been discussed urks the idea of increasing reimbursement rates to hospitals and providers and doctors to 110% of medicare rates, that's another $600 million. that doesn't sound like much money, but i compute it this way. in tennessee to come up with $1.2 billion of that $1.8 billion that i just talked about wroub equal to the amount of money raised by a new state income tax. that's a lot of money. and the state doesn't have a printing press so it has to balance its budget. so i've stug zug ed that every senator who votes to increase and expand medicaid ought to go home and serve as governor for eight years and try to pay for

the program and manage it. i'm not talking about the other inadequacies with the medicaid program, i'm just talking about the cost, which brings me to my amendment. the right choices program that's described in title three, section 311 sounds good. uninsured adults, give them access to preventive services until universal insurance coverage is made available through the gateway. i have a different preference for how we deliver services to low income individuals, as expressed by senator coburn's legislation, the widen-bennett legislation, by the gregg legislation and the legislation senator hatch is working on. i would like to see us give cash directly or vouchers directly to low income americans and allow them to buy their own insurance

or let them devise their own program by choice. but we need to make sure it doesn't impose an unfunded mandate from other states. okay, the federal government has paid for these higher reimbursement rates and we'll now, quote, begin to shift these gradually back to the states. the states can't afford this. they'll be bankrupt and our federalism will be destroyed if we take that approach. my amendment is can we -- nothing in this title should require states to use state revenues to fund the right choices programs. only limited to that. the words are written a little differently in the amendment as i've circulated it. i understand from the staff, there could be an improvement in the words, but my point is, i want to make sure that if i am government of tennessee in 2003,

which i don't intend to be, but if we pass it, we should fund it. that's my point of my amendment pop i thank the senator. as i understand it, the amendment is going to be accepted. >> i would just like to say that the language that senator alexander just mentioned, that he just spoke is fully acceptable. >> good job, thank you. >> we'll let you and senator sanders offer all the amendments, get that kind of cooperation. thank you. >> we have three amendment, but i don't want to -- however you want to work things out, john. >> chairman, i had an amendment that i believe is going to be agreed to by both sides. i hope it will be distributed. it's mccain number two. >> it's mccain number two,

titled to determine whether existing federal government sfon sponsored health and wellness initiatives are effective in achieving their stated goals. >> thank you, john for it. i think it's a worthwhile helpful amendment. >> could i just briefly, mr. chairman, i know we've got a lot of work to do. as i mentioned, the title of the amendment, secretaries should report to congress, evaluating programs as they relate to changes in health status of the american public and specifically on the health status of the federal work force which is only 1.8 misdemeanor employees including absenteeism employees, productivity of employees, the medical cost incurred by employees and health conditions, including workplace fitness, healthy food and beverage incentives. also include conclusions on why such existing programs have

proven successful or not and what contribufactors contributeh conclusions. we spend billions on government programs. we don't know how well they're working. this is just to get an assessment of all the programs concerns wellness and fitness or prevention programs. >> i thanks the senator, it's a good amendment, john. and all those in -- ask unanimous cob sent the mccain amendment be accepted? without objection, so accepted. thank you.

>> i guess the first one we'll look at -- >> which one are you looking at? >> coburn 21. >> coburn amendment number 1. >> mr. chairman, i will try to make my remarks have application to all three so we don't have to go through all three points for time purposes. we're contemplating a significant change in health care in this country.

>> when yet we're having a hard time getting by cbo something we think we can swallow. but what we've already done, we can't swal lee either. and for this section of the bill where we're going to spen money on infrastructure, i think of everything senator harkin has done, this is the at least important thing he's done in terms of prevention. there are several thing is agree mightily in what he's done well. i think we ought to have a hammer that says if we're still in trouble on medicare and social security that maybe we ought to not have to spend that

money on years we're in trouble on. i know we're in trouble until we decide we're going to fix it. and that, of course is the obvious point of my amendment. we're adding spending at time when we won't go and fix the things that are causing us to have a significant imbalance. by 2050, just 2050, over 65% of the federal government is going to be for those two programs. and another 25% is going to be interest. and that's assuming the bush tax cuts go away. that's assuming everything on a forward looking. so the fact that we wouldn't put -- again, it comes back to me. i know i see things differently than many of my colleagues. that doesn't mean i'm right and that doesn't mean you're wrong. but for us to have put $80 billion out there, over the next

ten years, when the unfunded was $16 trillion last year. that's not 509-year or the 75-year we commonly refer to, which is $39 trillion. when that is happening and we say we'll spend this and not address this, i think we ought to consider that. i think the other two amendments, one is related any year the medicare triggers is invoked. we ought not spend that money, the $8 billion. i think it was originally $10 billion. it goes back to the argument, and i actually see it different than many of you, i actually see a good portion of the problems that we're having in health care today related to the medicare program.

