepping between the doctor and the patient, which i hope all of us, i but we are not in the uncharted waters in that sense. >> mr. chairman on that point, can i say i agree with you but one of the things i want to make clear when i said government entity as opposed to cms i am also talking about the va or the department of defense, or any government entity from using cer to ration healthcare so the entity thing is a broader

concept than just a mess. i am more worried about cms because i think that is where, that is where all of this is going to happen. but, and i said before that there is nothing, and our counter, counter language if that is the way to put it, that says anything about the nine doctors for the healthcare delivery system and everybody involved in it from being informed or from any government entity to disseminate this information, which is very valuable information. we need this information. >> that language, reports and recommendations are prohibited from being used by any government agency or entity for payment, coverage or treatment decisions. now it seems to me that treatment decision involves being informed provider. if your prohibiting that information in treatment decisions you are doing exactly what you say you are not doing. >> it does not mean they are

going to have limit the dissemination of this material. >> mr. chairman, by my observation, we have now had the same debate under different forms or whatever for several hours now, and i wonder if we could-- >> senator enzi would like to be heard. >> absolutely. i would like to be able-- could i make a recommendation for a process, that senator enzi be heard, that i respond to the roberts counteroffer and then we have a regular order of proceeding? >> i will be short. mr. chairman, one of the reasons we are having difficulty here is we are trying to do this into few words. and it is a big issue. there are a number of amendments in on this the deal with a piece, and it is a small, each of them are just a small

concern, but one of the reasons mandate in my opinion means everybody. but, but if you just love of the little piece sodas the exception. it is not the mandate, it is the exception and my amendment number seven deals with quality adjusted life year measures that the government could use. and that is exactly what we are worried about with the european situation, where the blocks breast cancer patients from receiving breakthrough drugs, and they kept alzheimer's patients from receiving the early treatment. they deny the life prolonging kidney cancer patients and all of these things. that is quality adjusted life, qa l why. i'm worried about them using this information to make those kinds of decisions in america. my amendment number as is

prohibiting the use for the nine medicare benefits to the elderly and the vulnerable patients against their wishes. co which is be a little piece again so would not be a mandate. the would might be able to be used and it is the issues we are worried about. we don't bend-- i guess we would bend the cost curve by denying those things but i don't think it is it any of our intent to do that. so i think maybe we are trying to do this into a few words. and prohibited is too broad, because as you mentioned, it keeps, made it keeps the dissemination of the information from happening which is why senator coburn suggested that extra sentence. i do think we need to take some care with this and that is the reason there's so much discussion on it. it is critical to what we are trying to do. >> mr. chairman? >> senator hatch.

>> i agree in doing comparative effectiveness studies, however in terms of looking at clinical effectiveness outcomes, but not for making treatment coverage decisions, i believe patients and providers should better understand their care and the confidence of its efficacy. but, i don't think we should lose sight of the fact that the basic understanding that medicine is simply not an exact science. there is variability from patient to patient that directly affects their treatment outcomes. it is only within the confines of the physician and patient relationship and not some washington bureaucrat that these treatment decisions ought to be made. i think most of us agree with that in the question is how kennerly afis language better? clinical comparative effectiveness done right can provide this with valuable information while preserving and protecting patient choice and

medical innovation. but it should not encroach or hindered vances impersonalize medicine, which is something that is very important, certainly to me but to all of us. comparative effectiveness needs to focus on what works best clinically for an individual patient and not simply what is the cheapest option. that is what we are worried about here. you know, the information must not be used to ration or deny care. that is something that is a legitimate point here. i have been working with some members across the aisle to try to come up with a bipartisan way of solving this. done right though, comparative effectiveness has a lot of merit, no question about it and i believe swirls has to be placed in any legislation that we move forward that prohibits the use of cost base information or making treatment coverage decisions. i think we should do everything in our power to prevent the rationing of healthcare and

sometimes prayer crafts as much as some people don't believe it, i know it is true that bureaucrats do tend to get between the doctor and patient. right here in washington. if we have differences among the scientific organizations and so forth. it is a very, very complex field and like i say if we use comparative effectiveness studies to look at clinical effectiveness outcomes, then we are really doing what we ought to do with this. but i think there is merit and what the senator from kansas has brought up here. i hope we will consider it. >> this is one of those interesting debates right don't hear any disagreement about what we agree on, so there's a legislative record means a thing of all no one is arguing for rationing. no one is suggesting that there ought to be mandates that you have to follow the guidelines are recommendations from any entity or agency, and i, and i

