and kick that part out. >> i don't think we should limit it to 200% of poverty. i think we've put that sliding

done anything about prevention. and i'm not saying that some of these projects might not have merit. i'm just saying when we're talking about health care and we're including grant where cities may have a walk being trail now and they're going to put up lights, the cost-benefit ratio, the return on that is going to be highly suspect in terms of trial getting something done, especially in light of the fact that there's no incentive out there to get them to do it in the first place. and i know the answer is, well, people aren't -- if they weren't walking at night in a safer environment, then maybe they'll walk. the point is, everything we know is if you don't induce people to do the healthy behaviors, doesn't matter what kind of infrastructure you put out there. so the other thing -- and i'll note it again -- this grant

program markedly duplicates other grant programs that the federal government has. the hud grants, the cdbg senator burr talked about that. the hemingy communities program that's granted through the cdc, duplicates that. the transportation enhancement grants at the department of transportation, we're duplicating that. the safe routes to school program, we're duplicating that. the rural development program, senator burr mentioned that, the rural housing aprogram, we're duplicating that. identical grants, going to do the same thing as those programs are. we're duplicating it. the weed and seed program. same thing. we'll have a crossover and a dupe election there. and the department of energy efficiency and conservation block grant. we have duplication.

so, again, philosophically i'm opposed to us spending this money this way if we're going to spend 8 billion, let's go spend 8 billion on real spre vengs. let's enroll people in a precourse and get them the things they need. the let's spend 8 billion every year on caring for people with a comprehensive exam that don't have it today. let's go back to what you were just talking about with the murkowski amendment. let's put that money there where we're going to make a -- and let's pay for prevention when they encounter that, all right? let's pay for prevention. the let's since medicare and medicaid and insurance companies, all three bureaucrats, don't like any of them, they won't pay you to sit down and talk with the patient about what they need to change in their life. they won't reimburse you for that. so let's put the money where it's going to make a difference rather than jut put the money in physical infrastructure where

there's no guarantee. it may. but ujs we know, unless we incentivize through economic means, we're not going to get large participation in that. so that's the end of my sh peel. >> well, again, there are different sections to this title. one of them is the community transformation grants. again, we have to remember when we're talking about prevention and wellness, it's not just clinically based. senator coburn thinks i think because of his training more about the clinical aspect of it. that's fine. there's other parts. the there's the school base. we've talked about that. there's the workplace base, some of it being done here, some of it being done by the finance committee. there's also the community based. the trust for america's health, as i mentioned earlier, came out with this report and findings last year that they funded that showed that there is a big cost

benefit ratio to community proven community-based wellness programs that communities engage in. not every one of them are obviously beneficial. that's why we take a look at them. that's why we have these demonstration grants in there. and that's why this is i think a part of this excuse my using this word hoe list tick kind of approach to prevention and wellness. many communities have identified the biggest barriers to physical activity. happens to be the very things you're talking about. so if we want to encourage more physical activity, some communities have identified this as a -- as the major thing that they can do. now, i just -- one example -- sometimes we shouldn't use examples -- was a $40,000 investment from the center for

disease control and prevention in grand rapdz, michigan. it was through a program called pioneering healthier communities. it has become a $2.2 million investment in community prevention from private sources. one initial fund showed people what could be done and then they raised a lot of money, leveraged a lot of money, from outside sources. that's what i see us doing. some communities will engage in smoking prevention. on a community-wide basis, i know of another community that got together with their grocery stores and they decided to put heart healthy things along every aisle, what was heart healthy for them to shop at. not a bad yt. didn't find any of them along the candy counters or potato chips or things like that. the different communities did different things to, again, be engaged in a community the-based

prevention program. >> the key question on that, senator, is what is the results of spending the $2.2 million in grand rapids? what's the decline in chronic disease? what's the decrease in incidence in hypertension and diabetes? >> that's where we got -- >> you're making it based on something that you have no idea what the answerses are. you're just saying we've got a good program out there. they've sfwoent.2. we think's working. now we're going to throw $8 billion at it. >> we didn't spend the 2.2. >> we spent $40,000 and they did. >> right. >> you have no date are at that to show you've accomplished anything in prevention, lowering the chronic disease or lettering the cost of health care. so we're making assumptions without any of the data to know that we're making an assumption we're going to spend $8 billion a year assuming, taking grand rap rapids, which a fairly well to do community, and have the same results in the rest of the country. there's no scientific rationale to that at all. >> a report from the trust for

