great value. so it's not disease-specific but certainly in the case of alzheimer's, the extent someone can get some he,@@@@@ @ @ work. but pizzi is at home and he wants to keep her there and she wants to be there. getting that kind of help, to have someone to be supportive of someone with als or alzheimer's i think is of great value and i hope at some point we would look at providing support for those goifing support. >> i did not know 60% higher

rate among veterans. >> the als groups that we have been meeting with, there is a study, there's a registry within department of defense, to try to understand what it is that we're seeing. the registry is relatively new. >> if i could say, the incidence of ms, multiple cler oes is, als and a number of issues from gulf war veterans from the early '90s is what senator murkowski is referring to. >> is there any epidemiology cal research anybody has done on it? >> we've been working on it. >> there is research that's going on, but it's limited research. this is -- it's been described as an orphan disease. there's only, like, 30,000 people. only. that's a lot of people that come down with a disease that is absolutely, in my opinion, one of the ugliest ones out there. but the research has been

limited. they have not had but one new drug placed on the market since literally lou gehrig named the disease. >> really? >> i didn't know about -- >> but why it's connected to the gulf war is is still unknown. >> yes. >> mr. chairman, just one comment. >> yeah. >> as you work towards -- if you work towards something like that, using alwae ining alzheim the wrong label. we should use dementia. there's different kinds of dementia. and alzheimer's. >> i'm not sure when i characterized pizzi hollings if i had that right. thank you for that correction. mike, let us know where we are in the number of minutes. >> there's two. >> i have three.

>> that's five. >> six. mr. chairman, i've just been notified by my staff i believe this has been accepted on both sides. i'd like to ask for unanimous consent to accept hagan number 2 and burr number 6. they seem to have worked that out. >> any objection? if not, hagan number 2 and burr number 6 are adopted. i thank both of our colleagues for their work in that effort. i'll go in any order. how do you want to do this? tom, you said you had something. >> i have a meeting at 5:30. >> help you out. >> coburn 16.

>> as noted, senator harkin has created the proper emphasis of trying to change the paradigm from going to sick care to prevention. and keeping people healthy, preventing disease, and then managing wellness. many of the ideas in this legislation, section 301, the public health council, they have merit. but the way this bill is drafted, they only create more

government and more bureaucracy, rather than help us to focus on what works. so the idea behind this amendment is to replace the public health council in this bill, which is troubling both in its lack of focus and its unprecedented scope with a more targeted interagency working group to more effectively focus federal programs. the way this is written, we've got 18 federal agencies, most of them not related to health care in the public health council. i won't spend the time to go through that. however, what this amendment does is creates an interagency coordinating committee with similar purposes that includes all of the agencies under the umbrella of hhs, nih, cdc, hrq, and others as well as the more relevant agencies that are also on senator harkin's council, the va, the department of defense, epa, department of education and

department of labor. this interagency coordinating committee does not include the department of transportation. the department of housing and urban development, the department of homeland security. prevention should be about health care, points that i will will make and touch on. the other thing is, the health council inappropriately defines health promotion roles of non-federal entities, whereas this council has a laser-like focus on making federal programs work more effectively. i understand that none of the public health council's findings are binding, but americans might find it troubling that a federal board of bureaucrats would tell state and local governments, community schools, work sites, families and businesses what they should be doing to promote prevention. we've already clearly outlined here that the private sector is way ahead of us on

preventionment all we have to do is go to sass and dell and safeway and pit any bose to know that. there are great accountability measures in the council. they're not as sharp and defined as far as metrics that i would like to see. but they're not part of the council's purpose, and it's not part of the council's purpose to end the wasteful or ineffective programs that are already out there. the council, the coordinated council, i'm talking about requires specific plans for consolidating federal health programs and centers and plans to ensure that all federal prevention programs are based on sound science. the focus of the federal government shouldn't be on fixing what's wrong with what we're doing but fixing on what's wrong with what we're doing not telling local schools and businesses what's wrong with their efforts. so the idea just expands and changes senator harkin's idea to

make it more directed, more specific, and with a focus of eliminating duplication, some of which was in the other discussions we had, and this, quite frankly, comes from the patient's choice act where we do exactly what senator harkin does but we do it with a sharper knife, more refined pencil where we're actually putting the people in there that actually have something to do with health care on the coordinating council in the guise of eliminating duplication and lohoning down wt the message is we want to send. we also think that what we ought to be in this council is about receiving information more than giving it out. what is working versus what isn't. in other words, what can we learn as we write up this bill from what steve byrd did at safeway or what they did at pitney bowes.