think there's a danger, if we go down and flyspeck this on every imaginable situation you leave yourself and vulnerable to the fact situation you haven't thought of them there for because you have not included it must be excluded. there's a danger that because there will be i imagine down the road procedures and things that happen where people say it was not listed in the bill, so there. ahead. broader language tries to encompass and it makes more sense. we have exhausted this company-- conversation. i recommend-- look this is obviously-- we will be back at it again at some point but i think if we tried to throw words in here as we are going along and makes it harder. >> mr. chairman it is bend a one-sided debate and i think-- thank those on my side of the aisle for-- and think i will not ask you to restrain. for purposes of today because i

was cognizant of time and senator burr has flight schedules of cetera. first of all in terms of the roberts counteroffer, i am strongly opposed to that, because the term any government agency is too broad. kospi it is entity. >> he rightfully says-- excuse me, any government entity. he rightfully says that this could impact on the va or tricare and quite frankly, i would be able to make up-- want them to be able to make up their own minds. i think a government entity is too broad. it could have a negative impact. now i want to go to this term rationing. it is a highly charged, focus driven word. and we know why that word is being used, because it is meant to scare people. is meant to scare people about this health plan pagoda is meant to scare people about going to value efficacy, evidence

informed patient-centered medicine and quite frankly rationing occurs every single day. the minute you have a pharmaceutical formulary, you are being told by your health insurance company what drug you can take and what tragacanth take, but often it is based on financial arrangements rather than clinical evidence. what we are focusing on here is to be able to provide information for value driven efficacy-- for recommendations that would be based on value efficacy and evidence to be able to inform. now, i am going to ask unanimous consent that the counteroffer that i propose, which would say senators are prohibited from being used mandates for payment covered church treatment be

considered for adoption. >> reserving the right to object and died will not object, i just want to respond if i can and i am sorry. i don't know who is keeping time on this debate and i wanted to be equal. i respect the senator greatly and i know that we will work together down the road after this vote and i know you are going to win and we are going to be coming back and trying to make some accommodation here. the difference between private insurance i would tell the chairman, and he knows this, and medicare is that under medicare's balance billing requirements the patient can't even use their own money to get treatment that is prohibited by medicare so even though he would want to do it and pay for it as a sort of a co-pay, with their patients to can do it so that is one of the problems. the other thing is this business of assuming that i am using the word rationing as a scare tactic. it is pretty scary to me because

of all the experience i have had talking with hospital administrators, hospital boards, pharmacists, clinical lab people, ambulance drivers, nurses, doctors, whatever. i have got about three and 50 hospitals out there. i have got 83 critical access hospitals in kansas and i know a great many people in other states have the same situation with their own healthcare delivery system. i can tell you that they are very frightened and they are very frightened of cms because they have gone through this before, and i went to the whole case with home healthcare yesterday. this is a very real problem that is happening every day. i will give you a personal example of this. and i'm not trying to use this to frighten anybody or a scare tactic. it is real. i know it person who is a little mature in his years, who just went through knee surgery.

and, it was not a knee replacement but there were three mri's and he needs another one within three months. i know that that is not going to be permitted. it is triple imaging, and i know there are people here on this committee that no that is where a lot of fraud and abuse appears that the doctor feels he is not being reimbursed enough in terms of cost containment, that he will at all sorts of tests and things of this nature. we have to get to the bottom of it. i to know those particular three mri's or this particular individual or necessary and another and was coming up. and i also know that that would not be prohibited. court, that would not be allowed. it is my knee, so it is a personal thing with me. i think that is reflected all throughout many, many patients and many doctors all across the country. if you don't think rationing is out there right now and we are not rationing care and doctors

are making decisions not to serve patients, if you know, go up there in the real world and take a look. that is why we have special the hospitals. that is why we have the special the hospital, like a sheep. the factors they know i'm not going to put up with it, i can't afford it so they don't treat medicare. now take this to the logic conclusion, you are going to save a lot of money with medicare. the president says he's going to cut medicare simply because the doctors won't offer it. if that ain't rationing, i am not country. >> is there objection to-- to the counteroffer? then, mr. chairman-- >> the pending order of business would be, i believe-- >> it is the roberts amendment. >> let me just say, senator,

