precipitously. in no small measure because we z&z&k9&$z&z&""az&z& because we so i'm not disagreeing with you, there are points in which reducing personnel may in fact save the resources we need in the overall costs of health care. i think it's equally true that there may be areas in this debate where in fact investing in additional personnel may be necessary in order to achieve the desired results of reducing costs. this would make it almost impossible to show that sense of balance when it comes to that

debate. >> mr. chairman. i just wrote this down. sorry, i had to step out for a call. did you say there were 67,000 new employees in the federal government since this january? is that net? >> net. >> does that include the military? >> no. >> just civilian? >> this will be my last comment, i promise, so we can go to a vote and get it. this doesn't reduce the number of employees. this just says, don't net add any new ones and get the job done with what you've got. that's exactly what every business in this country's doing today. that's what every family's doing. they're making hard choices. and the real problem we have in washington is we never force the bureaucracies to make the hard choices. consequently, they don't. and what this amendment says is, make the hard choices. what's most important? what's most important, what's second-most important, what's third, and what is least

important should have the least attention paid to it. and this is a point of contention of building confidence, american people backing us. saying, do the commonsense thing. you can do more with less. let's do it. and so end of comments. i'm ready for a vote. understand -- i understand the outcome. >> it's all right. always appreciate the discussion. all those in favor of the coburn amendment -- >> i'd like a roll call vote. >> quick we'll call the roll. >> senator dodd. >> no. >> senator mikulski. >> no by proxy. >> senator murray. >> no. >> senator reese. >> no by proxy. >> senator sanders. >> no. >> senator brown. >> no by proxy. >> senator casey. >> no. >> senator jenkins. >> no. >> senator berkeley. >> no. >> senator whitehouse. >> no. >> senator encely. >> aye. >> senator greggg.

>> no. >> senator alexander. >> [ inaudible ]. >> senator mccain. >> [ inaudible ]. >> senator hatch. >> no by proxy. >> senator mutuali in in ing -- >> no by proxy. >> test eign ayes, 13 nays. >> number 72. >> coburn amendment number 72.

>> mr. chairman? since we decided we didn't like my idea of sending it all back to states, what this is is a compromise that says, perhaps we would allow hersa to contract in the states for states to put all -- funnel all their stuff into their three most areas of acute short aage.

all we're saying with this is, whatever the title is that we've got, whatever we do, this allows hersa to form a contract with the state to funnel all these monies into their three or more acute shortages. we still get money into the state but we add some flexibility into the state based on differing state needs. i think this will give flexibility to accomplish what senator murray is trying to accomplish. it still has control. it allows hersa to be in charge of that control. but it's an imperfect solution as compared to what i offered earlier and was defeated. but i think this one makes some sense, that allows the flexibility to really address the varying needs of the various states. that stops my debate. >> senator murray? >> mr. chairman, it's creative. but what it does is basically say there's only a small number of workforce shortages that the states need to deal with.

and we're not going to fix these shortages by only addressing just a small number of them. we've talked today about shortages for primary health care, for social workers for mental health advocates, for home health care workers. states have a variety of issues that they are trying to address. i think that one of the things we do do in this bill, separate from this discussion, that is we have a commission that we are putting in place to begin to look at what some of the national shortages are. and i think it's important that we do that. but this amendment in front of us specifically will direct the states to address the three most acute health care workforce shortages and perhaps leave aside a number of other ones. i understand the senators trying to get our states to have more active involvement in deciding what their own issues are. but that is exactly what we have done in the underlying bill is

push the decisions to the local communities to address the shortages that they have in their own local communities. so i would oppose the amendment. >> let me ask my colleague something. do i understand it that the commission would be required or -- to gather information from the states regarding what their needs senator this seems to be the issue. whether or not we're going to be listening to our respective states and what their priorities would be. as i understood it earlier, we had a similar debate, senator harkin made the point and identified several a areas where specifically the states were specifically mentioned. as to the importance of their involvement in getting back to the commission to make sure that at the national level, the point that tom coburn makes and i this think we all agree on, that there's a fear that this can be

sort of decided on mt. olympus, disregarding what's occurring in our respective states and the diversity that exists across the country. from connecticut and oklahoma. different needs. different climactic conditions. all sorts of things that can result in a different set of priorities. tom's fear that is this commission will disregard what the states are doing in this regard. our answer is that -- >> i would say to the senator the okay opposite would occur. what we're going to look to, i assume with the commission, is for the states themselves to work with us to tell us, here's where our shortages are. here's an information-gathering commission. then at the federal level we can make sure what we're doing actually works out in the real community. so we are addressing that within the underlying bill. >> what that means is we ultimately decide, they don't. and this doesn't stop, preclude any money to other areas. this amendment doesn't stop

