we're talking about four years. you get $1.6 billion in savings over the first four years of the implementation of this -- of the class act starting in 2016. so this is affirmative in the sense that it ensures people's dignity. it allows them to work even with a disability. and it's also fiscally responsible. and those who benefit from it are paying into it. and it's voluntary. no one has to do it. it's voluntary. so we have heard a lot of arguments, senator harkin, but i think we know from the work that you did, working so many years with senator kennedy on these issues and working in the committee this summer as one of our leaders, senator dodd, chairing the hearings this summer, and now as the chairman of the committee, you have been instrumental in getting this not just legislation moving forward

but especially on the class act, and i'm grateful for you taking on this responsibility. i just wanted to get your sense of -- of what you hear from people in iowa and your own experience with why this is so essential for the american people. mr. harkin: i thank my friend and my colleague from pennsylvania for really laying out why this is so important, and the fact that we're actually going to get savings from medicaid for this. now, that's helping the states, and that helps the states a lot. so you get a lot of banks for the -- a lot of bangs for the buck you might say with the class act that we have in this bill. i would say that -- to my friend from pennsylvania, i think one of the -- one of the biggest concerns i think that people have, they may not express it when they are younger, but once

they start working and they start having a family and they see one of their friends, a relative, someone in their neighborhood become disabled, -- and believe me, it happens to all of our families. it happens in our neighborhoods. it happens to our friends. they see that and they wonder maybe there but for the grace of god go i, but what would i do if something like that happened to me? what would my family do, my children, how would they function, where would the money come from? and so to be able to have the peace of mind to know that there is a program whereby they can put some money aside every month voluntarily for five years and that after that, they would then be able to access money if they got disabled.

talk about a great insurance program. talk about the peace of mind this would provide for people. and as i said, and as we both have pointed out, this is actuarially sound for 75 years. actuarially sound for 75 years. so it seems to me that for all these reasons, for the savings in medicaid, for the soundness of the program, but also for the peace of mind for people who are working to know that they now have a program, something they can access that will provide them -- again, i don't want to sell -- sell this for more than it is. this is not something that will make someone hundred% whole from their earnings, from what they may have been -- we're not trying to tell people that. what this will give them is up to $75 a day to help them with all of the things i pointed out. maybe getting up, getting ready

to go to work. maybe it's personal attendant services. it could be a whole host of different things that will enable them to live in their home, in their community, and, yes, maybe even be able to go to work every day. my friend from pennsylvania referred to the story i told earlier this summer, and i like to tell it because i think it is is -- it really illustrates what we're talking about here. i have a nephew, kelly, my sister's boy. well, he's not a boy anymore. he's an older man now, i guess you might say. became disabled at a very young age, age 19. severe paraplegic. and -- but he was able to go to school, go to college. he was able then to live by himself in his own home. he had a van with a lift. he could get his wheelchair up

there and punch the button. the doors would open, the thing would come down. he would get in the van. he had use of his hands. he could drive to work. he was able to start his own small business. but every morning, he needed a nurse to come into the home, get him ready to go to work, get him up, get him going, get him out the door. and every night when he came home, he stopped to do some shopping on the way. he would come home in his own house where he lived, in his own community, among his family. his family was close by. then he would have a nurse every evening do his exercises for him, keep his arms strong, do all of his other internal things that needed to be done, make sure he would get to bed. it happened every day. but because of that, he was able to live a full life -- and he still is. he is still an active man.

but that was -- gee, that was -- i'm trying to remember now. i have to think. that was in 1979, 30 years ago. so kelly must be about almost 50 years old now. i never thought about that. i always think of him as a kid. but he was able to do that, and he has lived a full life. he has been able to work, live by himself, do all kinds of wonderful things. now, how was he able to afford this? is his family wealthy? not a bit. not at all. in fact, his mother died shortly after the accident happened. my sister had breast cancer, died. at an untimely young age. but the way kelly was able to do all this is because he got injured in the military. he got injured while he was on board a ship off the coast of vietnam. and so the v.a. paid for all

this and is still paying for it, for his personal services so that he can live by himself and get out the door and go to work every day. i've seen what that's done for him. i thought to myself well, if we can do this for veterans, what about other people in our society who through no fault of their own, through an accident or whatever become disabled? and i thought about how much kelly was able to earn during his lifetime, the fact that he paid taxes, had his own business. you know, that was a pretty darned good deal for the taxpayers of this country. well, in a small way, that's what we're trying to do here. that's what we're trying to do with the class act, to build a system for someone who gets injured, becomes disabled, has some support mechanisms there so that they can also live a full and rich and happy quality life without having to go to a

nursing home. and that's what this is all about. that's what this is about. so as i said before, it has -- i say to my friend, it has so much to offer. i can't imagine that there would be any real opposition to this. voluntary. actuarially sound. provides a stipend to help people if they become disabled. so i say to my friend from pennsylvania that it seems to me of all the things we have been discussing on this health reform bill so far and probably all the other things we'll be discussing, to me this is one of the most important. this is one of the most important parts of this health reform bill. we've never done it before. but it's long overdue. it would be good for our families, it would be good for businesses, it will help our states because of the cutbacks that they won't have to pay so

