>> right, just like you're endentured to servearáb actually developing sur ricurri for any kind of medical program? it seems like we're assigning a role to him that is not a natural fit.

>> say again, i'm having real trouble hearing you. >> the question is why are we giving to the surgeon general the authority to develop faculty development programs and curricula and whether or not the surgeon general is tasked with something of this nature. it just seems unusual we would have him develop curricula for a medical program. this is in -- on page four, subsection e, faculty development. >> i'm informed the purpose of this sentence is to basically say that the surgeon general will be responsible for deciding what are the important things that he wants these public

health officers to know. and thereby can direct what the curriculum will be to meet the needs of the public health service. >> well, it indicates pretty clearly that the surgeon general shall development the programs and curricula. and so if it's not the intention that that be the surgeon general's role that they just kind of be more of an oversight, perhaps we need to look at that language. >> yeah, maybe we should change the lawn to say that the surgeon general is directed to ensure that the curricula meets the needs of the public health service. that's the idea. >> if you're willing to work on that language. it seems to me the surgeon general has a lot of thing he is needs to be -- >> i agree. i don't think developing the

curricula is not necessarily what we want him to be doing. >> right. >> i'm glad to work with you to get that flaung a form that better reflect what is we're talking about. >> thank you. >> i think everybody is probably pleased on page five where it talks about working through accredited universities and health professions. >> i can just barely hear. maybe everybody else can hear well. i just find in this room the sound goes right to the ceiling. >> i think everybody agrees on page five where you talk about going through accredited universities and training institutions. but then on page six it talks about the surgeon general establishing a graduate school of nursing. that doesn't seem consistent with the other part. were you anticipating an additional school being built under this?

top of page six. line four is confusing. line six seems to be pretty definite and line seven sounds more like what we're trying to do. >> i'm informed that should not be there. why don't we delete the graduate school of nursing from that. >> mr. chairman, could i make a suggestion. would you mind scrubbing this, not delay this but let us look at this a little longer. i think you're on to something. i think we do need to go down that track, but i'm a little worried about number three. if we've got accredited universities, why are we going to create another one?

>> let me just respond to your question. if you're talking about an hour or two here and still get this done today that's fine. if you're talking about a week from next thursday. >> i'm not, i'm not. i just want to make sure i can look at it and think through -- >> i don't have a problem. unless the chairman does. i'm trying to do this in a way that makes sense. so if you have other concerns, let us know just so we can finish it up this afternoon, that would be great. >> i think we're talking about the same kind of time line you've asked us to withdraw amendments and work with us on. sometimes that requires overnight. >> do you want to do it tomorrow morning? >> whatever time. as soon as we can get it done. >> that's fine. >> senator burr? >> mr. chairman, i would like to call up burr number four. >> burr number four. >> hopefully this won't be as contentious or as difficult to understand, because this was a program that's still currently in effect, but will no longer be

in effect after june of this year, i believe, june 29. as members are getting this, the amendment restores the medical student loan deferment program, also known as the 220 rule. this rule which medical residents have relied on for years was eliminated in the college cost reduction act -- access act of 2007 and has a negative effect on the ability of medical residents to pay their student loans. in 2007, congress passed a college cost reduction access act to make college and financing of college education more affordable to students. those are good things. unfortunately buried in the text of that bill was a major mistake. more appropriate, i would like to call ate malpractice committed against medical residents. the elimination of the 2220

pathway which goes into effect next month, all thanks to the reconciliation process, it should be noted, made an unintentional yet far-reaching policy change that affects thank yous of medical residents. congress enacted the 20220 rule in response to the massive debt burden medical students have. in 2007, the typical medical student graduate from med school graduated with an average of $137,000 in student loan debt. under the 2020-220 rule, students were able to defer their student loan payments on their federal student loan for up to three years during their required residency training. in other words, we allowed them to have a higher income before they were obligated to pay back those student loans. qualifications include an educational debt burden equal to or greater than 20% of their monthly income and the residents' income minus their educational debt burden equals

