the tax cuts? >> trying to manage things here. >> ready to go. >> thank you, mr. chairman. i appreciate all of the discussion that there's been on this. and i think it has been helpful. i guess once again shows that we probably agree on 80%f@@@@@@@), to do something about the chronically ill, the pre-existing conditions. we need to make things portable.

that's all secure steps, the community health centers is right there between the sick care and the health care because they can give advice that will be valuable to people and they do. but what we're talking about here goes into completely different area. and $80 billion, $50 billion, $130 billion, however you want to calculate the thing, and there are a bunch of ways of calculating it, is a lot of money. now it's only .200% of this or 5% of that or 3% of this it's still a lot of money. just a few years ago we passed some legislation to correct pensions. the ppgc was going to be $24 billion short. back then, that was an extreme amount of money. that was a crisis for our country. that was something we had to take care of right away. and we did. now we're talking about $80 billion as though it's the blink of an eye.

$80 billion is still a lot of money. and there isn't the specificity in here that american people are now expecting. they've seen us do a whole bunch of deals in a hurry where we said, yeah, take this little slush fund, $187 billion and do it to fix something. but just spend it fast and get it done. don't tell us what it is. they're not saying that anymore. they're saying there has to be specificity on everything that we do. and we don't have that kind of specificity on this and the little bit of specificity that we have, i think the people would disagree with what the use of it is to be. it doesn't get right to the problem of handling prevention or as i say, i prefer to say changing behaviors. if we don't change behaviors, it doesn't matter how many jungle gymors sidewalks or street lights or grocery stores we put out there. it's the behaviors that have to

change. so i -- i hope that people will support my amendment. i don't think that it ends anything that we can do. i think that it will be sure that we can fund the bill and do the things that we need to do. there are a lot of other discussion that's came up there that we could do. and one of the things that people said as we're borrowing from our grandkids, no, we're not. we're borrowing from our seniors. we're borrowing from our seniors. before the money that was coming in from kids that were paying into this -- in fact, everybody up here under 65 or 62 who are paying into the social security system was going out to seniors and a little bit extra from that was going into a trust fund. we have now tapped the trust fund. the money coming in to pay seniors for social security is not great enough to pay it. so we're tapping into the trust

fund. and that will reduce the life of the trust fund. so we're actually talking about having seniors pay part of the bill now. before long, we even have to pay part of it. and i do have to comment on the taxing the rich. just because there's some landmarks, we have a big hero in governors. that's the governor of maine who happens to be a democrat, paul dachi. and he just said that they're going to have a flat tax up there which reduces the amount that the rich are having to pay and increases the amount that poor are having to pay on their income tax. and when he was asked why, he said, you know, it's the rich that create jobs. it's not the poor. wild statement these days. but it shows the way that there's change happening here and the way that, you know, that we're going to have to be careful with the money. and i think we need to have a little bit more specificity and that it needs to go to incentives that actually deal with changing behaviors.

>> thank you, senator. senator hashg inz. >> one quick thing. this is not a slush fund. i understand the definition of a slush fund you is give money to a sector someone who runs the department and they can do whatever they want to with no transparency or accountability. every single dime in here has to come through the appropriations committee every year. every year. the appropriations committee has jurisdiction and authority to do -- to tell the secretary yes or no or to move the money where the appropriations committee and the congress. and this wants to move it. so it's not a slush fund. >> i thank my colleagues. it's been a good discussion this morning. and grateful to all of you. so we'll ask for role call vote on the amendment. please call the role. no. >> senator harkin? >> no. >> senator mccull ski? >> no. >> senator binghamman? >> no by proxy.

>> nor reid. >> no by proxy. >> senator sanders? senator brown? senator casey? senator haguin'? senator berkeley? >> no by proxy. >> senatorwhitehouse. >> senator gray? senator alexander? >> aye by proxy. >> senator isaacson? >> senator mccain? >> aye by proxy. >> senator coburn in. >> aye by proxy. >> senator roberts? chairman kennedy? >> no by proxy. >> the vote is 10 ayes, 13 neys. >> the amendment is defeated. and you were very persuasive. i'm shoe there will be more work done on this before we're through. senator alex and her an amendment. i know senator sanders has an amendment and senator harkin has amendment number two which goes

to the investment of funds. since we're on that subject matter as his -- here's what i'm going to do. it's noon. the idea would be -- we'll go into the half hour. we won't have any -- i won't ask for -- unless we can wrap the things up in 20 minutes. senator coburn has three amendments. others as well. i point out again that thanks to the work of senator harkin and senator enzi's staff and others involved in this. there were 50 amendment that's were agreed to out of 170. they did hard work. so even though we didn't debate all the amendments, that's a tremendous effort. i appreciate the things. i would -- tom, you are ready to go, tom harkin? are you ready to offer your amendment number two? why won't do you that? and then we'll go to senator alexander then senator sanders and senator enzi. go ahead, tom. >> mr. chairman, i just offer

