and i ask unanimous consent to be added as a co-sponsor of this amendment. >> is this one different than the coburn amendment? >> this is to ensure that duplication does not occur. and i understand that this is different from the amendment that was brought up@@@@@@

just went over a bunch of those duplicative programs and this particular case, what this amendment would do is it would prohibit the secretary from implementing these programs or any programs under this act that are duplicative. it's just that simple. >> here's the concern. it sounds very similar to what tom coburn offered. here's my point. maybe i'm not making this as clear, orrin, as i thought. as i understand it, this is -- there is, if by duplication we mean that if there is some spending already going on on one of the 15 programs you've identified, and the harkin proposal that's in the bill spends additional money on that activity, that there would be prohibited from doing so because some money is already being spent on it.

it's an existing program. and that -- i understand that point. but it seems to me what we're trying to do here is to provide additional resources, additional support for that activity. the fact that there's already some spending on it shouldn't exclude the program for getting additional funding and support. i pointed out and was wrong earlier. i said there was no oral care programs in any state. that's wrong. it's less than half the states do provide support for oral health. less than half do so in obesity programs. about 23 states do stuff for school-based programs. i mean, there's a disparate levels of funding and support for these activities that the harkin proposal has included. if we apply a standard that says if there's any funding presently going on that that program would be exempt and/or excluded from any additional support seems to be, in a sense, overreaching. i say that respectfully. but the whole goal here is to provide additional resources, particularly in the areas where chronic illness are costing us

so much in terms of health care. that's 75% of the health care dollar is consumed by chronic illness. obesity. school-based programs that deal with oral health. oral heelt being one i mentioned as well as in other areas that have been addressed. i think to say if any money is being spent on that you're out because it's duplication is going further than we want to do. i understand those who oppose us providing any direct funding in these areas. i disagree with that conclusion. but i understand that point. >> well, i'll take a voice vote on this. >> all those in favor of the hatch amendment say aye. >> aye. >> those opposed no. >> the nos have it and the amendment is not agreed to. >> i wonder if you would consider an amendment i haven't written that would say if we're going to do this, in this title of the bill, that we're going to eliminate the functions that are duplicative of that outside of it. in other words if we're going to do all this in the bill that we

would consider an amendment that says whatever you are doing over here under this program or under this program, now ceases to exist and will be done under this. would you all have consideration for an amendment that might be written this evening -- >> my only thought on that, tom, is sometimes they may appear to be dupe lick caitiff but there's a nuance. it goes to a different target population than this one. if it was exactly the same, sure. but sometimes there's a little difference. >> let me give you an example. if we're going to do something out here to educate people about x, y, z disease and we have this agency over here that's doing education to x, y, z and this agency is doing the same thing. we already have multiple agencies doing the same thing right now in the $16 billion outside of nih and cdc that we're spending every year doing

exactly the same thing. first of all, we can save a ton on overhead. we can make the dollars be spent much more efficiently. so i was thinking about this evening trying to get my staff together. we'll look at all these areas that you've addressed in here and see if we can't come up with something. i'm just asking would you consider it. if you won't, i won't spend the time on it. >> if those three entities are all targeting the same target group, population -- >> why y don't you work at it. >> or we could do this with the intention that a refinement of the bill out of the intention of the bill is to eliminate those duplications and bring them to one central source so that we do that. there's lots of ways we can do that. my problem is is, even though you get this cross-agency council, the fact is there's turf protection that goes on in administrations. and bureaucracies. and unless we specify what we want to do, we're not going to get there. >> i just want to respond. that's why we try to get this annual thing in here so that we

have the review and the evaluations. mccain amendment. we adopt it. so every year we get to look at this stuff. if this could be worked out, i have no problem with that. >> okay. i've got another obnoxious -- >> could i get clarification here? >> yeah. >> because the word -- as an appropriator, duplications can be a complicated phrase. first of all, senator harkin chairs hhs so he pretty much has a list that's been now working with sernt specter a number of years. so you know what the programs are. i don't know exactly when you were writing your bill duplicated programs because you fund the ones that are already authorized. so i'm puzzled by that. why we think there's duplication. now if we duplicate the work by preventive services or something else like that, it could be very complicated when we talk about the definition of duplication.

when there might be some programs that might do the same -- a couple of the same tasks or functions and yet might be covered under different programs. i just want to give you an example. one program that i've really worked on that i've enjoyed is with senator enzi to prevent elder falls. a substantial number of hospital admissions are due to either dehydration or to a fall. we worked on it. even people minimized their effort. part of that is you go to -- they are community based programs to create safe pathways for seniors either in their home or in the street. now you could also be funding some of those elder fall prevention programs that require physical infrastructure in a community transition grant, or it could also be part of national service with those bright, smart, hard working kids. so i want to be careful we don't

have unintended consequences because you might have this initiative to prevent elder falls might be actually happening both in the elder fall category but could also be happening at national service. see what i mean? >> that's a problem. >> so that's why -- >> the job -- look, this is difficult. i mean, look. we have a rather large federal government that's not highly efficient. >> yeah, i know. look at defense. >> i made the point while you were out of the room. you didn't get to hear my snotty comment. the point being is if we're not going to try to eliminate silos if we're not going to try to eliminate turf, if we're not going to try to eliminate

duplication, i can't think of one area that you can truly justify other than back up in terms of national security where we ought to have two different agencies doing exactly the same thing. >> take a look. i just want us to be careful when we use the term duplication. >> i'll be very careful. i know better. >> i thank the senator very much. senator enzi has an amendment or two and then -- are there other amendments pending on our side over here, on title 3? senator binghaman. let his staff know if -- >> we let him know. >> okay, great. mike? >> senator byrd, do you want to do byrd number 3 right now?