america's health entitled "prevention for a healthier america investments in disease prevention yields significant savings and stronger communities" concluded that an investment in proven community-based programs -- you asked for data. here it is. this is the book they came out with. >> i've read their report. >> they said that proven community-based programs to increase physical activity, improved nutrition, prevent tobacco use can save the country 16 billion annually within five years, the return of $5.60 for every $1 invested. don't take it from me. take it from the experts. >> could. but wasn't the operative word there "could"? >> what? >> could save 16 billion. >> could. >> could. that's my whole point. could. >> but they've already got data in here to show what the savings -- they have data here. >> this amendment doesn't eliminate those programs. it just says we're not going to

fund the infrastructure portion of it because we already funded in multiple other agencies. but we might want to do a demonstration program. we might want -- >> fine. let's do that rather than spend $8 billion. it is a big demonstration program. >> we're not talking about 8 billion. >> how much money are we spending on infrastructure in this whole bill? >> go to the community transformation grant. >> how much money are we -- >> 8 billion is the whole thing. >> is the whole thing for the grant. >> what is the money for community transformation? >> the grants are not $8 billion. >> how much are they? >> we didn't say how much. just such funds. >> so who is going to decide that? >> secretary of health and human services with this council we've established, to take a look at

this in consultation with cdc will will look at all of these different things. they can suggest them. we get the final say here on appropriations and the entire -- >> so if we write it, we're not going to score it. so the money we spent isn't going to get scored because it's written as such. i mean, that's how cbo does it. so we're not even going to score this portion of it in the costs that they have already. >> yeah, we will. it still has to go through the standard appropriations committee and the investment fund that we get, where we get our money. we already worked that out with the budget committee that would go through the normal budget process. so i don't understand what the senator is saying. >> i'm just saying the score you have now, since you have such sums in there, won't include these funds. >> but it's limited by how much money we have in the investment fund. >> which under this bill we're putting how much into the investment fund?

>> with will get up to 10 billion, as you know. >> i thought you had modified that back down to 8. so 10 billion. it actually runs at 2 billion the first year, 4 billion the next, 6 billion the next, 8 billion the next and 10 billion the rest of our lives. >> so it averages 8 billion over the next ten years. >> averages. >> that's where i came up with the 8 billion. >> that's just the average over the years. >> this amendment -- >> if you average the next -- >> senator, this doesn't get to all of those wellness programs. this just gets to the construction projects. i think if you're listening and looking at the letters you're getting at home when you're building the sidewalks and jungle gyms and lights and maybe buying grocery stores, that's what we're talking about in the construction pafrt. this is just the construction are. this isn't all of those other things. and even in those construction things one of my favorite organizations is an informal one just over the internet called

community airianism. they just keep track of things that are done in different communities that improve the mental wellness of the community, the -- how well people think about where they live. my favorite example of it is in st. louis where the city council saw there was a lot of graffiti, a lot of gangs, problems, and they decided they'd do something about it so they were going to send out a questionnaire. without spending money on a consultant, they sent out their own questionnaire. so they asked the wrong question. t the usual question is, what do you need to have a better community. instead, they asked, what does your community need? they had a blank for kids to sign if they wanted to participate with their phone number. as you know, hardly anyone sends a questionnaire back. they got 60% of the questionnaires back. half of those were signed. they decided they probably ought to put these kids to work so they turned over city hall on

the weekend to the kids to run programs. there was adult supervision in each room but the adult wasn't allowed to say anything. that was just for discipline purposes. and these kids cleaned up the community and eliminated the graffiti and reduced gangs, didn't eliminate gangs. it made a huge difference that way. but these kids did it all by raising their own funds for it. the city didn't put any money into it. it goes under the theory that if there's a lawn that isn't mowed and the window broken, it leads to -- it actually can lead to crime. just people lose faith in their neighborhood. so we're getting into that, which is a kind of wellness, but i think we can get the people to do these kinds of things so they really ought to be putting them into these other kiebds of wellnesses you're talking about rather than tconstruction ones. >> this is just authorized. we may not spend any money in th area. but i don't want to say that a community may identify this and if the council looks at this and says, this is something we ought

to try and look at and get some evaluations on it, to get some metrics on it, no, we can't. >> every community in the united states will will feel compelled to turn in jungle gyms and sidewalks and street lights and everything. sure they will. they would be negligent in their duty if they didn't put one in. >> mr. chairman, i would ask for unanimous consent that this amendment be noted as defeated 13-10 as if we had a roll call vote. >> what did you say, tom? >> i'd ask unanimous consent that this amendment be defeated. >> i object to the request. >> we'll have a roll call vote. >> look, i think it's ---or the these are authorizerations in this area, these are community based. as i read this, it's more illustrative in many ways than

