providers. so if we've got this right choices program designed to help those have these one-time health risk appraisals and provide for a level of screening. but i think we would all agree is beneficial. that's good. that's great. but what about these individuals that are medicare eligible, that '

are willing. and, so, i don't want us to be in a situation where we pass legislation that, again, you mentioned it yourself. we say well, okay, we did health care. we did health care back in 2009. we don't need to take that up for another 10, 12 years. and, again, we have made a promise to individuals. we've given you a card. but we haven't put anything behind that card. so, again, i throw it out for discussion. and i offer it as a challenge as

to how we provide for a level of care that is equal in rural parts of america as it is in our centers where we have some of our finest medical research facilities and hospitals. >> let me thank our colleague from alaska. others may want to make a brief comment on this as well. i think you raised an excellent point. obviously, we're going to try and do in this bill of increase the number of nurse practitioners and primary care physicians and do a lot more to encourage people to move into -- i think there is a natural encouragement for the health care profession but the cost of doing so can be prohibitive. so that will take time. but you're correct. and this is -- there are a number of people out there that are in just the same shape virtually uninsured because of the lack of access to providers. and so they become de facto the uninsured. if you can't get access to health care, we don't have

enough community health centers that senator sanders talked about, the 1,200 or 1,300 that we have around the nation that, is out of the question or maybe point out afrpg wrath where building a handful of 75 practicing physicians accept medicare. senator harkin championed this section of the bill for us. but to look at ways in which we may be able to accommodate a situation where someone is -- why they're a medicare or medicaid recipient if, you can't get health care, it seems to me at that point the status doesn't do you much good at all and how we might accommodate that kind of a concern, where that problem arises. i presume most of the rural areas, it may be others as well. i thank you immensely for that. >> i'd like to make a comment. in many of our villages, the health care to the individuals in those villages is provided through ihs. so we have, again, you've got another government plan. and as long as we have

appropriately funded ihs which historically we have failed to do, but there is a level of service that is provided there. so it's not necessarily in the most remote of communities as much as just in parts of the state where we simply cannot attract a sufficient number of providers. we can't attract the primary care providers. and, again, many of these are -- the largest city has the worst problem which is more than just a little bit ironic. >> will the agenda will lady yield for a question? >> yes. >> the reason that you don't -- they're not accepting medicare, what is the reason? is it the reimbursement issue? or is it that they just have such a heavy patient load they can honestly not be able to

do -- take one more patient? is it volume or reimbursement? >> it is not necessarily the volume but reimbursement is absolutely critical. the health care cost is delivery of health care as is -- as is many things in the state of alaska, is higher than the norm. we recognize that. but provider who is looking to cover his or her overhead, basically takes a look and says okay, how much of my patient load can i take on that are medicare eligible? and have this exceptionally low reimbursement rate? when i had this meeting on friday, i went around the room to each and every one of them. i said, okay, we're talking about a government plan. and under that plan, as it is sketched out right now, you would be -- would you be reimbursed medicare plus 10%.

what would that do to your practice? and to a number, every single person at that table said i would not be able to participate. i would not be able to participate if i'm getting medicare plus ten. so for me, not only do i worry about what that means to the individuals that are currently being covered, but if we were to enact it, how many providers then step out of taking medicare eligible individuals? and there may somebody eyebrows raised saying well, gosh, they are just trying to gouge the public here. how much money do they really need to make? but -- and i would be happy. i'm gathering information from the providers, you know, obviously we're not going to turn over the full books. but in terms of what it is that they can take on, the amount

they have to make. i had one doctor and he's -- his focus is on diabetes. i'm trying to remember. it was like for -- i got it right here. for every seven medicare patients that he brings on, if he has one who is a private care, he can balance that out. it's a 1 to 7 ratio. so when you think about what you have to do within your practice, the number of individuals that you need to see on a daily basis to basically cover your costs, i think it was described to me

that if he moved patients through one every 12 minutes, he could make his overhead. now these aren't guys that are practicing in sky high fancy locations where they're paying enormous rents and house lots of staff. these are -- these are small practices with not too many people. and basically trying to offer employment opportunities and to do what it is that they love. and as the doctor said to me, i didn't get into medicine to be kind of like a baskin robins take a number and every ten minutes i'm going to be rotating out so that i can make sure that i've made enough money today to pay for you. i want to be able to provide a level of care. and the patient who goes in there wants to know that they're being attended to. so i'd be happy to get some more of the specifics. i think they're helpful to the

conversation. >> senator, i -- this raised a lot of, i think -- in the con instru construct of the amendment and you raised a lot of important issues that go beyond the scope of my prevention type, one, of course, is the lack of primary care practitioners, family practitioners. hopefully we're going to address that in both this bill and the financial community bill that somehow we have got to increase the pipeline more general practitioners and fewer specialists. i had a heart doctor friend of mine, he's now retired and said to me one time, look, you want more family practitioners out there, which he said i agree you need, he said pay them as much as you pay me. you know? he was very honest about it.