harkin number two. that's what it is called in the books, prevention and public investment fund. we talked around that with the foregoing enzi amendment. but this is the specifics of the trust fund itself. it establishes an expanded and sustained national investment and prevention and public health programs. again, it dedicated stable funding stream of $10 billion a year from 2010 to 2019. now if you'll notice in there, because of the lack of workforce and so we don't put the money in there right away, we ramp it up so the fiscal year 2010 it will be $2 billion, then for each year we go up by two to four to six to eight to ten and then continue with $10 billion for the -- from then on. so we ramp it up over a period of one, two, three, four, five -- five years up that $10 billion level.

and, again, i don't know that i need to say a heck of a lot more about. this we already talked a lot about it. the reason that we have this amendment, it's also in the underlying title, the reason for my amendment is to answer some of the concerns that senator greg had in terms of being subject to the budget committee. and though we don't have this point of order raised. and so we had to change that. now this is still a mandatory money issue. you may have heard that exchange between us earlier. it is still mandatory. it's a dedicated stream of funding. the trust fund is set up so that the secretary of health and human services in conjunction with other secretaries and other departments can then begin to allocate or put this money out for different proven prevention programs, wellness programs that i would respond again to senator coburn has been an evaluation.

these evaluations must occur so that we're not just throwing money out there. we want proof programs that actually have a cost benefit ratio so that we're actually getting a benefit from what we're putting in -- into this. it also has to do with public health. we talk a lot about prevention. a lot of it has to do with just simple public health, too. from detecting and responding to natural disasters to disease outbreaks like h1n1 to providing immunization ands protecting our food and water supplies is all encompassed in that. our public health system has been and continues to be severely underfunded. right now as we know of the $2.2 trillion we spend about 4% is spent on prevention and public health. but 4%. as i said earlier, hopefully with this fund we'll get it up

to maybe about 10% maybe which i still think is probably underfunded. but that's the best we can do. chronic diseases cost us an additional $1 trillion each year in lost productivity. that we don't even talk about. so, again, that's what this trust fund is for. at present, most public health funding is unpredictable. it's generally provided to discretionary appropriations. for example, after adjusting for inflation, the center for disease control and prevention funding for emergency preparedness decreased $342 from fy-2005 to fy-2008 and chronic disease funding at cdc decreased by $176 million during the same time frame. that's because of discretionary funding. as i said earlier, it's the

other side of it. it gets the money. and we don't put it into prevention. and we willness. en that, is again, why we have to have, i believe, a dedicated trust fund that puts the money into this and as i said it's not a slush fund. the money hass to come to congress every year. the appropriations committee, the entire senate, the entire house has the ability to look at it and to vote on it every year. so that, i don't know that i need to go into it any more. i'm glad to respond to any questions on it. but that's the reason -- the basic reason why i'm marking the amendment is because of the objection rate by senator greg earlier in bypassing the budget committee and this rectifies that. it does not respond to what he said earlier. i said if we want to get into a debate on whether it's mandatory or discretionary, that's another debate.

this is mandatory. this is mandatory funding. >> so as i understand this amendment is to correct the issue raised by senator greg in terms of the budget issues that we're -- >> yes. >> -- that we will perform. i will lead my colleagues in a discussion about it. i appreciate my colleagues offering an amendment to straighten out that issue. >> he is the authority on it. i had to leave for a moment, senator. but i think some of the things that you had mentioned about it is that what we've done is eliminate budget points of order against it. and we have established a new source of direct federal funding, $10 billion by 2014 and the reason it's only $80 billion is that it starts at two then four then six then eight. and then $10 billion and continuing. and this would create a situation where public health service act programs are funded twice in the same year, once at the normal appropriations

process and again through directed spending which is always additional spending and establishes a precedent in which supplemental direct funding sources can be created in order to bypass regular budgeting decisions. what other federal activities and programs would demand a separate corrected funding source in order to fulfill their full authorizations? i work to try to merge programs, eliminate programs and we don't have any success with doing that around here. once a program started, it goes on forever. and this will be $10 billion worth of spending that people will want to dip into each and every year and, well, obviously, have the right to do that. the annual and budget was established in order to allow the congress to adjust yearly funding levels to meet changing challenges and the hope with that was that we would be able to cut back on spending, not just in crease spending every year. and the real problem with funding shortages for programs

authorized for too long is that congress has been irresponsibly passing additional authorization bills. authorization, just authorization. without considering the budget airy implications for the existing programs authorized. but looking back, removing effective programs or find ways to trim line the execution of existing programs just doesn't v so i don't see how this can be fiscally responsible.