mandating. so that we're -- >> and competitive. >> and competitive grants so this idea -- i mean, obviously we can conjure up our own reactions to these things. the words "jungle gym" i can say already is going to pop up. yet i suppose a community that decided they wanted to provide at school that's had a hard time doing exactly what you recommended a few hours ago and i couldn't agree with you more on it, that small, poor rural community have be a hard time making ends meet decides a kmunlt-based program might be to put in a good recreational area, including a jungle gym for that elementary school. so they start getting physical exercise to do exactly what you hope they do and do better. that to me, that community making a request like that, it shouldn't be scoffed at. it seems to me they feel they need it and they need help from

the federal government to improve the physical education of their children in that town, i don't see that as a bad idea. >> i think we ought to change it to a jungle chris. >> you know what i'm getting at here. i think these things could have some merit. we can always pick out titles and names of things that make us all chuckle. nonetheless, they can have real value to people. >> mr. chairman, i have one more amendment. >> withdrawing or just voting on it? >> i was serious about my unanimous consent. any objection to that, 13-10 as if we voted it? >> i don't want to speak for my colleagues. if someone wants to vote with you, i don't want to -- >> let's have a vote. >> call the roll. >> senator dodd? >> no. >> senator harkin? >> no. >> senator my cull 60? senator bing will ham? >> no by proxy. >> senator murray? >> no by proxy. >> senator reed?

>> no by proxy. >> senator sanders? >> no by proxy. >> senator brown? senator casey? senator hagan? >> no by proxy. >> senator merkley? senator whitehouse? senator enzi? >> aye. >> senator gregg? of bf aye. >> senator burr paye. >> senator mccain? aye. >> hatch? >> aye. >> murkowski? senator coburn? senator roberts? >> aye. >> senator kennedy? >> i'll vote no. i was going to mess him up on this thing. i was going to throw tom off on his prediction of the vote here. he votes no by proxy. >> the vote is 10 ayes, 13 nays. >> you turned out to be correct in your prediction.

one more, tom? >> amendment number 25. >> this is on federal messaging and health promotion. i mentioned this several times through the day. what this says is a national science-based -- a national science-based media campaign on health promotion and disease prevention. national. when i say media i'm not just talking about tv. i'm talking about internet, every way we can get the message out. and what it requires is a program that address ares proper nutrition, regular exercise, smoking cessation, owe bobesity reduction, the five leading disease killers in the united states, and secondary prevention through disease screening promotion. carried out by competitive bids so that we get good value for what we're doing. entities that have the ability to professionally do this and

will not duplicate any other federal prevention effort ongoing today. it's to be evaluated and subject to reevaluation every two years with data that will tell us whether or not it's had an effect so that we know whether we should continue to do it. it allows the center for disease control and prevention to also develop a plan for dissemination of materials in conjunction with this media program through all of the other agencies that have anything to do with health care, va, dod, medicare and medicaid programs. the second component of this allows t secretary through the directors for centers for disease control and prevention enter into a kral contract with a qualified entity for the development and operation of a

federal internet website for personalized prevention planning tools. okay? so it's much like you can go right now to the mayo clinic or google. we make this available and we put it out there. so we have this personal prevention site that you can go get on. we're going all the promotion, doing all the education through this media, and this paperwork trail where we're making the information available to the agencies if they want use it and we establish an internet portal that people can go on, and we actually put together the information, we send it out, we measure it, and we give them a way to evaluate themselves. and the way we fund it, we don't bring any increase in funding. what we say is d cdc, with all your other prevention programs, this a priority for two years. >> if you would -- i think it's a great idea.

clearly it goes back to the point you made earlier about education, about matching up the personal responsibility and structural ideas. tom, if you'd be willing to take out the strike language and take this -- i'd be willing to urge my colleagues to take the amendment. >> what specific -- where are you -- >> the first line is strike section 311. where is that? >> yeah. this replaces the right choices act. >> right. >> i'm fine with doing it. i'm not happy with the right choices act. i think this is a far better way of accomplishing exactly the same thing much more efficient and more than likely going to make a bigger difference in terms of health outcomes in this country. >> we already have in the underlying bill media campaign

and information to go out that goes through all of these things. so this is -- >> this is p much tighter than what you have in the other bill. >> yeah, it is tighter. i agree with that. it is tighter. and it's more specific. again, the requirements of the campaign in your amendment says shall address nutrition, exercise, the five leading disease killers in the united states. it's still focused on those five. >> well, but nutrition has to do with the others. physical exercise has to do with the others. in other words, you're going to address it all. i mean, if you're obese in this country, you have a 40% increased chance for cancer. that's something that will be communicated. >> i read it again. it's okay. >> mr. chairman, i will accept your offer. i will drop the strike.