that. all it says is we're giving hersa, you've got grants all across these things and our state, oklahoma for example, might not need it in three or four of them, hersa can sign a contract where they can concentrate where they don't have needs and put that money into where they have the most acute needs. in other words, we're not precluding any other area that the state might have from not getting appropriate monies. what we're saying is we're concentrating and allowing the states to concentrate on the areas of most. and what that does is we can have all the commissions we want. but ultimately the commission's going to take the information and decide how they're going to do it and decide 50 different ways for 50 different states. >> that is number -- there's nothing in this legislation that i'm aware of that would -- that prohibits a commission from responding to the one, two, three -- >> no, but there's nothing that mandates it either. >> in fact, mr. chairman, hersa will award grants to states based on what their needs are. >> based on what we perceive and whether we agree with what their

needs are. the onus is on the states to try to get the money. not on us to provide the money based on what the state says. and if it was written different where it says you must give it on the basis of the priorities of which the state says are their priorities, i wouldn't be offering this amendment. but we haven't written it that way. so the point is, all this does is gives flexibility to hersa. we know what hersa does. say, here's a state that has acute need in three areas that they may want to buff up their monies for the first two or three years in this and direct it in these three hyperacute areas. and then after that, go back and do it. but it doesn't preclude monies from going to the other areas where they have a need. it precludes money from going to areas where they don't have a need. >> this is more of a philosophical debate i sense. i certainly believe the states ought to have a lot of involvement. be able to express themselves. i don't see anything here that precludes that. it's a where you place the emphasis. i respectfully disagree with my friends. i understand the point.

i don't disagree with the conclusion. but i think it's tilting the balance here in the opposite direction than the way it ought to be. i appreciate the point. but i would oppose the amendment. any other comments? >> the balance for the most flexibility for the states. not the most flexibility for the bureaucracy that's going to tell the states what to do. >> the bureaucracy -- the word bureaucracy has its own pejorative associated with it and bureaucracy exists at every level. wanting to make sure these resources reach people that need and it in consultation with our states and local communities. it isn't just the states. in many instances the local communities sometimes get disregarded by states when they happen. >> sure. >> i wrote the fire grants. those dollars go directly to communities and bypass the state bureaucracy because i found in many instances the local community had a better sense of what its needs were than were necessarily going to be decided at a state level. i think striking that balance in all of this is important. at the local, state, and national level.

and i'm certainly would be willing to entertain language that would suggest that there ought to guarantee that these would listen to our states and our communities and what their priorities are. i wouldn't want to mandate that be the only criteria we use in determining these issues. >> mr. chairman, with all the new programs that we've got, what we're afraid of is having a bunch of stove pipes that don't really address the needs of the state or the local -- and i'm sure senator coburn would be happy to revise this to make sure that the three most important things of each of the communities would be considered as well. but the information ought to be coming that direction. we've got so many federal programs already, workforce investment act is one of those, we have stove pipes what you can use the money for. just because you have a bigger need over here and you don't have anybody that qualifies doesn't mean this money can be shifted over here. >> mr. chairman, that stove pipe issue is exactly why we've written the underlying bill the way we have. for states to put together

coherent plans that consolidate both issues and then those grants are awarded based on that. so we're addressing that here. >> i understand this. we're going to take money from the states and we're going to filter it up here and the states are going to tell us where they need to spend that money and we're going to decide whether or not we give it to them? >> the money doesn't come from the states, it comes from the taxpayers. >> of the states. >> of the communities. of the neighborhoods. in terms of the states committing streamlining plans. >> what was that, tom? >> i'm intrigued by this amendment. there's a couple of parts of it i'm intrigued by. and what senator murray just said, i'm trying to figure out. is it in this title that states shall or may or can submit a streamlining plan? i like that idea. >> it's a competitive process. so the states can, if they so desire, apply for these grants. doesn't require them to.