less than 220% of the federal poverty level or about $24,000. according to the association of the medical colleges, up to 67% of graduating medical students were eligible for this economic hardship deferment under the 20-220 rule. this impacts nearly 2/3 of all medical students. we should be working on proposals that make it easier for students to consider a career in medicine, not harder. the high cost of medical education is already affecting the medical student's career choices, deterring them from practicing primary care, practicing in underserved areas and public health service. working in medical education research. reinstating the 20-220 provision permanently ensures that medical residents will not be forced to begin repaying their loans before they have the means to do so. this amendment is identical to a bill i introduced earlier this

year as 646, the medical economic deferment for students act. chairman dodd, senator isakson, alexander coburn and roberts i'm happy are co-sponsors of the legislation. i believe it's entirely appropriate to consider this appropriate as part of this title since we're trying to increase the supply of physicians in this country, especially primary care physicians. and if this bill were to go through, mr. chairman, i think we could pass 2220 and we still wouldn't have enough docs in the system to take care of the population. the 2220 pathway is only available until june 30, 2009 bausz of the changes in 2007. if there was ever a time to act without interruption it's now. i would ask unanimous consent of the chair that i enter into the record a letter received -- or dated 23 june from the ama,

which shows the ama's support for this piece of legislation, as well as a letter that was sent to secretary margaret spellings when she was then secretary of education. and it is signed by 97 medical associations and state medical societies including every state medical society in the nation calling for the reinstatement of 2220. with recent reports showing the united states is facing a shortage of physicians in the future, reinstatement of this rule could prompt students who other wise could not afford medical school to get a career in medicine a second look. mr. chairman, i would urge my colleagues to pass this very important legislation. >> you're right. i am a co-sponsor of this bill. i hoped, by the way, and i would point out, i'm disappointed when we eliminated the 2220 rule in

2007. and as you recall that happening in the previous administration. and shortly after that happened, the secretary of education under her authority kept the rule in place to prevent it from impacting medical students and the cost, as my colleague pointed out. we've been in touch with the department of education to urge the secretary to keep this rule in place. we haven't had an answer back on it, but the department is still reviewing the matter. my concern is that, frankly, this would be eliminated again. and i couldn't agree with you more. we talked about reimbursement rates. we spent a lot of times this morning talking about education programs and the like. this is a very expensive endeavor for people to pursue this. so i feel that this has some value in terms of trying to make sure that people will consider this a professional life call and giving them some financial

relief in the process. i intend to be supportive of the amendment. and you could argue about it's a department of education issue, but it affects medical students and their access to these jobs. so i thank my colleague for offering it. my gut instinct tells me this rule is going to be eliminated again. and if it is, then this would be hard to get it reinstated. have to go through a legislative process to do it. so i think it's a good amendment. >> i thank the chair. >> others may want to be heard on this. i'm not the only person who has views on this. any further debate on this? i would ask all those in favor of the burr amendment say aye. those opposed? no. the ayes have it and the burr amendment is agreed to. >> there's a fly near you. ichs going to say we'll test your ability compared to obama's ability. but it flew away.

>> only obama could do that. >> did you catch it? >> i came close. senator gregg had an amendment. >> but you scared him enough. >> i scared him enough. he went down to the white house. senator gregg is not here. is he around? will someone offer on his behalf? >> any more on workforce? he's coming in the door. how many more amendments do we have on this section? do you know? >> i don't.

>> did burr pass? >> yes. >> we won one. >> should i go? >> yes. >> chris, do you want me to go forward? >> yeah, go ahead. >> i'm offering my amendment number 30. this amendment is healthy mothers, healthy babies amendment. it essentially says -- well, let me explain the problem first. in rural america and in inner cities in america, there's a tremendous shortage of ob-gyn doctors. and that shortage, at least in rural america -- i can't speak to urban america, is driven almost entirely because of trial lawyers and the effect they've had on the premiums which good, high quality ob-gyn baby doctors

have to pay in order to deliver children.@@@@@@@ against them. in fact, i had one doctor tell me that he literally -- he was practicing, would have to practice through november just to pay for his premium.

