about that. the question is it such a point of being exclusive and here is a language that time that a mean and others made a comment on the amendment is not a senate provision that is titled our amendment made by this title such as a rocket shell fund programs appear promising in the provision shall fun programs were to train all money primary care providers in i'm, there's an exclusivity with that that i am more worried about this and think there is a legitimate case to make and the one area i care is brawl was particularly pediatrics where i can really use some help the specialization areas of pediatrics. i don't want them to be excluded or is important to do so so it is that idea that it takes where we are picking the winners and

losers. >> i just want to say the reason you don't have pediatrics of specialists is you don't pay them. it is a is an same reason. you know, we have to pay and the payment their rancho between the pieta ecologist is about to honor to present. it is a but what manicure sets up and medicaid sets up the reimbursement mechanisms, if you look at the medicaid reimbursements per pediatrics of specialty is you will seem that they are paid on average of our less than what we pay under medicare for the same procedure done on a child which is much more difficult by the way that it is on an adult's. in his payments and as long as we continue to ignore the economic source of our disproportionate to mix up positions we're never going to fix the problem.

again, -- >> we have been over this before and as it will senator harkin about the cardiologists and why i don't get more people -- i said notwithstanding provision of this title, all programs authorized by this title shall fund programs to obtain only primary care providers and that i just worry about saying that, the reimbursement levels, but i don't want to be at a point where we clearly excluded where we come out of this by saying i measure pediatrics but even the odd pediatrics i would not want the department of health and human services and managing all this to interpret markup that we did not appreciate specialization and that is where the pendulum stores sweeping and reviews ms. a balance between the program number of special sessions and primary care. >> mr. chairman, i hope you'll

at recognize because i think we have a way to solve it. >> i'm going to go to bernie sanders and then you can max mr. chairman, let me just before you go to a vote to say that everybody recognizes there is primary care problem, but that is not the only issue we have in providing health care. if we just have doctors and we did not have nurses and occupational therapists and home visitors and all the other professions in public health we will not solve the health-care crisis. >> senator enzi it defines primary care provider in health care professionals -- i presume you mean by that that would include health care practitioners, nurses and so forth. >> no, he is talking only about doctors. >> only about doctors. >> that is aholt -- >> i am trying to help you. >> mr. chairman, that is the

crux of the argument that in addition to there has to be primary-care held teams that talented and overworked providers also turn to someone. i can and social workers. >> but that is why repoire de the report by billion in into hundred million into primary care providers and that is what i'm trying to change the dynamic here. >> i think it changes in the wrong way but we are ready for the vote he mack i agree to an amendment he met all those in favor of the enzi amendment and those opposed say no apparent it does appear to have an amendment is not agreed to. it let me turn to senator sanders and then mr. cockburn. >> thank you mr. chairman. in this amendment is placed on page 445 line 21. what is essentially says that under the health care workforce.

>> let me make sure everyone has a copy of this apparent him and mrs. sanders number three. [inaudible conversations] commerce wrightwood. >> thank you it mr. chairman. what this amendment does is it includes license complementary and alternative medicine providers an integrated health practitioners under the definition of health professionals to be one of the

professions the health care workforce commissioned study is to feature health-care needs so we want to expand the definition of health care providers. adel d.c. have to tell anybody on this committee that we are looking and millions of americans who go to chiropractors and natural pass them on to puncher and massage therapist and other complementary medical therapy and dashed their press as well as a chorus and mba. and i think that there are playing increasingly embroiled in delivery of health care. and i think they should be studied in terms of what the needs of those professions are with our whole health care picture within the next several years. >> is this basically a standing? >> we include complementary and alternative medicine providers to be studied as one of the professions under the healthcare

workforce commission of which is looking and a number of future health-care needs. >> is certainly agree with that. i think particularly in the area of chiropractor rain and some of the related fields they have done tremendous work in the esther punchers mccain houston's for people and i think this is a worthy of our adoption to give some attention. there has been a culture that excludes. it will be interesting to hear tom coburn has to say. whew. >> you have license complimentary and elton's their presenters and then license, all of these have a license of the city will practice with. >> i think that is to make their find work because the way it is a revenue was a licence complementary and alternative medicine providers but not necessarily less incentive rate of health practitioner so i want