whether it's the disruption and mall distribution, based on reimbursement rates that then get copied by the rest of health care, there it fw real rationing or the defacto rationing of care. the other thing we haven't talked about are the things that don't get paid for but should because most insurance companies won't pay for it if medicare hadn't. some go ahead, on things that are leading edge and make a difference in people's lives. we're not looking at that. if we're going to fix health care, we ought to address fixing medicare. we ought to say we're digging a big deep hole over here in terms of being able to fund medicare,

but we also are adding to our deficit hole which is going to complicate that. it's a very straightforward amendment that says we don't spend this $8 billion in years we haven't addressed years on medicare. >> i'll be very, very brief. my concern, obviously medicare and social security have got to be dealt with. we all know that. how we deal with it, there will be some debate about how you do it. the president realizes this is a high priority. the obvious question in my mind is one of the things we're trying to do with this whole section, or the whole bill for that are matter is to deal with people's health issues. obviously people end up on medicare with chronic illnesses and problems drive the costs up. to the extent we're able to induce the number of people who enter the medicaid, medicare age

period whoit chronic illness or manageable illnesses that cost less, obviously we're reducing the pressure on the medicare system. so the question for me obviously that i'm raising is, and i think they are legitimate issues. the author of this section will be the first to tell you why we need the accountability and i appreciate john mccain's amendment. we need to find out whether or not these things are going to work. anyone who tells you with absolute certainty they are, is not being candid. because we don't know. we think -- these make some sense, we want to try them. but obviously if they do work, the pressure on medicare is tremendously positive. so i would respectfully oppose the amounts for the reasons, not because i disagree at all with the goals and the determination to deal with these two questions and you've outlined it well in terms of what we're looking at. the cost to society down the road if we don't. and so -- that's right. >> let me comment, one

additional comment if i might. you know, take $8 billion a year and figure out what we could do with that in terms of -- just the $8 billion for infrastructure, incentivizing people to do the right things. $8 billion, educationing them about risk factors for their life. you know, think about what the potential gain might be, at least study it and say if we spend $8 billion through hrsa is to make sure every american adult knows the risk facemasks tos for diabetes and heart disease, knows the screenings you should have. appropriate screenings, female, male, adolescent, and, in fact,

encourage through public ad, through schools, here's what you need to know. i would tell you, we would get a ton of benefit out of that that we could actually measure. but what we're doing is we're directing money for infrastructure that we haven't said we're going to put the dollars there to incentivize people to use. you know with pittany bowes. we're living in the moment. my one big vice is eating a star crunch with a glass of mitting at night. the point is if i learned that because my bmi is elevated and i continue to do that, i'm going to have diabetes, and if i have diabetes, here's what that means for me, all these things in

terms of changing my lifestyle.r screened. so the goal is, i'm with you all on wanting to create a prevention environment, and create an expectation that individuals need to be responsible, but the first thing you've got to do is be educated

about it. i'm interested in us using what dr. cooper has down in texas, exercise and what that means. i don't know if you've seen el paso school system. for 12 years they had an exercise program in it. 6 their drug usage is down about 30%, their dropout rate is down about 25% rate. their graduation rate is way up. their grades are way up, their testing is way up and their college attendance is way up. through -- and it can all be directly attributed to a mandatory you will kper stiez if you go -- exercise if you go to these schools. so the neurosciences are starting to figure out if you exercise a child, they learn about 20% to 30% more because you have just flushed their brain with oxygen and the

nutrients that create new neurons and synapses. >> great. >> so we're build building a walking path. if you don't teach someone to do it, it's not a good -- it's a stimulus, but it doesn't accomplish the goal. i'm wanting to put brakes on that money to see if we put the money somewhere else. what i should have been offering is an amendment to eliminate this money and go the other direction. >> i was looking the other day. don't hold me exactly to these numbers but just to pick up the point on el paso. i think the middle schools and elementary schools, i think there's only 6% and 8% of those schools in the country have any required physical education programs. it's just an incredibly low number. a lot of budget issues and so forth. the economic situation has probably had a lot of impact on that.

i don't think they've had what the benefits are. >> the bmi went down 18%. >> i agree. i don't agree with the amendment, but i agree with everything you've said on that. we have a school in iowa, every kid from first grade to 12th grade has to exercise. even kids with disabilities have to exercise. all the way through school. i said many times i would be glad to work on you.

no child left behind? how about no child left behind in toemps their healt their heo. >> we didn't vote on the alexander amendment. all of those in favor of alexander number one? the ayes have it. >> we could say we give another $8 billion for i.d.e.a. and you get a portion of it if you have exercise in your school. you want to make a difference in prevention, there's a way to do it. we underfund i.d.e.a., let's send this $8 billion to them instead of build sidewalks and basketball courts and we'll see a much better impact in terms of future health. >> we're still on 21. >> do you want a roll call vote? >> all those in favor say aye. >> aye. >> opposed say nay.