and it's really having a devastating effect on mothers and on children and on prenatal care. it's a long drive in the winter to go from burling, new hampshire, to hanover to have to see your ob-gyn. it's a long time anytime over the mountains to have to go from lancaster or colbrook down to laconia. and that's what we're seeing across the country. it's not right. and there are ways to address it. this is not a theoretical exercise. it's a real exercise. we know that california and texas have both put in place limitations that are reasonable so people who have a bad experience and have an event which causes them physical harm, those people can get recovery in

those states. and yet you can have a system which isn't so excessive that you have massive settlements driven by the trial lawyers bar that undermines the abilities of doctors, especially baby doctors to practice and deliver babies. and so what this amendment does is track the texas law and the california law so people will have to set up damages and lawyers will still be able to get percentage of their fee, their contingency fee. but it sets reasonable caps so that we end up with a policy across this country that encourages ob-gyns to go out and deliver babies. and we all know that defensive medicine takes up about 30% of the cost of medicine today. we know that much of that

defensive medicine is at the margin of needed because it's done for the purposes of completing a chart so that when you have an issue down the road, you've got the documentation. and we know that's having a huge effect on driving costs. so addressing malpractice liability is critical. but even more important, we know a mother that has to get in the car and drive for miles to see a doctor in order to deliver a child or make sure her child is having decent prenatal kair is put at substantially more risk than somebody who can go in their hometown or just go down the road a few miles to see the ob-gyn and have this very exciting event, the most exciting event, really, in any life, the delivery of a child, dealt with in a much more

reasonable and humane and civilized way. so this amendment is the healthy mother, healthy babies act. i hope it will be supported and accepted. >> i would be delighted to offer a few thoughts about this amendment, which brings up once again the regrettably internal desire of certain interests to get between americans and the jury system that our founding fathers set up that is an integral part of the constitutional system of the government and has as one of its key functions the assessment of damages. it is clearly the case that juries are in some circumstances

unwelcome they tend to disrupt the status quo as a place where they appear and the observations about the united states of america is in the chapter heading on responding to the tyranny of the majority. but orp rations that create substantial harm, hospitals that create substantial harm, doctors who create substantial harm, obviously would like to have the jury system go away and not to be accountable for their injuries. there are about 100,000 americans who are killed every year by avoidable medical error and the lethal medical errors that end up in fatalities are the tip of the iceberg. underneath that is the rest of

the iceberg. all the medical errors that didn't end up in fatalities but ended up with an extra month in the hospital that ended up with a compromised child or ended up with the wrong leg off. or ended up with whatever the mistake was that didn't happen to kill that patient but created enormous damage to that family. and the notion that the solution to that problem is to be put 100% on the shoulders of the victim of that injury to me i think is very, very pour public policy. exacerbated in this case by the fact that all of those victims are going to be women and children. and it applies i believe not only to the delivery of children but to all women's health practices that ob-gyns provide. so if a cervical cancer is detected in a woman or not detected, she would lose her right to recover from her economic injuries.

and to the extent that women lead traditional lives at home instead of working in the marketplace, they won't suffer economic damages. so stripping that away from them hits them particularly hard and they'll be treating differently than the man who has a prostate cancer that was not diagnosed and goes to his doctor. so it create arts official gend gender-based discrimination about other areas of care and i think it stands on a fundamentally phony premise, which is this is what's driving the cost of our health care system. less than 1% of the health care system goes to these medical malpractice premiums. once that became clear, the insurance industry invented this shadow of defensive medicine, that the good senator from new hampshire indicated represents 20% of our health care costs. with all of the decisions that a doctor makes every day and all of the signals that direct their practice, the notion that the