to verify for the record that she mean this is says their license for this they're eligible and there are a lot of people who. >> the answer is, yes, and that is important to point in. >> we are only interested in licensed providers by the state. >> any further debate about this. i want to thank senator sanders for his amendment, one who started the office and i appreciated this and more and more americans are seeking alternative medicine and more visits to can practitioners are year with right now and there are seeking a less invasive types of processes and that is also a per practice are not getting the kind of up front preventive care to keep people healthy and the first place and that is what people are seeking. so i think this amendment is a red spot on the orient. >> i'm going to be associated

with one of the schools which is dependent by higher education commission that is in my state. also at the university of maryland we do have a center for integrated health. >> mention massage therapists, is that license? >> yes. >> i can recommend one if read one. >> we just had a big trial over massage therapist. [laughter] >> moving by the long, all those in favor say aye and those opposed to name. the amendment is agreed to. >> want an income and not critical of the desire of senator murray and but what we have done in this bill is we have assumed every state in that the same and we have assumed that every state is the same and what we have assumed that we know what the states need and

the purpose of this amendment and des moines to modify it in ways that will meet with you. we don't know and so with this amendment does is strikes in large portion of the title x of for the authorization and millman grants will will and increases it to a billion mahwah. coburn number 70. 11 and i am willing to change the last member to what ever you wanted to be but here is my point. is what we need in oklahoma different what senator hearing aids in washington throwing i have a shortage of one type of public health professional and she might have different period we know is the states know they need so the whole idea behind this would be changed this title where we left off the states decide to do with they need to be a so we take this $4 billion

or five points $6 billion increase in the same okay, we have the santa millman grants and were forced to run programs and we let the states this person or they need them, not under what we are going to say they need, we are going to let the states decide what they need. this does three things and one is that markedly improves efficiency with which the dollars can rule out because the states know where they need to spend the money would. never too long, never to look it goes by to the assumption and reinforcements assumption is that policies are different. what we need in rural western states is oftentimes different than what tom harkin mining and i along reckon i can't wu. >> mr. chairman kim and because there are different views and different problems and difference shortages. in general other shortages you

bet. other petitioners in shortages and oklahoma we have done a good job with our p a program but not as good job of the earners practitioner program so it will allow the flexibility of the state's to decide where they want to put the money based on the shortage that they have. rather than washington to signing with what they are going to do so the whole idea is to move it out of here, but a closer to where it is going to be spent with the wisdom of the state's knowing how best to spend the money. so we strike all of the title with the exception of a commission in the state works worst of all the programs and i am willing to change that and to whenever you want but i think it is much more effective if we are going to have an impact on these shortages and were all well, as chairman is pediatrics of it allows them to really directed where as in a large urban areas

we don't see as much pediatric some specialists know what we are doing is prescribing but they need is rather than what we think they need is from washington so it changes the locus of decision making and they said to the states and allow us the states to design her to apply the moneys to meet the need the have and it covers all the areas we have talked about, all of the physician extenders in cornyn allyson and allows the state is suing a decision rather than -- one. >> mr. chairman, i don't disagree with senator coburn that our states and local communities know better here go with their needs are and their local workforce communities need to be absolutely at the table part of the process and the decision maker moving that form. that is exactly right we wrote to the section because our states their original areas need a comprehensive coherent plan of to meet their own health care

work for a sneath at home. i don't disagree. what we have done in this bill is leveraging existing resources to build the persian senator coburn is talking about what the amendment eliminates the finance it -- financing mechanisms that help our students get to schools and takes up the education and training programs for them to get the skills needed and eliminate them rossetti programs for health workers some i think our bill does exactly what we need to do which is to make sure the federal garment is a support to leverage those local partnerships and that is how we have written this moment. so i will oppose the amendment because i don't want to see us take out the broad diversity issues we put into this bill and i would remind all that is how we have written this bill to make sure we leverage federal dollars to kill those partnerships and a local

