operators. i support an effective programs, not popular programs. madigan said of trust fund for hhs to spend billions on wallace we should improve our prevention agency cdc and prevention. we are giving cdc a lot to do in this bill on top of their heavy workload. as an even have enough funding to evaluate their own programs but the title of this requires them to by employers wellness programs and a set of trading more than 15 a programs we should modernize current programs. we should evaluate and improve our federal programs before we spend tax taxpayer dollars in aid to ensure those programs are not duplicative. this title requires incentives to develop recommendations relating to prevention specifically employer sponsored -- programs. i'm concerned these recommendations will become requirements and employers must have the flexibility to provide effective on this programs and

in good job of this right now and should be allowed to continue to innovate. government mandates will make that difficult if not impossible but employers are not the ones who must bear the burden of multiple federal requirements even with the stimulus funds for political leaders in 19 states are still struggling to negotiate budgets. according to a recent report by the national conference of state legislatures states will face $121 billion budget gap in the coming year compared to the 102.4 billion for this fiscal. all states must be held accountable for spending federal funds decanted too programmatic more mandates. some of them may have value but overall it's a wrong approach peregrinations of an economy this bill must not turn into a christmas wish list for every person interest group in washington. so i urge my colleagues to reconsider the scattered approach of work contacting our biggest health programs and are you departure as a way.

not eliminate ones that are successful. >> thank you very much and i will turn to senator harkin and then open up from eminence. >> thank you very much. there is a lot of what senator enzi said that i agree with. when it comes to prevention and wellness we have a scatter gun approach. we don't really have any real structures to this that are delineated by the people that no one works. we don't have any real guide posts out there. that is what we're trying to do in this bill, and this title is to add some form and structure to its, not in a way of telling people what they can and can't do, but to make it easier to be healthy. to change the system and structure so that people find there are more incentives by not

telling people what they can and can't do. as i said yesterday i repeat for emphasis sick when dr. andrew wiles said the human body wants to be healthy, it is in our dna to be healthy but we have corrected all the structures that make it difficult to be healthy so it is hard to be healthy and easy to be unhealthy. we need to kind of change that around. i would say to my friend from wyoming that we have to entities in the preventive services task force has been in existence since 1984 and the committee provided services task force. these are experts. i think we have a structured, but we haven't really been enabling them to give us any kind of a guidance in the past. we tend to do that more in this bill to give them more credence

into use in their suggestions as to what we ought to do rather than this scatter gun approach. so we're not trying to tell people what they can and can't do by saban r. glen to make it easier to be healthy and get more incentives up front. whether employer based community-based a lot of things we can do and a lot of committees have argued then that. >> senator i also point to his what they have done in oregon. there may be others i don't know about that have set up the structures so that people is easier to be healthy to walk or bike and do different things like that in those cities. one of the reasons we have set up the public counsel that goes across all the departments is so that and all of the legislation we passed on all the rules and

regulations promulgated by these departments they will start thinking about this. i mention on transportation that some have suggested when a book of the taxpayers' money into building highways and roads and bridges and things like that that people put in their bypass and walking paths. they don't now and i always mention in virginia we reached bought a house and sending an was because my school is less than a mile from our house. so there were no sidewalks and was a very busy street with no sidewalk. why are we doing things like that? transportation, that is not in their purview. they don't think about things like that so you're not telling people they've got to walk but at least you are making things available so that makes it easier for them to do things like that.

and that is sort of a response to you're opening comments. the thrust now just say again i think the heart of this whole bill, listening to senator coburn this morning i think there is a lot of money in the system and a lot of it is for chronic illness and i know the figures are, maybe 70 percent paris this year 70 percent goes for chronic disease much of which is preventable. you can't get those people off now but we can start looking ahead which has ever paid for emphasis take one of the reasons for the trust fund and will keep sending is that if you put prevention and make it compete with dollars that are being used to take care of people that are

sick the money going taking care of people that are sick are wins on this link so have to set up a structure to move this ship as i call at that is handed down one way on sickness care to more health care and will take more time but require some restructuring and i think some additional funds to do that so and away i kind of agree there is plenty of money there but i don't know how you get the ship moving, as you do some other drastic things but that is not a part of my title, i want to focus on prevention and thomas and not coverage. in that is coming on another title. mr. chairman, out like to begin this morning by dispensing. you'll be happy to hear this with the amendments. our staffs have done a great job, they worked all weekend. i don't know when they sleep. seven of these are contained in

my technical amendment which is called harkin a one which has been cleared by both sides and there are 39 other amendments we can exact and those have been shared by both sides feared a 3907 only comes to 46, is now to me by nearly 50? 46 amendments. in shared by both sides so i ask unanimous consent that harkin won the be accepted and that senator enzi 44, 45, 49, 62, 69, 73, 76, 81, '83, '85, and 92 the accepted, that number number five be accepted, hatch 10, 11, 13, 19, 25, 14 and 17 with some modifications be accepted,