so we need to have some way of getting young people, as you say, want to go into medicine not to take a number but to actually be able to treat people and treat patients and make them well and keep them well. that takes time. and involvement with patients. and understanding, you can't do that in ten minutes. so we have to somehow -- i thought, you know, what we need to do is if you want to be a general practitioner, family practice, we ought to pay for you to go to medical school. just pay for it. pay for it. we'll pick it up. i went through the rotc program. they paid my whole way through college. i went to the military for five years. i thought that was a pretty good deal. and so maybe we ought to think about that. the national health service corps. maybe we need to expand that and provide -- let people know that if they want to go to medical school and be a general practitioner, by gosh, you're not going to have the same debts to pay off as someone who wants to be a specialist.

they're going to get theirs paid for. they won't have that debt hanging over their head. secondly, we've got to figure out some way to get more practitioners to rural areas. i come from a town of 150 people. i still live in the house in which i was born. not tom people co many people a that. i know what lack of medical care means in rural areas. the problem is, i'm sure it's true in alaska, but in iowa, you spend a lot of time. you get general practitioners, they go to a rural area, they're just out of medical school, they're just getting married and starting their own families and they're working 15 hours a day, seven days a week. they never have a vacation because there's no one else to fill in for them. and they're there three or four years and they're burned out. they're just burned out. plus they don't get the right

kind of reimbursements. so the whole thing -- i've seen so many general practitioners come to rural areas. they're there two or three years. and they're moving on because they get burned out. so that's another thing we have to think about is how do we provide more incentives and support for general practitioners in rural areas? so you know, sign me up. i mean i'm glad to work with you on this. on the right choices program, the only reason we designed it that way is hopefully the finance committee is going to be addressing some of these things through medicare and through medicaid in terms of screenings and i mentioned that earlier. providing for these kind of screenings. i just want to address that population out there that both don't have insurance, don't have medicare, don't qualify for medicaid.

the roiight choice and program recinds that. and now everybody has a plan and exchange, then they don't need. this i just want to try to get early on these people over the next five years so that they would have these kind of screenings and things early on so that when we get the exchange and they now have a health program that they're involved in, then this right choice dies. >> can i just add on that, though, we have a high number of incidence of breast cancer. we've been sending mobile mammography out to the villages trying to encourage women to get screenings. and one of the concerns that we have heard, the hesitation is i don't want to do the screening

because if then i find out that i do have breast cancer, i have no way then to take care of it. so if, in fact, we do move forward with the right choices idea, we provide this one time you get this wonderful screening, but if we haven't given them anything more beyond that, you know, i don't want to know if i can't deal with it after the fact. so that's the reality we're going to have to look. to. >> good point. just on that point alone, i was speaking to a ceo of a major u.s. corporation that provides extensive health care plans to their employees, thousands of them. and he told me the other day that one of the benefits they provide is a -- i think it is a physical exam. i think less than 6% of the employees actually take advantage of the yearly physical. for exactly the reason you just identified. in that case there, they have a good health care plan.

so just the people get fright ened about learning what their health care condition is. in your case obviously, people don't know how to pay for it. beyond that, there's -- that's the lifestyle kind of changes that i would have thought that was an easy one. you have free health care exam knowing what we can find out today what a difference early detection can make in so many areas, and, yet, this difficulty that many people have that if i don't -- if i don't know it exists, it isn't there, mentality is that a major problem in terms of getting people to do things differently. and anyway, i appreciate this conversation. it's been very helpful. i appreciate as well, your idea of senator harkin working on some ideas here. before this journey is overwith, if you think about ways to accommodate that particular need. i'm told senator that our staff are the experts in this. they know everything. that for individuals on this right choices to -- if they

found to have a disease, the program will help connect them with providers for treatment and that this fund that we have will help pay for that treatment, currently the uninsured have no interest in doing this. they make sure people with get treatment instead of waiting and going to the emergency room and costing more money. there is that provision in there. >> i thank my colleagues. you've been very helpful. senator enzi, we cleared out some matters. we had a long debate this morning. it is a very important bill and one that we'll be discussing and working on over the coming weeks as this process moves forward. we'll come back at 2:15 and continue this afternoon. senator sanders has an amendment he would like to offer and i'll make that the -- my first amendment after we get back very good. 2:30, not 2:15.

we stand in recess. wñww

>> this makes modest changes on page 367 dealing with school-based health. all that it does is underschool-based health

clinics, what we talk about is comprehensive health assessments, diagnosis and treatment of minor, acute and chronic medical conditions and referrals to and follow-up for specialty care and what this amendment adds is and, a-n-d, oral health services. so essentially all that it does, when we're talking about school-based health care, let's remember, i know that in my state, i expect that in many of your states, a lot of kids are having a very serious problem getting the dental care that they need. when we talk about health care, dental care should be considered an important part of that. the reasons are pretty obvious. if you as an adult, you grow up without teeth, you can't digest the food that you eat and that causes problems. if you have an infection in your mouth, obviously that can lead to serious health problems. if you're lacking teeth, if you're in pain, as a kid, you're going to have a hard time doing your school work, and in fact, teeth decay, people don't know

this, tooth decay is the most common chronic childhood illness, it's prevalent five times more than asthma and seven times more than hayfever. i think this is a very modest common sense amendment that i hope my colleagues would support. >> any further consideration debate on this? thank you very much, senator sanders, for your keen eye. it was an oversight. i appreciate that. tom? >> just a query of senator harkin. if our goal is to get everybody in health care with either government option or everybody insured and access, should we put a sunset on this, school-based health clinics if in fact we're going to create access through the rest -- should there not be a sunset that says in this that at some point in time, whether we do oral care or not, is there a timing point when everybody has insurance, everybody has a medical home, that we still want to continue to fund school-based clinics?