risk of being sued will do something that's not indicated medicine, but there will be no effect whatsoever of the fact they get worked on piece work basis. so every time they send something out they're headed towards their profit structure, it doesn't make economic sense this would be such a huge determinant of all of that. i know it's part of what heem say. i out it it to be the case. i think there are too many other price signals going on to pick this one out and suggest that that is the case. if there are areas where the liability is so great and clearly, there is a very substantial liability when a child is injured at birth as a result of the negligence of a doctor, the consequences for that family and that child can be catastrophic. the settlements are massive, as

senator gregg has said, but the settlements are massive because the injuries are massive. and they last for the lifetime of a newborn in some cases, requiring state support, nursing support, family support, all kinds of different support through a long, long, long lifetime. so yes, the settlements can be massive and if there is something we should do about that to make sure that in the insurance business of cost spreading, there aren't isolated pockets in rural communities where we need to do a better job of spreading risk, because they do so few infants that they can't make their payments, i think that's something to look at. but i'm not willing to look at something where the full cost of this problem, of the hundred thousand lethal medical errors and the hundreds of thousands of harmful but nonlethal medical errors, the cost of all of that, of that entire social problem

gets dropped squarely and exclusively on the shoulders of the people who sustained those injuries and the worse the injury you sustain, the more harm you suffered, the more damaging the industry to you or your child, the more of this problem we ask you to bear by doing this. it is, i think, very poor social policy and a very unfortunate way of responding to this problem. >> mr. chairman? if i might respond to the impassioned and extraordinarily strong lawyerly like presentation from the former attorney general of rhode island. as if he were presenting his case before a jury. >> he's great. >> it was excellent. but the point is this. this isn't so much about containing costs, although if this approach were taken as it has been in california and texas, it would contain costs. it's about access. it's about access.

it's about giving a mother the ability to see a doctor in a reasonably prompt way without having to travel a great deal of distance. it's about access which saves lives. i would have more confidence in putting a doctor in the room than putting the lawyer in the room and i think most mothers would probably approach it that way. they want to see a doctor in a reasonably prompt way, reasonably near where they live. in rural america, that doesn't happen today. now, rhode island's a small state and i'm sure the ob-gyn practice in rhode island is probably pretty contained and people can get to doctors. that's not true in most sats. it's not true certainly in new hampshire, which isn't a large state, but it has areas that are fairly rural. the only reason doctors aren't delivering babies in those regions is because of the cost

of the errors and omissions policies. believe me, the harm that's caused as a result of not having a doctor within a reasonable distance is -- far exceeds, i think, the anecdotal statements from the senator from rhode island. in addition, this doesn't cut off recovery. if it cut off recovery, the people of texas would have rejected it. the people of california would have rejected it. two of the largest states in this country are under this regime already. this simply creates an opportunity for the baby doctor to practice in a rural area. how many programs have we talked about today, 20 or 30 or 40 or 50? that have been directed at getting doctors, primary care doctors, into rural america or out of the cities where they're concentrated. probably couldn't do anything more constructive in that area than to allow doctors in those

areas to be able to deliver babies. they're still going to have to pay an errors and omissions policy. they're still going to be subject to liability. liability's still there. if the action is incompetence and maliciousness, then there's no caps at all. but as a very practical matter, if you don't put something like this in place, you're not going to get doctors in rural america and you're not going to get them in inner cities. it's that simple. it's not a question of maybe or if or possibly. it is a fact. doctors will not deliver babies north of the white mountains. because they can't afford to. i don't know what wyoming's like. i suspect you have the same problem. so this is just a reasonable attempt to try to address access for women who are bearing children. it's not an attack on the judicial system or on the jury system. i love detoqueville.

if he saw what was happening in this country today relative to doctors practicing medicine or delivering babies, he would be upset about that, too. so the jury will still be there but the recovery will be something that allows the doctor who isn't involved at all in that case to have an insurance policy that he or she can afford. in new hampshire, most of our ob-gyns are women. so this is -- this is an attempt to address the problems this committee has spent a lot of time and created a lot of authorization initiatives under and do it in a much more simple and appropriate way, and an appropriate way that's been tested. this has been tested. it works. it works in texas and it works in california. >> let me, if i can, this has been a debate i know, i shouldn't say i know, some of my