and i don't think we have a cbo score on this new direct spending. but it seems to me like we ought to be lowering the cost of health care, not raising it. and while we talk about prevention doing that, we're all in agreement that prevention will do it. what we're down to is not having any specifics on how this money will be spent which is the reason i call it a slush fund. and in this time of raising deficits and trillions of dollars in debt, i don't think we ought to be increasing the spending here without specificity. and there's nothing in this amendment that will insure that the program is funded through the trust fund will be held accountable. as senator coburn said. i could debate it some more but we spent about three hours debating it. so there is probably not much place. >> senator brown? >> thank you, mr. chairman. thank you senator harkin for this amendment, especially for your work on the section of the

bill. i watched in the late 1990s from the health subcommittee and participated in the doubling of the funding for nih something that i know senator harkin and all of us were very involved in, all of us supported. i also watched during that same period no real change in the cdc budget. nih has some -- way more interest from people that dress well and come to washington and lobby and have way more interest from regular people that had parkinson's in their family or have multiple sclerosis in their family, organized groups that advocate on behalf of the sick and we all supported that. cdc doesn't have the same kind of organization lobbying for them. they're far and away in georgia or somewhere. and they're not even nearby. they're seen as an organization, a government agency that helps the poor but nobody else for reasons i don't understand

because it's all about public health. the point is that we have been generous as we should have for nih. we have been way less than generous in funding public health in this country. we know that from visiting our own public health departments. we know that from visiting with cdc campus and seeing the fiscal facilities, the contrast of senator mccull ski and her state. as a result, public health is -- we don't have the public health system we should have. just the other day and my thursday morning coffee i have for anybody that comes -- that's from ohio that's in washington, they -- a woman came up to me and she was saying you got to do something for school nurses. i am in my school district, i'm one of two school nurses serving -- i believe she said 1 different school buildings, grade school, junior high and high school. so i know this amendment isn't per se or this section isn't per se about school nurses, but i do know that we simply haven't done

the job we should have. 25 states only have obesity funding, 25 states have funding for coordinated school health programs. cdc can't do all this alone. and in summary, right, we spend $2.2 trillion nationally in this country for -- on health care. we spend approximately 4% of that in prevention and public health. this, if anything, is not enough, senator harkins, effort notwithstanding, we should did at least this. that's why i support the amendment. >> let me just say, let me just people know, we're going to -- we have a good debate on this generally already. we'll go to the senator in a minute and then number nine as well. this is -- there's two or three defining moments in this debate. this is one of them. the agenda will come with coverage issues. there are play or pay issues. we have big issues. i don't minimize the other qualities we have and workplace. they're very, very important. but i think, again, coming to

the point where we've all made the conclusion, properly so, that prevention is going to be critical. if we don't get this part right, make the necessary investments, then bending that curve is going to be nothing more than a lot of talk in, my view. we've all been around. i have certainly been around long enough to know that watch matters take a top priority and then something else happens six months later, a year later. other things move on. it's not to indict the institution, just the nature of it. they respond in a different manner. we did health care. that is done. we did that. and we have the authorization battles. we know what those can be like in terms of ever meeting the goals. this is a critical moment, a critical point as to whether or not we're actually going to do what we claim to do. what i like in a sense about what tom has done, this is mandatory spending, no question about it. but obviously we're dealing with something that consumes 18% of our gross domestic product right now. and we're being told if we don't come up with a reduction in the cost of health care that, number could easily jum top 35% of

gross domestic product. that literally half of the gross income of working families will be spent on health care premiums. that's the challenge. and the prevention is a critical component of bending that curve. and so it is not enough that we merely talk about it, we really have to get tough about it if we're going to achieve the goals. and what i like what tom has done in a way is the temptation to honor and micromanage the situation saying you must do the following in a sense. and there is such diversity in our country. and obviously alaska is a different state from connecticut. you have county i think probably areas of tundra that are -- so we all represent different constituencies and different needs. and how communities will react to this and respond to the challenge of prevention is going to be a tremendous challenge. and the last thing i'd want to support is a bill here that says specifically what you got to do in some remote village in alaska or some urban center in