>> mr. chairman, i call up byrd number 3. >> byrd number 3, please. >> and i don't know how many members we have pending. i know there may be -- we took about 50 this morning. whatever number we've dealt with here. my intention is this evening to continue to work on title 3 with the hopes of completing it this evening if we can. so i'll put my colleagues on notice. >> good. >> mr. chairman, you have successfully chased off the cavalry, so, mr. chairman, amendment number 3. the kennedy bill does not explicitly require the school-based health senators to follow state laws requiring notification of the reporting of

child abuse, child molestation, sexual abuse, rape or incest. this amendment clearly states that the school-based health clinics shall follow any such state law and that any provider of services found to be in violation of such state law shall not be eligible to receive additional funding under this section. now some might say why is this even needed? why is it necessary? children are one of the most vulnerable populations in school-based health clinics. will be in a unique position to help protect these young patients from inappropriate contact. it's essential that school-based health clinics entrusted to provide care to our nation's children and adolescents adhere to the state laws that have been put in place to protect them. taxpayer dollars should not support programs that did not comply with state law that protect our nation's children and adolescents. it is as common sense at that. this section emphasizes compliance with federal, state

and local laws concerning patient privacy, student records and provisions of comprehensive primary health services in accordance with state and local laws and regulations established standards and community practice. mr. chairman, it's just as important that school-based health clinics comply with state law requiring notification of reporting child abuse, child molestation, sexual abuse, rape and incest. it's absolutely essential. all states have statutes identifying persons who are required to report child molestation -- child maltreatment under specific circumstances. these laws can differ from state to state. but regardless of what is required, school-based health clinics should comply and those that do not should not receive sbhc funding. >> i'm sorry. i didn't hear that last part.

>> would you like me to read the whole thing over again? i'd be happy to. >> richard, i -- on page -- on page 369, we require them to comply with all local and state law regulations. >> section "d." this could be an add-on. >> so why is this different than what we already have. >> my understanding is that the requirement is from a clinical perspective. >> this provides comprehensive primary health services by health professionals in accordance with the community practice reporting laws and other state laws, including parental consent and notification laws that are not inconsistent with federal law. what are we missing? >> my understanding is those are not child abuse reporting standards. requirements. >> if a state had a child abuse reporting standard, couldn't

that be included? >> no. >> is it included or not included? i don't know the answer to that. seems to me it would be. so this is the modification? is that the one you just gave me here? same thing? why am i looking at two? well, kay, do you know? i'm looking for an answer on this. >> i'm sorry, mr. chairman. i was looking at this amendment i was getting ready to put forward. but as i continued from what i think we're talking about is that if it's required under state law then -- and federal law, that they would have to abide by it. >> reporting laws -- reporting laws and other state laws. >> they definitely have to require that to do that. >> i don't know what -- i'm willing to accept your moment. >> my understanding, my staff's understanding is this applies to clinical only and would not require the reporting of child -- >> they would have to -- >> if your state requires you to

report abuse of incest or rape, how would that not -- the reporting laws require that, what am i missing in this? >> any doctors office would @ rrrr

>> so if we decided that, then go to someone where -- then who would decide whether a person is making the best efforts to comply with the program, say, to deal with their diabetes or high blood pressure. senator dodd gave an example of someone who has a significant genetic propensity to diabetes and yet even though they might have it, they are keeping it under control. they are an aggressive tester. they are consulting on a regular basis with a diabetic educator. so they are doing all improvable, demonstrative steps. but they still have it. who decides, is it secretary of hhs? is it the employer?

is it the person who is -- the self-injured. by the way, i want to promote these employer based initiatives. i think they are outstanding. but you see who decides whether someone is in compliance or making "a" for effort. >> the differential is 20% and the employer sets up the procedures where the person gets prescreening, stops smoking, who pursues healthy lifestyles, gets an economic benefit from the differential. >> we heard one employer talking about -- >> but the decision process won't be any different. it will mean that differential can go up to 30% with the potential of going to 50% if the secretary sets out certain standards that will be met. >> i think the goal here is to reduce the health care premiums for everybody. and so if you can incentivize a

huge number of people that are currently not getting screenings, are not, you know, just doing the nurse coaching that's available. a lot of very simple steps that really over the long run will be much more from a preventative nature. i think that's what we're talking about here. if we go from 20% to 30%, then i think that's more of an incenti incentive. it's not to ever punish anybody who either has diabetes or has other chronic diseases because, one if they get the screenings, if they go and do all the procedures that are required, be sure they check their blood sugar, be sure they do all those things, then hopefully, they, too, would be able to qualify. but the overall amount isn't going to go up for somebody else. i mean, it's not like if it goes to 30%, somebody else is