communities to me their local employment means. >> mr. chairman, you have a national commission that will set the priorities and is going to set the priorities and everybody is going to be subservient even with their input there are going to be subservient to a national commission and what we need is of the state's to reign supreme on how this money gets spent where rather than to have to go through the exercise of demonstrating to our bureaucrat in washington that disagrees with the savings it needs. we all know that happens now and every program have got. if you have the federal nexus with the news around the state's next the states don't end up with the flexibility and another is a state commission but there's also 20 new programs run by the federal government in this title of this bill. 20 new federal programs. one of we don't need that new federal program in connecticut

over oklahoma? why don't we just get them the money and give them the flexibility to spend money. they're not stupid. we don't need washington telling us how we spend the money, we know we have a problem and our problem stiffer than connecticut or washington so the idea is to let the states be what they were intended to be and which will do is get surprised by the efficiency in and the response much better than treating 20 new programs into new commissions. less and make sure the money is spent. means and what then these are and the people in the states and should not have to come up with their hand out to a commission that says that is not the national interest. this isn't about the national interest, in dollar interest locally in terms of applying these funds. >> let me say and again up. there is no significant debate, the idea you have a national

commission disregard of the state's means i think this is as baffling and exaggeration because obviously the needs of our states are critical in winning sudan. where a high of national health care and obviously our responsibility is to canada and is somewhat to make proposals to address these needs and just writing a check and sending it on and while i have great respect for it happening around the country and as to the sense delegate our responsibility. you need to have the combination it seems to me or you are listening carefully to what our states are saying and obviously the nea is a very from one place to another in a country and i think this bill reflects the insistence on listening to those ideas and thoughts as we move forward in these areas, but what senator murray has suggested i think you are addressing illegitimate issue about may be

sure the states are going to be listened to in this by simultaneously in wiping out a lot of other areas entitle the subtitles the, section 431 of this as well as the recession is sections of the bill and in order to address the issue of insisting that our states be listened to we don't to sacrifice these other provisions as well. i would be willing to list the language to talk about how the national council should take into consideration diversity of our states, and if they make your calculation on these matters but i want to get involved or i ever eliminating all sections of the expense of what we're trying to achieve. >> i have to, number one, over 200 places in this bill we leave absolute discretion to the secretary of hhs. 200 times in this bill we are born to let them decide. we are going to delegate responsibility to hhs and the

tenth amendment does have priority in saying it stays have some responsibility. but if we are saying a delegate our responsibility to the states that in a secure, it is their responsibility. we are taking money from him, 200 times in this bill. >> in the bill? >> i'm not saying this title, i was very clear, what we say the secretary of health and human services will make all these decisions. in this title we create 20 new programs and to commissions. more government, bigger government, government coming from washington to tell us how to solve this problem and all i am saying i don't expect it to be accepted, i understand that and i don't expected to pass but the point is when there is some virtue in allowing some freedom

for the states to make the decisions without causing them to have to jump through the hoops of what we in washington think is best. >> i don't see any debate about that but for us to sit here on a bill -- this is not uncommon for us to sit and micromanage every detail. we defer to the secretary of interior and the secretary of state, a lot of areas is a common practice rather than to sit here as a committee and to write every detail -- that is why we have the secretary of sec chairman to to manage these matters day to day. we may maintain oversight authority, the preparation of the rising process every year to determine whether of not the schools are being addressed are met. i have yet to hear a debate about the importance of states respectively, and certainly we have in this bill as well. >> there is something i don't understand because when you're talking about this i remember this is my title but i remember

going over its end in five and it's as written and -- required responsibility is receiving a planning grant to carry out the following. analyze state labor market to treat the career path ways for students be identified the current and projected high demand state or regional health-care sectors for purposes of planning career pathways. as he identified it district private resources, this academic -- it is all up to the state so it is of the state that basically we the sides and rear telling what they have to decide in. >> assuming that we know the parameters that have to make a decision under but every parameter you can imagine. and make the point is a limit