this has been a good debate and obviously and fortunately we have to resolve this. there are some common points of interest and all of this, but to move the process along, we will have to come back to a. i realize their whole host of amendments. i hope we can clean up by this and eventually of the evening we were able to come to an understanding that would allow us to agree aunts of language on this. so common that case we will just have the pending business, the roberts amendment and it will have a vote on that and i will encourage the participants in this discussion to spend some time over the weekend to come back and cipa can't do something to correct this. in order to move along and get two of jay-- other subject matters this whole section we will deal with now and then encourage further consideration and discussion. we will leave it that way. >> if there's a possibility for more discussion mccann probably

do that with a voice vote. >> all those in favor of the robbers amendment say aye. those opposed, no. the nose hava, and we will leave it. >> i would like a roll call vote. >> why do you were visiting their suggested the discussion was still going to be open, that may be leakages do it by a voice vote but i would defer to your wishes on that. >> dr. coburn had just given to the chairman that extra paragraph that we protect the dissemination on all that to doctors. and then, if we could combine that language to the language that we have work done, both the senator from maryland and myself, and use the word prohibit, i think we are that close with all this debate. i don't know if the ranking

member can tell me what the differences between a voice spoke and i guess if you have it recorded, you lock it up and put it on the bookshelf and you don't ever take the book back. >> i just got the language. i appreciate tom coburn submitting it. words are important and i think a good suggestion, but rather than just a step in this a day at this very moment, we will take into consideration. >> the difference is the majority would then be locked in with their boat, and i would prefer not to let the men until they get to see the alternate language. >> mr. chairman, first of all, one, a voice vote or a recorded vote, whatever is the pleasure of the other side is fine with me, but we are going to live in those papers passed back and forth on the same topic. we are now at the plant, and

where there's a fundamental difference within the committee. we can have 50 amendments all versions of the same thing, but ultimately we are going to have to come to closure on this, so what i would like to do-- i would be happy to read senator coburn's language, etc., but i would like to come to closure now on the roberts amendment through either a voice or a recorded vote. >> you have party had the voice vote in your party won that. the only question is whether i call for a recorded vote. if we continue working on this, even though there seems to be, seems to be great distaste for doing that, but i would really like to continue working. for me this is probably the biggest issue in this whole healthcare business. >> it is not a distaste for what we are trying to achieve.

it is certainly my attention on matters like this to continue to work where we can reach accommodation. that is the whole point of the process, so you have my commitment on that. >> i think we have been in working together. i accepted 17 amendments is today. what was that? 17 amendments we look through every single one. we have tried to do it-- >> i'm not question in that. i'm not questioning that. there has been a vote, it is a voice vote. i'm going to leave it there and we will continue to try to seek some accommodation. >> mr. chairman we do appreciate the acceptance of the 17 amendments. we do know that we are left out of the drafting of the bill. we have any ideas at all, there will be put in there somehow but we do think we appoints the need to be made and we are willing to make the effort to make them. we are willing to make the effort to sit down and some of these probably have to be member to member decisions rather than

staff decisions. >> i promise people we would complete our work by, between 12:00 and 12:30. there are additional amendments the people would like to raise outside of this section. >> mr. chairman i want you to know that there are 15 amendments on comparative effectiveness. we have spent two days some of them, so i would hope as part of one point discussion and content that we would also have the agreement and process where, because all 15, as senator coburn and others have said, are very much on the same thing in even the same words in some ways, so i wonder, as we look at these and began work within the comedy that, the standard you are setting, could we also talk about the process, because given the schedule, we will spend 30 days on 15 amendments all on the same thing. >> if your intention is to

reject all 15 of those comparative effectiveness agreements, it will save us time here in committee and it will take additional time on the floor. because, we will need to talk about this section a lot more unless there is some belief that it is not going to be rationing. and, as long as we believe that, we are going to need to debated and the american people need to know it. hopefully we can come up with some wording that gets rid of that very contentious think, and if we do we will make great progress on the bill. if we don't, we want. >> that was intention. >> if we debate of the tiananmen amendments would the gentleman from wyoming before time agreements on the floor? i think we are going-- because i go with what senator roberts has said, the two big points of contention will be some version of a public plan and whether we