the elimination of the hiipa variance for getting people incentivized for getting people to do the right things for their health and we've eliminated the 20% in the base bail, i don't know when that's coming. >> we just fixed it. >> oh, you did while i was out of the room? i stand corrected. they tell us we need more room on it. so i hope you will consider it if you look at the background on it, this isn't my idea or richard's ideas or the others, this comes from all around the country. this also comes from what we've seen happen in other countries, especially switzerland, where they have coordinated all of this to where they have a real sharp focus and it's about the people that know about health care so you get information coming in, you filter it with experts, and you merge that with the government programs and then send it back out. what that means is we'll get much more effective utilization and much more value for the

dollars that we end up sending out there. >> well, i'm trying to compare the original bill with this amendment. some differences are that you set it up with the secretary of health and human services. we set it up with the president, give it more visibility, get it up a little bit higher. the president appoints -- establishes this council, appoints an individual to serve as chairperson. we did not limit -- we delineated some of the people that ought to be on it. it says, the head of any other federal agency that chairperson determines is appropriate. so we didn't just say that's all that's got to be on it. secondly, on your point about receiving it, we ought to be toing more to receive info than

giving it out, i draw your attentions to subsection d-2, which says after obtaining information from relevant stake holders, d-5, paragraph d-5 says that the council shall establish processes for continual public input, including input from state, regional, and local leadership, communities and other relevant stake holders. so i don't see how it can be clearer than that, tom. >> the difference is you create a level. i take the people that are there already and put them together. you create another level of bureaucracy, and what i do is i take the people that are already there that actually have knowledge about this and redirect it. >> that's what we're doing. we're just saying, people from the existing agencies. we're not creating a new bureaucracy. people that are already there,

we're just pulling them together. >> i stand corrected. >> i take -- >> the other thing is we have a set of goals. it's called healthy people 210. right? >> yeah. >> what this coordinating council will say, how do we get there? that's one of our standards that we ought to be going towards. there's no standard in the present bill about healthy people 210, and we're saying you've got to have a measuring stick. at least we're putting a measuring stick. and i would say, again, consolidating federal programs is going to make us much better and much more efficient. the other thing we do is we make sure all of the federal government health programs are coordinated with the science-based prevention recommendation by the centers for disease control and prevention. that's a requirement of the coordinating council in this amendment. it's not an option. it is a requirement.

in other words, let's take the knowledge we have and put it into this council so that the stuff that comes out of it is based on science, not on fluff. we also require the secretary to annually report to us. you did that as well. >> we got that. >> and then we do periodic reviews, which you do as well. >> yeah. >> so there are some differences. what i see the difference is mine is designed to compare where our goals that that are set before us today, healthy people 2010, two is eliminate duplication and fine-tune the bureaucracy. and to not include agencies that don't know squat about health care and aren't going to have any input into health care. >> i still think that it ought to be done by the president to give it more visibility. i want to -- he has the bully pulpit. it gets more public out there

than a secretary would get. secondly, the other thing, tom, i read yours over the weekend. i really did. i've got it all marked up. i did read your amendment over the weekend. i guess we want it to be broader than just the specific on the five leading disease killers. your report and plan, as i read it, is -- i circled all these specific, specific, specific, strategic plan on the five leading disease killers, five leading disease killers. i also had something here, you had transferring the nutrition guideline development responsibility from the secretary of agriculture to the center for disease control and prevention. actually, it ought to be shifted to the institute of medicine, quite frankly. >> i disagree with that. >> well, there you go. >> yeah. >> i agree that it could be shifted but not to cnn dc, institute of medicine know more

