rather than throw away another $80 billion on what may or may not work when we know there are examples of what does work and would be far more efficient by any objective assessment one of the use more efficient use of taxpayers' dollars 16, they didn't take into account the finance committee number and that number gets to 30 million, nonetheless, the idea that we'll adopt a bill

that costs $2.3 billion, and there's no way in the world any of us will support a proposition that does that. clearly, until we get to these numbers and try and fit in a policy agenda here that does achieve the affordability, accessibility and quality, we'll move on that bill. you're absolutely right on that point. i know you keep mentioning that, but there's one member, my colleagues will agree on this side that just won't happen. >> we'll have a final score before we have a final vote on what bill is. >> absolutely. absolutely. absolutely. >> think that's going to be very important. >> of course, it is. >> before we vote out this bill that we have a scored bill on the amendments. >> i couldn't ask any member to vote for a bill that we don't know what the numbers are and to the extent possible. >> mr. chairman? >> okay. >> i'll come back. two things on point. we've all referred to the success of several private

sector self-insured companies. pitney bowes, i tack for granted, is self-insured. there are several million americans that have made the shift. they have made the shift. their companies have walked them through the shift to making healthy decisions to doing chronic disease management. we've listed a few of them and there are hundreds around the country that have done that. in title three, i understand senator harkin's going to offer an amendment today that would directly affect these companies' ability to do it which is -- it deals with hipa complications and i understand that's in the works to do. i just want to point out to the chairman and other members, when you get to title one, there is a similar provision in title 1 that will basically change the ability of all these private companies that have self-insured their employees and are the innovators of how we do this successfully. they won't be able to do it if, in fact, that provision in title

1 stays in. so i hope the chairman would share that language. >> senator? >> now i come to you, tom. i apologize. >> thank you very much, mr. chair. i just want to clarify one point and then make a comment. i believe the only section of -- part of this title that has been scored is the right choices program which has been scored at 5 billion a year because that's the amount in the legislation, is that correct? >> is that correct? >> can i ask that? is that correct? that is correct. >> just want to note that while the number 80 billion is being thrown out there, certainly if you want to share where the number is coming from, the only number i have in front of me is the 5 billion for the right choices program. >> mr. chairman, if i can clarify that point. >> the cbo has not seen the new language from senator harkin and senator harkin's new language is that cbo will have to score $80 billion. so when it is scored it will be

scored as an $ 0 billion. it will be scored as 80 billion. >> over ten years. >> right. >> mr. chairman? >> so to complete the point. the piece we have is the 5 billion or the right choices program and just to take that and if it is $80 billion over ten years, that's the right choice, that's 5 billion per year over the first three years. this program sounds to me like exactly the sort of common sense that we'd want to have. we know that there are few diseases that create 75% of the costs in the health care system. we also know that a lot of those costs are tied to the uninsured because their diseases progress significantly with little prevention, little disease management. so this section says, hey, since we know the uninsured are a major source of expenses and not to mention significant source of

loss of quality of life for american citizens, let's take, while we're getting affordable, accessible healthcare for all americans in the time that intervenes, let's take and proceed to reach out and do disease management for those who are uninsured that that will have both a tremendous return in terms of the quality of life of citizens and a return in terms eventually in terms of the cost of health care. that certainly appears to me to take a very common sense approach in using the dollars very smartly. 5 billion a year, yes, it's a big number, but it's .2%. it's two out of every $1,000 a year we currently spend on  health care dedicated towards managing key diseases that drive health care costs and loss of quality of life and so certainly, this piece which seems to be the significant factor in this section or in this title really comes across

as let's apply common sense. the management of major diseases that drive health care costs and decrease quality of life and fill that gap until all americans have access to health insurance. >> i mean, just from a budgeting standpoint, because the senator said 15 billion would be part of the $80 billion. my understanding is the 15 billion for right choice is a separate program and the 80 billion. so the total number will be scored somewhere around 95 billion. >> you are correct. >> 18 or 15 billion? >> 15. i'm told by staff that senator gregg is correct in that. >> i've been looking for any kind of paper that has this 80 billion on it, and i haven't seen it yet. i'd certainly like to know those details. tom? >> where we are because we spend

$60 billion, through nih, cdc and the other ancillary programs, 63 billion. of that, 16 billion is not spent at the cdc or nih. there's not one metric that measures what we're doing now, whether or not it's successful. we have 16 billion out there, supposedly on prevention. some of it is doing good stuff, but we don't know. so now we're writing a bill and not knowing whether what we're doing today works and we're adding money to it. what i would propose, and whatever we end up doing, we'll come ahead with metrics and it's got to be transparent about what it does. you know, we don't have any metrics on the u.s. prevention task force, whether or not they've been successful or not. we've not independently measured the money we spent here. what has it done?