have compared the effectiveness. i think those of the two most points in the bill along with others. wouldn't you agree? >> that would complete the list of things, yes. >> how we pay for it probably will be a point of contention. [laughter] >> let me just say-- look, let me suggest. let me suggest-- this is going to be a process that we are going to put the time on this. i have tried to be extremely patient terms of everyone being heard on various matters but they also need to move this. as the chair of the committee, acting chair and senator kennedy's replacement, i have got to move, in order to get a job done. of the state can't go on endlessly. i want staffs over the weekend to work on these matters. there's 171 amendments pending in the prevention section and i

would urge the members to work on those and try and have a product ready the first part of the week. in terms of adequate time to respond with amendments will be provided with certainty, but we need to get this job done. i pointed out yesterday every single day 14,000 people in this country lose healthcare. by this weekend that will be 20,000 by the end of monday it will be some 42,000 people in this country who will lose healthcare that they have today. every day, those of the numbers so well understand to be patient and to get it done right and i'm determined to do that but there is a crowd out there. everyone around this table have healthcare. and omnibus will have to worry about something happening to one of our families, children, grandchildren. they will be properly taken care of but for 20,000 people over saturday and sunday calusa healthcare that sense of confidence will be there and they are looking to us in

counting on us to get this job done for them. these are very important debates and i don't minimize them but in the final analysis we have got their responsibilities to come up with an answer to a problem that is beguiled our country for six decades, and it is getting tougher and harder to deal with it. every of the congress and every administration has failed. democrats and republicans for the last 60 years. i'm determined as i know my colleagues are, that we not fail in what is absolutely essential, no longer and susceptible or sustainable for country. employees to be patient but some point i'm going to move this. of the means test in the leader to go over the fourth of july break and so forth, i will put my colleagues on notice. this is not just in the issue we are dealing with. this goes to our heart of the company-- country's ability to get back on its feet again so i'm as patient as anyone i know an institution but i will insist that we work to get this job

done and again i say that with a full understanding that i like working with my colleagues, i like giving people a chance to be heard. i like a full floor debate on issues but i also know when i'm being taken to banish seven i'm not going to let that happen. there is a tipping point at which we will have to move along at a pace that may not satisfy everyone's interests and we may go through a heated discussion. i don't want to be taken advantage. as a way of dealing with these matters and i urge my colleagues to do so. >> mr. chairman i am very disappointed that you think we are taking advantage of you. >> i did not say that. >> that is a very important point, and your example of 14,000 people a day and losing their insurance is very important but cbo says that the bill that we have the force causes 10 million people to lose their insurance. and we have got to fix that. we have been left out of the trapped in part. >> those bureaucrats. >> it is important we have our

amendment. >> those bureaucrats. >> i no amendments have been accepted and i want people to look of those. most of those are technical corrections and that this might get to the heart of the bill. what we are talking about on some of these amendments that we are taking time on to get to the heart of the bill and coverage-- we started and what is supposed to be the easiest part of the bill. coverage will be the more difficult part of the bill and we will have to get time to talk about that. i hope that this might condense into one day of talking because i think there are opportunities for us to make a difference there too. >> mr. chairman you when i came off of a couple of weeks of keeping man in a legislative issue and it came to conclusion, a bill that had been around for a long time and you are passionate we'll engage in you are fair. i want to a dallas that. let me just remind the chair and all the members, there are some pieces in the base build that

are enacted a year after the bill is signed into law. most of the bill takes effect in 2011 and 2013. even with passage of this bill, most americans aren't going to feel any impact until the next to administration, because of the 2013 date. so, i realize that the chair has been given a task that he didn't necessarily create the legislation are the timeline. but, i would plead with him to continue to show his patience that i know he has. if we get to a point where this up, it up. but, think there are many of us that are pashtun down the side about getting it right. there seems to be a difference on comparative effectiveness that maybe we can close that

gap, but it took us a day and then have to get there to realize that comment that is where we are. there are other issues that may take that long, but i urge the chair, don't cut the debate short, because this is a debate we are having for the american people. i thank the chair. >> any further comments from my colleagues? it is noon and unless there are other amendments to be offered, mike, let me say to you here that we will set a new time for the cbo meeting and we will also and consultation work with you to set a new filing deadline in light of the-- >> could i just say something about cutting the debate short? we spent all week on this. we have got a lot done. mostly what we have gotten done is because of our willingness to accept amendments, and in many instances it is ben willingness based on