about nutrition than the center for disease control. >> again, what i'm trying to do is get in one place, @@@@@rrrrgr there are five diseases that are preventible that account for 75% of all of our costs. >> i agree. >> we know that. >> i agree. >> we make reference to that. but we're not limiting it to that. >> could we have our staff work together? >> sure. i'll work with you on that. look -- >> there may not be that much

difference. >> if we can get money and eliminate duplication and have accountability and responsibility, i'll work with you. i'll work with you all night to get it done. >> good. >> tom, what are those five? >> diabetes, obesity, chronic obstructive pulmonary disease, heart disease and stroke. hypertension is a component of both of those. >> 75% of the cost. of course, you have to look at the end-stage costs when we haven't managed it, which we discussed yesterday ad nauseam. >> that's why we keep saying we've got to shift this to prevention. those are preventible. we've got to get new structures out there. >> i've said all day, all of us want to do -- we all want to get the dollars to prevent it. the difference is we really disagree on how you do it. in my next amendment will be, i disagree that building bike paths is the way to get there.

>> i'll withdraw the amendment in the hopes i can work with senator harkin's staff. >> pull that together if you will will. we've reached an agreement on senator burr's agreement number three. it's becleared on both sides. this involves the state law, parental consent, notification laws anz the like. i want to thank senator hagan for her involvement on that and others. we combined the two and senator harkin as well. i'll ask unanimous consent that burr amendment number 3 as modified be agreed to. all those without objection so agree. one more, tom? >> yeah. i've got to find it. >> sure. go ahead. >> go ahead. >> sorry. i'm going to bump in front of my colleague here for what i hope will will be a quick amendment. this is my amendment number 10.

this is as it relates to the right choices program, and as the language is drafted now now, the eligibility requirement is that the individual is 350% at the fpl, federal poverty level. i'm proposing that in an effort to deal with the costs of the bill that we have in front of us that we replace it with federal eligibility requirement of 200% of the federal poverty level. the amendment also includes that one of the criteria for eligibility be that the individual must have a chronic disease condition. and i recognize that that may be a negotiable proposal here. we are looking at this right choices program. it's been scored at $15.2

billion over ten years. i'm not questioning that it is makes good sense to have some kind of a one-time health risk appraisal, but i think in an effort to look at the cost and look at where we are spending our dollars, to reduce it from 350% of the fpl, which is about 77,000 for a family of four, to a level of 200%, when we were discussing schip and where we were with that program the discussion at that point in time was having the fp l at 200%. in alaska we're at 170% of fpl with our schip program. you've got to draw a line somewhere with the cost and in terms of those who are covered, and i would suggest that 200% of federal poverty level gets us to

the point where we are providing a level of screening and health risk appraisal for those who truly would not ever consider going in for one and setting the fpl at a lower level allows us to deal with the cost some what. i throw that out to the members. >> i'd say to my friend from alaska that that's the objective of the right choices program is to prevent, to prevent, disease in the first place. so if you limit it only to those who have a chronic disease, then you're not getting ahead of the game. the concept of the right choices was, okay, you've got people in medicaid and medicare, finance committee will provide certain things with that on co-pays and deductibles. then you have those who are insured. you've got that group this between that in five years or

supposed to be on some kind of exchange. this idea is to get to that group right away with certain types of screenings so that we can get ahead of the curve and prevent it. for example, if someone is pre-diabetic, to get them the information and stuff that they need on how to forestall the onset of diabetes. as you know right now, medicare, for example, will pay for nutrition are counseling once you have diabetes. >> right. >> but they won't do it if you're pre-diabetic. so to just say you've got to have a chronic disease before you can get in this i think defeats kind of the purpose of it. now, regarding the 200% of federal poverty level, again, we tried to structure this sort of almost like community health centers, that people do have to pay, but they pay on a sliding scale for these services,

depending upon where they are. so that's in the bill to pay for that. we had it at 350% because that was sort of the schip guidelines in two of our more populous states, as i might say. >> right. but should we be going to the most populated states and using that as our criteria, or is it not more reasonable to go with the criteria that we see more of our states utilizutilizing, whi around 200% of poverty? >> well, if we're going off that group of people, obviously they live in the most populous states. so that's -- >> you've only got two states, my understanding, new jersey and new york, that are higher than 350. >> that's right. >> but those -- >> are they higher than 350? >> yeah. i believe they had requested the waiver so they are in excess of that. but all the other states are