>> let me -- go ahead. >> senator coburn, i don't know what your experience has been in oklahoma, but my experience in vermont has been that school-based health care is enormously cost-effective and it works really well. we have had not a huge number, but we have now two or three schools that do in-school dental care, phenomenally successful. you want to talk about success programs, these really have worked. so i'm a big advocate. this issue was raised before, that we have kids in schools where they don't even have nurses. so kids have illnesses that nobody is picking up on and ten years from now, we spend a lot of money dealing with those illnesses. so i think investing in school-based health care, making sure that we have the health and dental care that those kids need is cost-effective way and it saves money long-term. >> we don't have a sense on this

because -- the only thing we have a sunset on, this is stuff we got to increase and continue to do, was the right choices program. that was -- we discussed that a little before lunch break. that was to get people who were uninsured but not on medicaid, not on medicare, to get them involved in preventive services right away in the interim. we sunsetted that when they all get on an exchange and we sunset that but something like school-based, i don't see any reason -- >> to this extent, it's a five-year program, the school-based clinic, authorized for five years. it would have to be reauthorized at the end of five years. >> that's the answer to my question. >> okay? >> so it is in a sense sunsets. >> we come back and do it again. in that sense. further debate? you want a roll call vote on this, bernie? all those in favor of the -- roll call? all right. clerk will call the roll on the sanders amendment.

>> senator dodd? >> aye. >> senator harkin? aye? >> it was aye. >> senator mi cull ski. >> aye. >> senator murray. >> aye. by proxy. >> senator reed? senator brown? senator casey? >> aye. >> senator haguen. >> senator murkley. senator enzi? >> aye by proxy. >> senator alexander? >> aye. >> senator burr? senator isakson? senator mccain? >> aye by proxy. >> senator coburn? >> no. >> senator roberts? >> aye by proxy. >> chairman kennedy? >> aye by proxy. i want to recommend that all

future amendments be offered by senator sanders. very good, senator. lamar alexander, you're up. >> thanks, mr. chairman. i have an amendment to title three, section 311. the purpose of it is to make sure that the right choices program which is in that title doesn't require the states to spend any money on it, and this is a relatively small item, probably, but i would like to make a larger point in making my proposal, if i could say just a word about it. >> certainly. >> we have talked a lot here about cost and usually the cost is described in terms of cost to the federal government, and the cbo, congressional budget office, score has said that the kennedy bill even without three of its major points would add $1

trillion over ten years. senator gregg has said that once the program is implemented fully by the fifth year, it would be more like $2.3 trillion. but i would like to talk about a different sort of cost that i'm particularly sensitive to because of my experience as governor, struggling with the medicaid program and watching every other governor struggle with the medicaid program. in 1980, shortly after i was elected or maybe it was '81, i came to visit president reagan and i suggested to him that the federal government take over the entire medicaid program and let states take kindergarten through the twelfth grade, all funding, just a grand swap. my reasoning was that i thought the program was inefficiently run because we had the federal government paying for 60% of it and writing the rules and then the states paying for 40% of it, a little less in tennessee's

case, and having to live under the rules. so we had a case of people in washington saying this sounds like a good idea and putting it into law, then all of a sudden when governor dodd or governor alexander, governor mccain or govern enzi in their home states try to implement it and they find out they have to pay extra state money for it and that has to come out of the money for the universities or whatever place. without getting into a long discussion of it, this was the principal contributor over the last 15 years, the increasing costs of medicaid to states, of the lack of state funding for higher education, and it's really put our public research universities in dire conditions, and has caused a big increase in tuition at many of our community colleges and public universities because if the governor and legislature don't have any money left to make their contribution to state higher education because they have spent it on medicaid, then you either cut

classes or increase classes or raise tuition and tuitions have gone up, causing a lot of frustration here in congress when we increase pell grants. so i'm looking with a very critical eye not just at federal deficit increases but that what would the impact of anything we do on states who are particularly struggling this year, we know, for example, i'm going to ask to we know for an example and i'm going to ask for a new york times article june 2, talking about states turning the last resorts and budget crises, state employees being furloughed in hawaii and california. $24 billion in deficit. kentucky taxing whiskey, which seems appropriate and cell phones. but states are really struggling. if i could add this to the record. >> i took a look at the draft of

the kennedy bill. i asked my director to look at the bill and let me know who might be the consequences to the state of tennessee. of course, we're at a preliminary stage and not zefrg drafted but we know one thing, the stimulus package as this given our state and states a breather our state will have about a $600 million gap. then if we were going to go ahead and expand medicaid, the program through which we deliver health care to 150% of the poverty level, that would cost our state another $600 million. then if