burkowski seven, 12, 13, 14, 20 other, 45, 66, 70, 75 and 76, and coburn 35. i ask unanimous consent that all of those i have read the -- >> is there objection? without objection so ordered and the 46 amendments that the senator from iowa has just enumerated are adopted and i think my colleagues for their work on lobbying of that large number can i just a couple of things. in looking over the amendment offered by the republicans

signed it seemed to fall into six broad categories there was limiting funding for prevention efforts to the investment fund and workplace wellness, opposing the temporary clinical preventive care for the uninsured and right choices section, limiting the activities of school based health, prevention for the aging, a community prevention and states' concerns. seem to fall and those kind of categories. i don't know, i have just suggested that if we could maybe it works to those that way it might be a logical quote kind of a process. that would be the best way to proceed or if you want to open it up. >> i think what senator enzi said, this will be a major debate on the trust fund into that is not technical in nature, that is a hard or a least a major portion of this overall

effort and endeavor some might be a good place to begin and so senator enzi, why don't you take over him mack okay, thank you mr. chairman a. i offered my amendment number one. >> the clerk will -- make sure that we have that. is that striking? to maximize all funding for the prevention title and redirect it toward lowering the cost of health insurance for low-income americans so i will go ahead to mad go ahead, it is pretty clear. >> we want to ensure that are spent on toys will programs but are spent for reducing the cost of insurance for those in need. the bill as you will notice is chock full of programs to build sidewalks, that's senator harkin already mentioned but not to reduce the cost of health care.

putting a sidewalk in place in a jungle gym in place and putting these things in place does not assure the people and use them. i guess it could encourage them to use them on the sidewalk issue alone. our first child when i went to school was able to cross a very busy highway and walk several blocks to school but by the time we had our third child would not dream of doing that and it was for the safety of crossing the highway, put the fear of being conducted in kids are afraid of that now and that is why we provide all the bus service that we do. and bus service eliminates sidewalks and exercise. the old story about how when we were going to school we had to walk several miles uphill for several feet of snow. both directions. and [laughter] it doesn't apply anymore. the schools are expected to provide bus service and health and safety in everything that

implies and i go into each of the things they're. i think my eminent is pretty straightforward and redress prevention funds. even with the amendment to the prevention title spends which you will be proposing will spend over 85 billion and includes 12 new authorization lines that don't specify funding. those could be spent on lowering health costs on always will projects that want to improve health outcomes. we need to provide incentives to change the behavior's and i don't think that just building things does that. nothing in this bill is to deregulate decrease the number in jordan in the late 36 million without insurance the title only spends money on this project when it should be providing insurance to millions of uninsured americans here and i know that we want to get from secure to health care. the only proposal i have heard of them do that are one similar

to the safely project and several other companies are doing that with incentivize people to make good choices. i think we're even doing a disservice by mentioning prevention because most people out there when they think they're prevention are thinking of the government or somebody else doing something to see there are not hurt. it has nothing to do with their personal choices and a lot of these are personal choices plus dna problems but on the hole each of us makes to us is that two of our health everyday and their to be better ways to incentivize us to do that. just putting a few things in place to play on or walk on i don't think does that and at the same time we do need these 36 million people without insurance so i would hope that we would strike that bunning section and save that money.

>> well, the idea behind the prevention and wellness title is to begin to shift our emphasis. i make no bones about that. as i said before we have to change not just to do medicine but the medicine we do, not just the way we pay our bills but really the medicine we do in the medicine we do ought to be more preventative. and more up front and more wellness types of programs and interventions, but has to be comprehensive. you can just do a little here and say we've taken aware the workplace and take care of the clinical here though it has to be broad and has to be pervasive in our society that we gear ourselves towards a wellness structure. just changing structures so that we put more of it up frontward

and again will i think a lot of what we are talking about will benefit of low-income americans feared as you say you want all the money to resist health insurance for low-income americans but quite frankly the low income americans more than any other group suffer from chronic diseases. they don't you write, they smoke, they go too fast food places all the time. maybe the grocery stores in the neighborhood don't have fresh fruits and vegetables and things like that that senator brown of for the last farm bill and the setting up private programs to see if we can't restructure that so people that live in low-income areas have opportunities to offer health care foods so it has to be pervasive. for things on the meal, part of our bill is the meal act that i worked on with senator burkowski and others were longtime, the

national restaurant association signed off and we had an agreement so that every chain restaurant will have total amount of calories for every single item have. and if you're someone who is watching their sodium intake are fat intake you can ask that the counter i would like to know what the total new tranquillity is of this item number the they have to present you in written form. doesn't have to be on the menu board but they have to have it available in the senate and the things that doesn't tell people what they've got to do but gives them the information that they needed to make it healthier choice if they so desire. we did that and the senate cafeteria about three years ago. and we turned it over a new

vendor. before working on to get reinstated, they took by every entrée i am in the cafeteria down below the calories, that and sodium of every entrée item in you'd be amazed how people going to the line began two now the different things. the have the information. some more than anything that is what we're trying to do and just take all of the money out would end it. that would be the end of our endeavor to try to shift the system toward eight willis and prevention and the reason these are in here is to do it in a comprehensive manner and quite frankly i say to my friend a lot of this is geared toward low-income americans to help them have a healthier life and health your lifestyle.