connecticut that the difference is they're significant and mammoth and there ought to be the opportunity to respond to those. but if we don't do this, if we walk away from this section of the bill and don't really do what needs to be done on prevention, in my view, then i think we're going to miss the opportunity. it will be hard pressed in my view to make the case to our respective constituencies that we have invested in the decisions that will get us to the point of we're not watching our economy let alone the moral issues of that 14,000 a day who will lose health care in this country every single day. and make a difference on the four chronic illnesses that are preventable. this is a big vote. none of us like the idea. i certainly don't about mandatory spending. it is troublesome to me, troublesome to all of us. but there are critical moments in my view where something is so significant and goes to the heart of what we're trying to achieve in a more macro sense than just some other bill. this is at the heart of whether

or not we're going to be able to survive kmefkly and provide something basic as health care in our nation. and the major, major, major ingredient in that will be our ability to really put our shoulder behind prevention. this is the vote on shoulder behind prevention in my view. the last debate on this issue. i have great respect for the issues. and what tom coburn said is correct and tom harkin answered. you have to have transparency and metrics. if we're going to succeed in the years to come, we have to demonstrate that what is occurring out there is actually working. if we don't do that, then obviously people undo all of it. so i want to express my support for his concepts and ideas that we've got to have in place. you can't just write the checks and not demand accountability for these dollars. but if we don't have this moment here, i worry about whether or not we can really achieve the goal. so i thank my colleague from iowa. i want to be heard on this amendment if, not, we'll go to senator mcculski.

why don't we vote on this one? i think we debated this already. the outcome i think is -- yeah. we'll have a recorded vote on harkin number two. >> senator dodd? >> aye. >> senator harkin? senator mccull ski. >> aye. >> senator binghamman? >> aye by proxy. >> senator murray. >> aye by proxy. >> senator reid? >> eye by proxy. >> senator sappeders? senator brown? senator casey? >> aye by proxy. >> senator haguen? >> aye by proxy. >> senator murphy? >> senator whitehouse. >> senator enzi? >> no. >> senator gray? >> aye by proxy. >> senator bier? >> senator anderson? >> aye by proxy. >> senator mccain? >> aye by proxy. >> senator hatch?

>> aye by proxy. >> senator coburn? >> aye by proxy. >> senator kennedy? >> aye by proxy. >> the vote is 13 ayes, 10 neys. >> the amendment is agreed to. >> thank you, mr. chairman. and, you know, you kint of sit back and listen to the colleagues on both sides and i think you said it senator enzi. we're all in agreement on it about 80% of what we're talking about is always in the details. but the goal is certainly there when we talk about prevention. we all recognize this will be integral to whatever plan we put forward. and the hope truly is that we'll see a reduction in costs. i appreciated your comments, senator dodd, about the differences that we see throughout the country and that in one part of the country

thicks athic things are going to be a little bit different. this is where i have real heart burn when you talk about a public plan which is kind of a one size fits all approach to health care. and what works for you in connecticut or you in iowa or you in maryland really may not work well for a state like alaska that is exceptionally rural, remote, and suffering from a lack of access to providers. the amendment that i want to bring up for discussion today is that one you probably will react to it in surprise because the amendment will clearly add cost to this grant program, to this right to choice program. what i'm proposing that s. that we strike the language requiring eligibility to be based on being uninsured and provide that if you've got government insurance but you lack access to a family general or internal medicine

provider, you're eligible for services provided under the right choices program. now this is clearly going to expand any expenses. it's going to allow more individuals to be eligible for the services. but the reason that i bring this up and the reason i ask for consideration at least a discussion on this is what we have in front of us is a bill that doesn't really provide access to care just because you have a government insurance plan. and i mentioned before to my colleagues that we can come up with the best plan in the world. question have great on paper. but if we haven't given access through providers, if we really don't have those that are providing the care, we have

given the american consumers nothing in terms of real benefits. so what we're seeing -- and i'll use this by way of example. i was up in the states this weekend and met with a group of providers. i talked to them about what's happening with access to care in anchorage. i think i mentioned you to, anchorage is our largest city n anchorage, there are only 13 out of 75 providers are accepting medicare right now. so if you're on medicare and are an eligible individual, there are a lot of folks out there that have no one to see them. the orthopedic surgeon, same one that actually worked on my knee, gave a couple different stories. he takes medicare. he is seeing an elderly woman who came to him from one of his

patients, the mother of one of his patients. this woman has nobody to see her. and so as a specialist, she doesn't have any issues that an orthopedic surgeon would need to deal with. but he is saying somebody's got to take care of this woman. and so i will take her on. but when we want to talk about things that are driving up our health care costs, when you got specialists providing primary care to people because they don't have access to a provider, what are we giving them? what are we really providing to them? and so i -- i -- i know that i've been harping on this point for a while. but it is a point that needs to be made because it's not just in states like alaska where we're experiencing this. we're seeing this in rural parts of america where you simply don't have sufficient numbers