>> we just send money out there and say this sounds like a good idea. some gup told us it would be a good idea and we never go back and measure it. when you look at this $5 billion and you have 47 million people uninsured and we'll measure chronic disease and give them a wellness program that's $100 person per year. it will be hard to manage chronic disease for $100 per year. once we finish this grant, and we have -- i think you all call it the a greg art, what says this doesn't continue? you know, the reason prevention and management of chronic disease works on all these plans is because those people have skin in the game. they have skin in the game. there is a financial reward, monetary reward either through a

decreased premium or an incre e increased incentive payment to do the right thing. we can build all of the walking trails we want, football stadiums, but if you don't put skin in the game, people aren't going to do it, and when we talk about neonatal problems, just go look at the numbers. look at title 19 and look at medicaid, and you can explain all of the low birth weight. you can explain all of the problems that we have in this country because we offer a program that's sub-stand art to people we say we're covering and then we complain that we have this big problem with neonatal births, low birth weights and neonatal mortality. when you look at the different level of care, if we come through this and don't give medicaid patients the same rights as every other patient in this country, we will have failed because what we've really done is say you get a lower level of care.

yeah. we'll take care of you, but not quite as good and that's exactly what's happened today and you look at the health statistics just like you said, senator standa sanders, and when you look at it you see a lower life expectancy. it's not because of poverty, we have a system that they don't have access to specialists in this country and they don't have access to 40% of the primary care so we give a physician extend tore say oh, now you've got coverage. so we need to be very careful about how we go about this. i believe senator harkin wants as much as i do to make prevention, and i believe everybody at this table, make prevention, wellness and manage your chronic disease a key component of what we do, but how we do it makes all of the difference in the world, and we have a model that's out there now. what we ought to say is how are they getting it done and how are they saving money at it and how

can we copy that? >> we haven't done that, we can say here's a top-down approach and here's how we're going to spend money and we've forgotten the thing that makes it successful and that is putting an economic condition in association with the management of chronic disease, wellness and disease prevention. senator sanders mentioned community health centers. they're highly effective. they're -- as a matter of fact, they're so effective they're killing some of the private health care that's out there. and we pay a 20% premium to them over what we do the private physicians that they're running out of business and in this bill we take away the underserved categorization of community health centers so we will put more government in where we already have private health care, and we're going to spend more money and we'll eliminate more private health care under how this bill is written today

because we take away the underserved criterion associated with community health centers. i believe everybody here wants the same thing. i think we have a big difference on how we get there. one is a government-run approach that says we're going create the structure so people might do it, and i think we can spend a whole lot less money and create incentives with how people react in their health interest and economic interest and still have a government program. so it's not about being aye against a government program, it's about how do we most effectively get that government program to incentivize the management of chronic disease, wellness and prevention, and i don't think what we're doing -- i don't know whether it will work or not, but i can tell you it's not efficient. it isn't going to be efficient because we've missed the one connection that causes people to change their behavior.

and that's economic. it's an economic incentive, and we can -- greed does conquer difficulties. it does conquer difficulties. innovation comes from it. people will act in their own self-interest. ask safeway, ask pitney bowes, when they start incentivizing chronic assessment and they lower the cost of participation, guess what happened? they went from 80% to 20%. >> greed didn't actually conker this time around. >> i'd be happy to go into this debate. i'd be happy to see that as many at this table as well. we set up and we are responsible for the majority of that. we allowed greed to run amok, i agree, it did solve of the difficulty of loaning the mortgage loans. we certainly loaned a lot of money to people that couldn't afford it. i want to go back to what richard burr said.

if we don't design something that incentivizes people to utilize whatever program we put up and you all are in charge and you're going to ride it, but if we don't have the incentives for them to utilize it, it will be highly inefficient, and the second point i'd make is all throughout this bill there's not transparency once and there's not a metric anywhere to say what are we doing and what will we do? >> the transparency and accountability and metric, that's a good point, but tom harkin has a good answer. >> first of all, there are a lot of different things that have been brought up that i'd like to respond to and i'll take it in order. senator burr brought up the medical coverage and we have it

in the bill and also that we're working with the finance committee right now@@ hv@ @ rr@' >> can i point out one thing to my friend? >> yeah. two examples, real quick. the u.s. preventive service task force as it relates to psa exams