so i hope that we would reject the amendment of the senator from wyoming. >> let me just say about this and then invite others to comment, i think judd gregg made a good point yesterday. he is not here but made a good point i thought in talking about how the bulk of the prevention of this leak or to incentivize individuals to change lifestyle behavior in all make a huge difference so it is sort of a bottom-up approach and i agree with that. is a critical component of this to encourage people to change live some behavior. it is not easy. it only one of the more difficult things to do when they incentivize changes in behavior was to get people to duet. the idea that sounds great and easy enough but if you are

addicted to smoking or addicted to a certain kind of whose real-life some of what the people to shift in as a lot more difficult than people assume and so just saying it or even when you are putting out awards for doing it and all companies provided additional vacation days where days off and as we heard from steve deberg and safeway reduction in premium cost is so even then it is hard to get people to make those ships. i'm sure tom coburn will tell you as a doctor how hard that can be. smoking i can tell you how difficult to change that have. a people try seven times before successfully dropping the habit or reducing the smoking so it is difficult so the bottom of approach -- that we finish my thought. the bottom up approach and i know the finance committee is going to allow that to the tax provisions with but i think there is any value in in a top

down trading the structures and the opportunity for those things to occur. also is important and it's on awful lot to expect people to make those choices when they don't know what the choices are. it is not directly related so i want to be careful about drawing to tide and analogy and one of my daughters is a very serious food allergy to the point where they are not life-threatening, sir, reading labels is something i never imagined i would do a lot of. i read every label. it is hard because a lot of it is pharmacology. there are 11 different descriptions of milk and try to understand what she can and can't have. that is not everybody in the population but it is unfortunately growing number of people to be able to have that information so she will be safe. where we got to eat, anything she does, plates and so forth very conscious. i think the idea of making sure

that people can have it the possible information on the opportunity is in the other part of this equation between individual responsibility but taking advantage of that responsibility so they do have the information that is intelligible and don't have to have a ph.d. to understand is going to be critical in reaching that balance between the two obligations. to take advantage of the opportunities and responsibilities as an individual and my sense is that our committee your wallet can do things on the individual side to it in large extent our responsibility to deal with more structural issues and would be the case and the finance committee. the point i wanted to make was a good point and i agree on the point but i think it is one side of the equation. i can do everything possible but there is no way i could pick up a product without a label until

my daughter is going to be safe. i don't care how much i studied whether or not that product has -- this is process and a place where it may have been exposed to. that is a great piece of information and there's even airborne elements that can put my daughter at risk. there is no way as well and forces and i commend those stresses without that information so while the analogy is not entirely fair with the food allergy and has some legitimacy when it comes to making sure people are aware of what the choices are. so i commend my colleague tom harkin for his work in this area and we can make fun of some of this stuff anyway but i think we do the point try to make by minimizing the importance of what these opportunities remain. >> before we go off the deep end on this i'm not eliminating anything, not eliminating most of what a senator harkin said.

of the meal act can happen, it needs to happen. the meal act will happen. restaurants across the and and as states have been waiting for some kind of direction from congress that make them the same across the country so there weren't having to decide on kind of a menu in california and another in iowa and connecticut. so that is something that is tremendous and on the fall. that is not the $80 billion worth of cost. we talked about we don't want kids to eat fat foods and want them to exercise, we don't want them to smoke -- that's not the 80 billion is about. of a 80 billion build structures and there is no way in there to get the kids incentivize to use the structures here and i'm not sure how saint ides of fact that, but they're all nice things we like to buy the right to have and can be shot already in stimulus, but they are not, definitely not hill ready.

they're not something that is going to cause the people to do those things right away. there are other ways we can get people to read better foods with a meal act and have them to get exercise but that is with some incentive. there is a lot of equipment out there not being used toward and we could make that more available and smoking we did something and i said it was an adequate but the best we were going to do and i am pleased that we're able to do that but that is not what a billion is about and 80 billion is rather unspecified. there were more specified the things talking about like getting people to stop eating bad foods and salty foods and of those things incidentally burger king right now has a sign on the counter where you go to order and says, if you hold the cheese and hold the mayo is a 160 calories. i bet that that gets more than the chart you have to read a that talks about the difference

sandwiches are and the different categories, as some things like that