>> no, i'm wondering about like in b, the state shall submit to the secretary of the plan for streamline if anything funds. under the program descrubbed in subsection a. i have a bit of a problem with "a." but i like the idea of having states thinking about how they would like to streamline in these programs and stuff. i suppose if you just say they can do it, i don't know, would they do it? or should you say they shall do it as a prerequisite to getting these grants? i don't know. >> just think about the burn jag grants. i know them very well. >> they're very flexible. so that oklahoma may have this need on meth labs. may have this need on drug courts. may have this need over here. and what happens is, we give them ultimate flexibility with that money. we give them ultimate flexibility to meet the need. and the way this is written, there's not -- because if you don't have a need, you're out of luck in applying for the grant, even though proportionately,

your total need in your state as far as the workplace shortage r >> i think it's get don't go restrictive in the sense of where states can have a multiple of interests that they want to serve, some have more priorities than others. but shall, requiring them to do

that, seems to me making a burden on the state. and that's the difficulty i have. i wasn't -- i didn't frankly, candidly, i didn't get -- i should have obviously read b and c. but again -- >> we're not requiring them. what we're saying is the bureaucracy has to establish a place where they can create and allow it if they want to. saying they shall establish a program to permit each state to streamline if they want to. they don't have to. they get a choice to do that if they want to. >> now senator murray just told me that if states want to apply for these grants then they have to come up with a plan. they don't have to apply for the grants. if they do, they have to come up with a plan. is that right? >> they require it under the law. >> which means -- which means if they disproportionately have a need in three or four or five areas, and they want to go after all of it, they don't have the flexibility to -- if it's really about health care manpower shortage --

>> but -- >> and if, in fact, oklahoma has a shortage in every area, but our most acute shortage is over here, but i can go take nurse practitioners, which we may have plenty of, and i can apply for that grant, but i don't have the flexibility to then turn around and use it on pas. >> but this is -- but you're not prohibiting the states from targeting three areas. if connecticut decided they wanted to target three areas, there's nothing in this law that prohibits my state from targeting -- or five areas, or one area. >> no, but to your disproportionately excludeing -- in other words, the whole idea is to ramp up the money in the most acute area. >> i think that's fine. you've got a good amendment here. we're trying to help you on this one. >> help me, sir, help me. help me, help me. >> a couple of pieces here that i think can -- >> hersa is going to contract this. in other words, hersa's going to hold them accountable -- >> it's not limited -- first of

all it's not limited to the commission either -- >> i think you have to look -- >> hersa can say -- >> basically saying that it will take all the health care different funding pots and put them into one pot and allow states to be flexible with it. sounds good but we've been in these situations before and accountability is also an issue we have to deal with. we have done many, many things like this where we've thrown money at the states and we've had to live with the fact that they've built swimming pools in the middle of the night or whatever. there's a reason that we have the way that we have structured this bill, so that we can provide to the states funds for programs that we have outlined and discussed in many different ways. and i would just say that what sounds good on a piece of paper doesn't always comply later. i would just urge this committee to vote no. >> all right. further debate on this? want a roll call?

>> you bet. >> clerk will call the roll on tom coburn's amendment number 72. >> senator dodd. >> no. >> senator harkin. >> no. >> senator mikulski. >> no. >> no by proxy. >>er? bingham. >> no by proxy. >> senator murray. >> no. >> senator reid. >> no. >> senator sanders. >> no. >> senator brown. >> no. >> senator casey. >> no. >> senator hagan. >> no by proxy. >> senator berkeley. >> no. >> senator whitehouse. >> no. >> senator enzi. >> aye. >> senator greggg. >> aye by proxy. >> senator alexander. >> aye by proxy. >> senator burr. >> aye by proxy. >> senator mccain. >> aye by proxy. >> senator hatch. >> aye by proxy. >> senator macao ski. >> aye by proxy. >> senator kennedy.

>> no by proxy. >> 10 ayes, 13 >> number 783. coburn number 73. >> this is just another level of trying to keep us accountable. since we don't want the states to do it, and we don't want to give the states flexibilities, how about if we find that a work

force program is ineffective, allowing the secretary to say so and redirect the funds to where the program is effective? that's all this amendment does. if the secretary says this isn't accomplishing anything, we're throwing money out of the door, i would like to redirect this money to a program that's working. >> it just gives the secretaries the authority. >> mr. chairman? >> we trust the secretary for everything else in this bill. why can't we trust the secretary to make that evaluation? >> mr. chairman? >> well, first of all, the end of the line legislation calls for the creation of a data analysis center so these work horse programs will be tracked very closely. one of the problems that gao has commented on repeatedly it the lack of data, the lack of standards and benchmarks and within the end of the line legislation we create that framework. i think the question of accountability is accountability where, and i think if we create

a program which we are several programs in this legislation, we ultimately have to be accountable for whether the program is terminated and the level of funding. routinely each year the secretary of every department makes that recommendation to us in the budget. they put some money in to a program and some programs they zero it out. in fact, there are a number of programs i would suspect that hhs today that have some up with a budget of zero funding. the secretary doesn't believe or the president doesn't believe or omb doesn't believe they work, but ultimately i think the accountability has to be here in terms of terminating a program, shifting funds to another program. that's the legislative process, and to short circuit it by giving -- and this would be i think unprecedented, actually allowing the secretary to terminate the program effectively and redirect at any