this final point and call the question. one of the reasons this country is in trouble is because we do a delegate to all these agencies without the oversight and all be happy to pull for using excite member of oversight hearings the senate has done and this congress and every congress since i have been here. it is a pittance compared to what should be based on what we do delegate because oversight's hard work and not associated with clamor and so we don't. to give you an example in 2006 my subcommittee held more oversight hearings than the rest of the senate combined. my one subcommittee of been the whole senate combined, we don't do oversight. and what i am saying is if we really want effectively to change the dynamics in terms of health care providers don't put the bureaucratic ropes on the states, give them the

flexibility and trust and two oversight, but don't do it ahead of time and say, on your knees and we will tell you whether or not you can't. we will have a bureaucrat that will decide whether or not to meet the goals of the legislation before you can do what is in the best interest. >> want to move to the vote but i have to clarify and love senator coburn passion but it is like catching a whole basket of balls thrown at you with arguments. i just want to clarify that one we have done very carefully throughout this title is to make sure that our local community is work to develop what skills they need within their communities and provide federal support to allow them to do that. we do have a commission on this, it doesn't mandate anything in is to give us the information so as we are looking at our appropriation business i assume they will want that and can make

good decisions about how we proceed with all the work we have to do. i think this bill is written very well. i appreciate the what is thrown at us to make we will have to wait until lunch. i thank my colleagues and we will take a recess until 2:30 p.m.. [inaudible conversations] [inaudible conversations] >> the committee will come to order, we have a members and i thank my colleagues for being here. we are about to vote on the coburn amendment when i will do, take a couple of minutes if you want to mention again. before i do that i have had a

conversation with senator in ca about schedules and about what our plans and schedules over the next several days for this committee and let me revisit the issue over the lunch break and i realize all this is subject to obviously votes of other matters and i gather a meeting on our republican friends this afternoon so we will take a break for members to attend that meeting but here is the plan. we're in the midst of dealing with a workforce. my hope is we would be able to complete workforce and even after the meeting today to come in this evening to do with the fraud and abuse section and then complete that to section to name and that would leave long-term care questions. i don't have is korea on long-term care. if we don't get a score i won't

bring it up. i can into this going questions so if i get is going issue on that we will go to that for tomorrow morning with the idea to be able to complete that by around 12:30 p.m. realizing that again based on the votes of other matters members want to clean up things before you leave to go back to our perspective states but the independence and the break and then obviously leaves any other outstanding issues that we haven't quite completed but hopefully can do that in the last day and have and secondly we use the issue's of the pay or play issues, the issues involving the public auction for lack of a better description and at the follow on biologics we will have to get to at some point. my point would be the have done a lot. if we get that much done big issues remain. but we don't have scoring yet on

those matters and i can't very well as colleagues to engage in those matters if we can't answer this going questions yet we don't have that. i think it is two our advantage. we have done a lot of work. we have marty dealt with in this committee and i would instruct staff of to work over the break on these other issues that are complicated issues to see if we can't maybe even come to some agreement and that may be possible. i'll try to encourage that the lease for members to understand the issues. we will come back on july 6th and my view would be to gather together and see where we are on those matters and to reignite or restart of the markup on that tuesday with remaining issues to complete our jobs to the extent we can. two complete our work but that will give us a sense of accomplishment of what we have

been able to do, it's time to take on these outstanding issues that are very difficult and also use that time what we have completed to sit with the finance committee and begin to try in these areas and build where we can as a possibility during that break next week. i realize all of this is subject to what can happen over the next day and a half but i prefer to get this done by tomorrow. if we can't we will stay in a number two completed. i'll try to complete that much of this and leave the remaining issues where our discussion later on so that is a sense of how my to proceed in the committee to complete our work. >> are you still anticipating having some kind of a draft to was before we leave for the brain? >> if i can do that i was like to do that for you and if that is possible i will, but i will

get it to you as soon as we can even if we are not to get it to members who have an opportunity whenever they plan on a journey but if i can get it to you and i will. on those matters and i realize how and for that is to review this before we come back so those are importance and i hope we have old-time. >> old china two not been in jam anybody and we have thinking about amendments and you have my word on that. >> and i am going to appreciate what cbo means and how problematic that can be a. >> i do want to say something about the schedule because i think the three open areas in this bill we are not going to get accomplished and today is so you said that tuesday and wednesday we