says the evidence is insufficient for recommendation in men under the age of 75, yet the american cancer society and urology association offer it to all men over 50 years with a life expectancy of at least ten years. as it relates to breast cancer associated with mutation effects. the task force recommends against routine referrals for counselling and the routine screening for sus sent ability gene, testing for women whose family history is not associated for an increased risk for del torious mutations in breast cancer susceptiblity gene. the comprehensive cancer network recommended for women who meet criteria for hereditary breast or another cancer syndrome. my only point here is we're relying on this

government-formed task force that is so far from where the cancer individuals are. may i respond? >> absolutely. >> i looked at both of those. the task force always erres on the conservative side. they're putting at minimum. at minimum you have to do these kinds of things. there may be other things beyond that that may be advisable, but the services task force has always been very conservative and always shoots towards a minimum. we're putting teeth in this bill for u.s. preventive task force. the recommendation in men 75. that's why we tlft for congress. if we decide in our collective judgment here based upon what the u.s. cancer society or the lung society or heart association says it is acceptable, we can change that.

we, by law, under medicaid now you can get your ps attested if you're age 50. or you can get your mammograms if you have less than what the u.s. services task force and they're in that advisory capacity to give us that information and your best wisdom. congress can always decide to do it differently. they just give us the minimum. so that was that i also -- you mentioned the fact that there are hundreds of companies out there. i've seen a lot in my own state. there are tens of thousands out there that aren't. so that's why we need to push ahead on this and to get more incentives out there to get other companies and stuff involved on this. to my friend, senator mccain, one of the reasons we put that kind of vague language in there was because there are a lot of communities in the united states

that are doing interesting things. some may work and some may not. we don't know, and that's why we have the u.s. -- there are two task forces, one is a preventive task force and the other is a community service task force to have them look at these and evaluate them and try to get some -- yeah this, works, this doesn't work and try to get some evaluation of these and try to look around the united states and see what different communities are doing. as i said last year the trust for america's health came out with these studies. i'm not an expert in this area of studies, but they seem to have a pretty good backing from medical sources and other prevention services that they stated was pretty valid of what the return on savings were for certain proven community services, preventive services. so that's why we left today. we didn't want to save this, this, this and this. we wanted to see what works out

there. >> let me say to my friend on the appropriations committee, vague language, i've seen the results of that many times in the past and it has resulted in billions and billions of taxpayers' dollars being waste with earmarked pork barrel spending against corruption and that's why i'm against it. >> well -- >> -- i've seen it time after time. >> every section of this bill we've put evaluations, evaluations, evaluations, so part of the money we're talking about here we're still back to the enzi amendment, i think. part of the money we're talking about will be used for constant evaluations of what works and what doesn't work. >> it's very important to remember that this is directed spending. so it's even taken a further level away from any congressional oversight because it doesn't go through the appropriations discretionary process, it's just, bang, every year $8 billion goes into a

slush fund called a trust fund. goes into the slush fund for the purposes of the secretary to spend whatever he wants subject to the appropriations committee maybe stepping in and saying we'd like to spend here and there, but it's totally outside. when the appropriations bill from hhs comes, this will not be an item that will be subject to -- >> mr. chairman? >> i'll make two points. one is evaluation is totally different than having to prove your metric that you're accomplishing something. that ought to be associated with every grant that you have to prove that you actually made an impact and if you can't do it it shouldn't be eligible to pay the grant. number two, we've gone from 10 billion down to 8 billion, but this is mandatory spending, folks. this is 8 billion you're going to borrow from your grandkids because we sure don't have it and everybody needs to know that. this money isn't going to come except from borrowing it from your grandkids because we're

absolutely out of luck on medicare. we're out of luck on social security. we're out of luck on medicaid and we're running a $2 trillion deficit this year and we're going to add $8 million and we'll say grandkids, we're going to do it now. just another chink at lowering your opportunity and lowering your standard of living because we don't have the guts to pay for it by decreasing spending somewhere else to pay for it. i wanted to do it senator harkin, we're not going to eliminate the -- in this country to pay for it, not one. >> i say to my friend, i think it was senator white said that. i made a note here, about short term. about looking at the short term and the long term. if we are going to borrow from our grandkids, which we co, obviously. i can't think of anything better to borrow for than to make sure by the time they start getting up in age, they have better prevention and better wellness