time in the course of the year, you know, not through the budget cycle, simply saying i don't like this. this program is not working et cetera. i think the question is account ooblt, that the accountability should be here. we have to stand up. otherwise, i mean, again, can't think of any other situation or week to tell a secretary, for example, secretary gates, can you terminate the f-22 program at any time you want if you don't think it works, and we have no say about it, and can you direct that money into helicopter lifts. this is essentially a legislative process, and, again, the final point i want to make is that this is done with what senator coburn is suggesting, it's done every year in the budget. the secretary makes recommendations to omb. the president sends up a budget and some items zero funded,

presumably because they don't think they work or for other reasons. sometimes it's good evidence or not evidence, and some programs are funded in excess of what we think they should be funded and then we make those judgments so i think accountability is the in the legislative process. >> you know, it's amazing to me, 227 times in this bill we're going to trust absolute authority of the secretary to write all the rules, all the regulations, all the parameters of everything in this bill, and we're going to allow her to have that much power and then we're going to say, gosh, she couldn't make an evaluation about a program that's ineffective. to answer senator reed, we have three times a year where you can stop that. we always have a supplemental, at least one. we have a regular appropriations process and then you have a budget process so the most it could go is about four months. if you disagreed with it, you can add it back, but the point

is look at this big contrast of where we trust the sent and where we don't. the fact is if she -- if the secretary of hhs has the knowledge to write all the thousands of pages of rules and regulations that are mandated by this bill and then in the same breath to say we can't trust her ability to make an evaluation about a program belies, belies any sense of common sense. either she's trustworthy to write 10,000 pages of regulations which is going to come out of this, or she's not. and if she is trustworthy for that, then why isn't she trustworth toe make an evaluation as to whether the program is working. we're certainly not going to do an oversight hearing on it. and if our past experience is any indicator of our future efforts, so i -- i'm -- i'll stop. i'm beleaguered to understand

the logic where we can trust the secretary with this much power on -- on something that touches every american in this country without our oversight. we leave the discretion, major aspects of this bill, we leave the discretion to the secretary and then we have the temerity to say but you can't trust them on any program we've written in here to say maybe we could use that money better, and i want to redirect it and you can have a shot at it in four months if you think i'm wrong or to hold a hearing. >> senator reed? >> mr. chairman, first, we are giving the secretary very specific guidance in terms of the programs that we want her to enacts. some guidance is, again, some of the details have to be worked out. we can't do it. she must do it. and she will do it pursuant to rule-making which will give the opportunity for all the stakeholders to make their

comments. we'll give people the opportunity to go into court and stay, you know, you've transgressed a congressional authority that you've been given or you've failed to carry it out adequately. that's quite a bit different than giving whoever is the secretary the ability to simply say outside the appropriations process, outside the budget process, i'm taking money from here and i'm putting it here without any congressional review, without any oversight whatsoever, without any attempt -- any ability apparently to go to court, et cetera, so there is a great difference i think between the policy-making rules she will have and the regulations she has to promulgate in terms of just the way our -- the way the system functions. i mean, it's -- it all comes back to sort of regular order. you know, she will not have the ability to say by fiat this the way we're running this program because it has to be promulgated through rule-making to have the

effect of war. >> actually you've just described why government has problems operating. we don't give the administrators the power to make decisions in their area. we have the power to correct them if they make them wrong, but there's no short-term solution to anything. you know, when the appropriations comes outs or when the budget is done or when the supplementary is done, and that's it, but they are in charge of huge areas here of work force and goals, and we supposedly make them accountable but we don't allow them to make any changes unless we say so? and that's how we get stuck with a lot of these programs. i've worked with a bench of the pre-schoolchildren's programs, and we used to have 109 of them. we're down to 67 of them now. it hasn't been mostly by legislative action that that's happened because each of those programs is usually named for some former senator, and if you

talk about eliminating that program, that former senator will be in your office explaining how valuable that program is, and -- and i -- i did some check on one of those programs where i had to talk to the former senator that had done the program, and he explained to me what a great program it was and how it worked, and i asked the people out in wyoming that were taking advantage of the program and they said it's my baby-sitting service. no, they don't learn anything but who would take care of my kids if we didn't have this program? so a lot of times we lose focus of what it is and because it's named for somebody we're not willing to do it. if it were already cancelled and we had to reconsider it, it might make a whole different approach to the way we make our decisions. >> well, my only point, i think senator reed captured this. this is our system of government, is a system of checks and balances where we don't empower any branch of our government with the exclusive ability to make unilateral decisions, even the president's