>> na ya. >> the nays have it. >> medicare trigger, same thing. >> can we do them on block? >> medicare trigger. that's 22. actually, we can't. because 50 is different. 50 is different. i may actually get a vote out of you. >> medicaid triggers. >> we're not going to spend this $8 billion. >> all those in favor of the amendment number 22. all in favor say ay sne. >> aye. >> opposed no. >> no. >> nos appear to have it. i just want to tell, after we finish the coburn third amendment. jeff we go to you and then we go to orrin hatch. go ahead, tom. >> if we're already spending money in that area, why should we spend more? so what this amendment says is anywhere we're actually doing it already, why spend $8 billion on

doing it more? until we know it's making a difference. so if we're already building bike trails through the transportation program and through all these other areas, we shouldn't spend this money on bike trails. we're creating dual and triple streams of money to accomplish the same thing. this amendment says if we're spending the money already through another function of government, through another funding source, that we would not use that -- this money would not be used in that direction. which would mean we would use it in something else. still doesn't drop your amendment, it still doesn't keep us from doing it. but just says once we're doing this with a funding source, why come in with a second funding source to do the same thing where, in fact, there may be a point in time. how many bike trails do we need in the country? nobody's ever asked that question. i know we're still building them, but what is the ultimate

number of bike trails? when do we stop? and when do we stop in oklahoma versus iowa or arizona? when do we have enough? we don't ask those questions. we just send the money out there and let them decide. >> i say to my friend from oklahoma, this amendment is pretty darn broad. it takes everything up into it. as i said this morning, for example n chronic disease prevention. we fund a lot of things now through other areas but we barely scratch the surface. $50 million a year for heart disease and stroke prevention programs. that's nothing. >> but we spend more than $50 million a year through the american heart association doing that same thing which you don't count. in other words you ear counting just what gets spent by the federal government. there's hundreds of millions of dollars on streak prevention. >> there's diabetes, that's

tobacco, even school health, oral health. then there's environmental health programs injury prevention programs that we do fund. what i'm trying to do in this bill is get a new frame work, most of which goes obviously through the center of disease control and i might add. cdc is the center for disease control and prevention. and to get through this and pull this together under one regime. and that's why just to say we're doing it in some other area, a lot of those again are discretionary. they're not funded. that's why i argued for a mandatory program. >> and i take your argument in face value. and, in fact, let's move all the rest of the programs to the cdc so we have one source, one place to do it, one management team we

can hod accountable that gives us metrics and say we spent this money, what did we get. instead of saying here's hrsa, here's this, here's this, and here's cdc. why not put it all in one place? why have competing programs doing exactly the same thing? what is the sense of that? why not put it international one place? >> if you're going to do this, pull everything else out that's doing the same thing and put it in cdc. if prevention is going to be a focus, let's have somebody responsible for it, hold them accountable and see what the money does for us. >> one is your amendment talks about activity whether they're do you me duplicative.

there's nothing in here for the uninsured. >> that's not true. hrsa does a ton of stuff for the uninsured. tons of public programs. those people receive that information. >> there is the opportunity for duplicative issues available. this is broad and sweeping -- >> i intended it to be broad and sweeping. there's no finesse in what i do. you all know that by now. it's out there. >> mr. chairman, i've got to respond because you said you said if this does duplicate. well, it obviously will duplicate a lot of programs. i listened and we're all in agreement with the things we want to fund. first and foremost, it will duplicate most of what cdc does under the prevention piece of their mission.

two, the department of housing and urban development, the cdbg grants. the cdbg grants are programs to provide grants for urban communities grantees may fund activities that meet community development needs related to health and welfare of the community. they're going to be a recipient of part of this $10 billion a year the department of transportation. they're in charge of bike trails and pedestrian trails. department of agriculture, the rule development program is to help rural communities build and improve community facilities such as schools and health clinics. the list goes on. i mean, we know how the vote is going to come out, but let's all admit. this is a duply kage duplicatie currently do and for some reason

we believe by putting $80 billion into it it's going to work. and senator harkin have talked many times. i wish i could go to cdc and remind them that prevention is part of their name. this provides them a tremendous amount of money. this does not force cdc to do anything with prevention except spend a tremendous amount of money. but we can't be assured it has any -- i realize i'm getting close to home here. excuse me, $6.4 billion annually to carry out their mission. well, $6.4 billion. why do we still have prevention problems? is it going to change when we get the budget to $ billion annually? or $10 billion annually or $20 billion annually? we have no matrix design to

figure out when we've been successful. and the truth is that we're doing a good job of duplicating efforts that are already in place that don't work. and the argument that we're making -- i think it's wrong -- is that if we just put more money in it, these programs will work. and i will tell you, in fact, every example we've had of success of prevention and wellness and disease management doesn't have anything to do with washington examples. because we haven't been successful. we have failed at every turn. but private, innovative companies, as a matter of fact, there are some public health entities across the country that receive hrsa money -- >> the point we're making here is not so supplant, but to supplement the various

prevention efforts. so there is to that extent obviously, if you're talking about the fact that you're spending $10 on a prevention program out of the cdc, this increase in funding obviously takes that $10 to $15 or $20, whatever it is. so in a sense you're adding to the program of prevention to make it more effective. hopefully the combination of incentives on the individual. and maybe at some point, tom coburn's suggestion of something in the educational area i think has a lot of value. maybe the missing ingredient between the personal incentive and the structure that will link up the two that we'll see greater usage. but the idea here is to add resources, admittedly preventive programs, you're right, richard, on that point. the question is given the range of things that need to be done in order to provide the opportunities for that to occur, the harkin amendment includes it. >> mr. chairman, let me just point this out