for them not to be stuck in the system of health -- of sick care that we're stuck in right now, so i can't think of better use of the money than to change the system. senator gregg, the fact is that the transfers of these monies, judd, are subject to appropriations. so it is subject to appropriations every single year. it will be outside to be kept -- >> i didn't hear that, what? >> it will be outside the 302b cap. you will get this allocation and get this on top of it. >> yes, but it's still subject to appropriations transfer. >> when you're outside the 302b cap you're funding this outside the budget. so this becomes an off-budget event for all intents and purposes. >> senator enzi, i think that's right. i thought we'd worked that out. i thought we'd worked that out. >> so you can actually score

this. >> that's right. but before, i still congratulate the creativity of the staff. >> if the objection is to mandatory spending, well, then, i plead guilty. of course, it's mandatory spending if that's your objection. i thought you had a different type of objection. my objection is it's mandatory. you'd think as an -- that i would be opposed to a mandatory funding, but sometimes i think it's necessary, and i repeat for emphasis sake why it's necessary. if you pit prevention moneys and wellness moneys that we're talking about here against the immediate needs of people who aren't sick, you'll lose. it will suck up the money and we'll never, never get this system changed. so i just -- that's why you need a separate mandatory stream of money that goes in and can only go for prevention. >> no, that's not true. >> what should happen here is exactly what senator colburn has been talking about which is that if this money is appropriate, if

this is needed it should be a priority event. you should get it as part of your discretionary cap. $8 billion goes on this exercise of prevention and it comes out of some other account so that we're not adding it to the debt. there's no reason not to prioritize and make these hard decisions because if we failed to do that in this area, we'll fail it to do it in another area and we'll fail to do it in another area and we'll end up with $1 trillion or $2 trillion of unfunded expenditures which go right to the debt. >> very good. let me turn to senator enzi, and i appreciate the comments. >> i think the question is really do we consider prevention and wellness important enough? important enough, that we fund it without having to compete against the demands of chronic disease and illness and all of the other things that we put money into. if you don't think so, then you support getting rid of all of

this, but if you think it is that important to begin to change the structure of the medicine we do, then i would suggest that we should not support the enzi amendment. >> mr. chairman, i'd say that's a fulls choice. look, the pentagon has at least $50 billion worth of waste a year in it and to say we won't go make choices about getting rid of the waste in the pentagon. we won't do it to pay this. instead, we'll charge it to our kids because we don't have the guts to stand up and make the priority selections that we need to make. i believe in a strong defense, but i also know what the waste is in the pentagon, and the fact that we won't go after all this waste. you know, we'll have a census that's going to cost two and a half times what the last census costs and we won't go after that. we have $80 billion, they say $72, but i'm talking fraud and medicare alone. we won't go after that $72 billion? it's well in excess of that as

far as gao is concerned. we won't go after that to pay for this? no. we'll just let the $72 billion go keep going on right out the door and charge $80 billion to our brand kids. we won't make the hard choices every family in america is making today. this is something about prevention, but you're talking about infrastructure here. you're not talking about the real interaction between physicians and patients and television advertisers and say if you eat this you're going to turn into a rogue lizard. we don't -- we don't know what we're getting in terms of value of our prevention programs. what we do know is if you give me 16 billion i can educate everybody in america tomorrow about what to do and not to do, but we don't have that. we don't have a metric so we'll take another $8 billion and put it in infrastructure for prevention and a way to get there which some people will use, but if you don't incentivize them, they won't utilize the $8 billion they'll

spend on infrastructure every year, they're never going to do it. >> mr. chairman? >> senator casey. >> one comment on the discussion. it's important we understand what this prevention policy will result in, but in terms of the cost question which is critically important to the american people, i think what we'relying out of the discussion, i know my colleagues will disagree with this, but if you want to talk about cost over time, let's focus on another cost. giving people tax cuts. we've had a long discussion about that, but i don't know what we got for that. eight years of giving very wealthy people tax cuts and when this administration came in the door the economy was in the ditch, okay? so if we're going so if we're going to talk about $8 billion and $8 billion every year over ten years, that's

important to discuss that. but i'm still waiting to hear what we got for giving wealthy people tax cuts year after year after year hundreds and hundreds and hundreds of billions of dollars piled on top of each other. so i think it needs to be put in per inspective in terms of what we got for it. and i'm still waiting to hear that discussion. >> senator sanders? >> i echo what nor casey said. many people voted to repeal or make more exemptions in the estate tax. and that's roughly $1 trillion that goes to the top .3. it makes the very, very wealthiest people even richer. 99.7% of the people don't get a nickel. i think within that context, putting $8 billion into prevention which will shift the paradigm in america in my view, keep people healthy long term cut health care costs is an excellent investment.