>> let me make one other suggestion to you, tom. you've got in paragraph f of personalized prevention plans. at least that first sentence, with eliminating the amount to be spent on it is one thing, it says funding for the activities authorized under this section shall take priority under funding for the disease control preventi prevention. >> when they're doing the same thing, chris. >> it's the media thing. >> yes. in other words, if we're already doing this, the idea behind this is let's -- we know that if we put information out there and we do it in what was it, madison avenue style, if we can get people to buy junk food, we can certainly get them to buy this. and if we do it in a coordinated way -- >> gotcha. let me make sure i'm clear on this. your deal on the priority funding is not priority funding for everything else. >> no. just the things for which

they're already dog in this area. >> the media. >> well, for example, if in fact they're trying to lose weight and they've got five programs with the states to lose weight, the first thing, the priority is let's get this media going. doesn't mean they have to stop it. it means they put this first. because we have a lot of data. look, we have a lot of data that says we're ineffective. for example, if in fact the cd c cdc -- >> would this cut funding for breast cancer screening? >> no. >> it would take priority over that. >> no, it wouldn't. no. because it takes priority over messaging, not screening. messaging on breast cancer. okay? breast cancer is one of the five. cancer is one of the -- that's the fifth group actually. >> one of the successes we've had with breast and cervical cancer xreeng and it's been a

great success has been in the media campaign and getting the information out. >> and they were not going to do anything any less than that when they were going to spend all this money and have a coordinated event. we're going to coordinate the message in terms of the media. we're going to chordor nate the same message. they can take the same program they're doing now. what we're saying we're going to take a new look at this and make it a priority. >> well, are we okay with that part? okay. >> take the strike out. >> the strike is taken out. good job, tom.

>> thank you. >> i'd ask for all of those in favor of the modified coburn amendment as modified, say aye. >> mr. chairman? we don't have a forum. >> who had to make that point? >> i'm sorry. >> her voice in the back of the room. >> what happened? how many are there? >> can we work on this tomorrow? finish it up tomorrow? my only worry about it is you may not be in such an agreeable mood tomorrow morning when we start. i have a meeting that started at 5:30 for which i'm late. >> we got the eight. merkley is here. merkley's here. >> that only gives us seven. >> merkley is way in the back of the room. >> senator merkley -- >> that takes us to eight. count yourself. >> oh, eight. >> that's what's wrong with this bill. you're having trouble counting. you're in the room, jeff. that's all i needed to know. the coburn amendment as modify, all those in favor say aye.

opposed no. the coburn amendment is adopted. we're going to try, tom -- there are basically three amendments, two amendments left. >> three. >> that senator enzi has. i'd like to finish those tonight so that the staff and that will be it for this evening, will have finished the prevention section. and tomorrow begin with senator murray and interested members on the work force. the staff has done a lot of work in that area as well, but senator enzi's staff has already done the work on prevention. they haven't had as much as they'd like. we're making real progress here. i want to thank all of my colleagues, particularly mike for being here with me. tom, you've been terrific and a real help and others. senator harkin, i thank him as well. we don't have to go into evening and finish up 40 minutes, half hour. >> we're going to finish this now?

okay, good. tomorrow we'll begin on wo workforce. that will be the goal. >> want you to go ahead, mike. start talking about it. >> i've been informed that i'm number 80, that that is kind of included in the burr amendment. >> okay. adopted? so we can drop number 80? >> yes. >> number 80 is gone. 80 is withdrawn. is this enzi 80? >> yes. okay. so i'd offer enzi amendment 50. >> enzi amendment 50. i have 51. >> while that is being passed out, i would say that is to ensure that the secretary conducts workplace wellness evaluations in publicly funded programs before evaluating the privately-funded programs. i'm not sure why we are having cdc evaluate programs outside of the government when we haven't evaluated the ones in the government, so this would ensure that we would have evaluated our

own programs before we starts a cessing the value of the impact of the privately conducted programs and that only seems fair to me that we talked a lot about the ongoing evaluations and stuff, but it is not one where we have evaluated. so i don't think that the taxpayers ought to be supporting ineffective programs in the government and then spending money to evaluate whether the private sector is doing the right thing or not. so i think that we ought to have that evaluation. >> mike? >> yes. >> i'm getting that section, but i remember when we were drafting this, the purpose of this was as we found like in safeway and other places, there are some workplace bonus programs out there in private sector that are doing a good job and probably a lot of them that i don't even