below 350% of poverty level. so, again, why would we take the highest number and say, okay, this is the level that we would set, if most of your states in looking at the chip program are looking and saying, well, somewhere between 200% and 300% is where they are landing? why are we going to the highest level of poverty that only two states have? now, as far as your comment about the requirement that you have to have a chronic disease condition, i recognize that that is an issue and one of the things that we're trying to do with this is to get people in for the zreening so we can then be more proactive. i think we also recognize that

so many with these chronic diseases have this co-more bitty a are the ones that have the conditions that lead to higher health care cost. i can look at that aspect and accept your argument so perhaps we pull that one out of the amendment. but, again, i would make the argument that we don't necessarily need to go as high as the two highest states in the country when it comes to the percent of poverty level. >> i would say to my colleague that, again, we're trying to get the most people in, start getting them these screenings and stuff, and the idea is the uninsured. it has nothing to do with federal poverty level. it has to do if you're

uninsured. we want to reach the broadest group as possible. plus, we did put in there this sliding scale to try to balance some fiscal matters along with i think the desire to get as many people on the right choices program who aren't covered by insurance as soon as possible. that's why we picked the high number. >> is the cost sharing, though, just for those above the 200% fpl? >> yes. i didn't the understand the question. >> so if there's going to be cost sharing, it's above that 200. the so below 200 we pick it up fully. the is that correct? >> that's right. >> again, i would argue that sticking with a higher number you're still going to get your individuals covered, they will

will just pay more in terms of their cost share based on your sliding scale. is that right? they're shaking their heads in the back. >> what was the question? >> the individuals would still be able to have this one-time assessment and screening. it's just that they would participate at a higher cost share. >> they would have to pay more. >> right. the so we're not the necessarily excludeing these individuals. >> no. but they would have to pay something. >> right. right. the which is not unreasonable. >> well, but we did make them pay something. you're saying that above 200% of the federal poverty level they -- >> that they would have to pay -- >> everything. >> no. the they would have to kick in, according to your cost sharing. >> yeah, i do.

in the underlying bill, if you're over 200% of the poverty level, you have to kick in something. am i not right? >> just make the point since we don't know the numbers, what percentages where, if you're at 50%, what percentage have insurance on average. at 300%, what percentage have insurance? >> these are only uninsured. >> i know. we don't know the numbers. that's the point i'm making. how many people is that, at 350% of poverty level, don't have insurance or choose not to get it? the other side of this is, under what you've written, you have allowed people who have decided they're not going to have insurance, now you're going to fund them even though they have all the means in the world to pay for it. so designing -- we ought to be designing this around what the

demographics are as coverage is related to income as a percentage of poverty level as it rises. even though you're going to make them pay more, but the fact is we're going to cost shift again to those people who have the money. the there's 11 million people in this country who have plenty of money to buy health insurance who choose not to. they're gambling on their own insurance. >> again, we're not forcing anybody to do anything. >> no. but what you are saying is they can take advantage of this even though they choose to be irresponsible. >> up to 200% of poverty. >> up to 350% as you have it written. >> then they have to pay something in on a sliding scale. do you want to do a community health structure? i think the center is very supportive of those. you can go in there -- you can have private insurance and go into a community health center. >> i just want them to pay the same things to the physicians in town competing with the community health centers as you pay the community health centers.

because there's ae's 20% differential. you paid medicare and medicaid pay a higher rate to community health centers than they pay to the very doctors they compete with in the very town they're in. that's the only thing i want to change with community health centers. >> now we've shifted. >> let's -- >> want to vote on this? >> i'll take a voice vote. >> all oez in favor of the murkowski amendment say aye. those opposed say no. nos appear to have it. it sounds to me that this one here, did i hear some common language, though, that -- >> possibly with -- >> is there any common ground? just a misunderstanding? >> i don't agree with the chronic disease. >> and i think that we would be willing