much in medicaid. so for all those reasons, i think my friend -- i thank my friend from pennsylvania for his strong support of this and -- and i say to my friend ted kennedy, we're going to get it done. it's going to happen. we are not going to let this bill get through and go to the president without having this in it. it's going to be there. make no doubt about it. and we're going to make it work. just as the veterans' administration worked for my nephew kelly all those years. i would yield back to my friend from pennsylvania. actually, he asked me a question and i kind of got off a little bit there in telling my stories. mr. casey: no, i'm glad you told that story. for me, this summer, beginning to learn about the details of the class act, it was a way to to -- through the life of your

nephew to be able to tell the story about why it was so important. i was thinking as you were talking about the program and the class act itself and your own personal story and why it makes such sense, sitting here to my left on the floor is kelly garner. she worked for years on this legislation with senator kennedy, and she would know better than i and senator harkin would know better than i, ted kennedy not only liked this and fought hard for this program, but he wasn't a guy who just liked interesting ideas. he wanted it to work. and look, there are times we'll be talking about the children's health insurance program this legislation. that is -- that is a program that had its origin in government and there is a lot of government involvement in that program. i support it and will fight to the end of the earth for it. this program, the class act, the program that results from the class act, is different. it's really a hybrid. it's really in many ways a

creative way to provide these kinds of services for people with disabilities. it's not a government entitle program. it's a program that doesn't confer rights or an obligation on government funding, nor does it affect receipt of our eligibility for other benefits. it stands on its own financial feet, the point that senator harkin made. and why wouldn't we do this? and this wasn't just -- this wasn't just dreamed up this summer. senator kennedy, senator harkin, kelly garner and plenty of other folks were working on this for a lot of years. this is the result of years of work. not just a couple of weeks or months. so they worked on this to get it right, and we have it right. it's -- it makes sense fiscally, it makes sense in terms of the dignity of people's work or the dignity of being able to stay in

your home and be provided basic services. all of our families are affected by this. at some point or another, you're going to have a loved one who wants to work but has a disability maybe or wants to -- and needs long-term care services and doesn't want to leave the home. everyone is affected by that. there's not -- there's not a member of the senate on either side who isn't going to be affected personally someday by this challenge, and all we're saying is we've got a way to make it a little easier for folks. as senator harkin said, it doesn't solve all your problems, but it helps provide the kind of services that we should have a right to expect. so we have got this figured out. some of these things we can figure out, and because of all the work that was done over many years, this program, this voluntary selfinsurance program is one way to -- the selffunded

program i should say is one way to do it. senator harkin has been leading and we're grateful for that leadership. mr. harkin: if the senator would yield again to me? two other things. i'm glad the senator mentioned connie garner who worked with senator kennedy for so many years on this, has her own personal story to tell regarding this very poignant story. and i want to thank connie for all of her wonderful work on this and kind of shepherding this through. she is probably sitting over there wishing that we had said this and that because we probably forgot something and she knows better than what we know, but we do our best, connie, we do our best, okay, with what we have anyway to try to explain this, but i thank connie for all of her great work and leadership and getting us to this point. i wonder if i might impose upon

the senator, if i might not digress but talk about one other part of the picture here that we're talking about in terms of of -- of covering people with disabilities. so we have been talking about the class act which is prospective, it looks ahead, it provides the mechanism whereby middle-class families can plan for the future possibility of an illness or disability by putting this money away every month. we've talked about that. but one might ask the question what about those who are disabled now? what's happening to them? the millions of americans that are already living with a disability. well, mr. president, in 1990, we passed the americans with disabilities act.

we began to break down a lot of the barriers in terms of people with disabilities and accessing daily living, accessing employment, transportation, but what happened was a few court cases started interfering with this but there was one court case in particular called the omsted decision. 10 years ago. it came out of georgia. it was a case in georgia. it went to the supreme court. the supreme court said that based upon the americans with disabilities act that a state had to provide the least restrictive environment for a person with a disability.. well, this was wonderful, because the only option for many people with disabilities right now is to go to a nursing home. in fact, our laws, our federal

laws are basically skewed towards putting people in nursing homes. let me explain. right now, about the only support that a person with a severe disability has right now is through medicaid. well, as you know, through medicaid, you've got to spend down until you become poor and then you get access to medicaid. but under our laws, medicaid must, must pay for you if you're disabled and you qualify, they must pay for you to be in an institution, a nursing home. must. they have to pay for you. if, however, you are a person with a disability and you say, but i don't want to live in a nursing home, i'd like to live like my nephew kelly, i'd like to live in my own house with my friends, in my own neighborhood.

medicaid does not have to pay for that and in most cases does not pay for that. in the vast majority of cases does not pay for that. and so there began a movement in the mid-1990's to poi fo providr funding for individuals with disabilities so they could live in their own homes in the community and not have to go to a nursing home. well, that bill never got anywhere. it was called micasa. the medicare community and services act. i always delight in telling my colleagues that the first sponsor of it in the house was the first speaker of the house at that time and he just taken over. his name was newt gingrich. today he's still supportive. i haven't talked to him lately

but a few years ago, he was still a strong supporter of micasa. it later became something called the community choice act, but we could never get it enacted into law. it is a part of this health reform bill in this way: it provides that if a state -- if a state implements this community choice act, which would allow people with disabilities to live in the community rather than in a nursing home, they will then get a bump-up, they will get a -- a 6% increase in their federal match for medicaid. as you know now, the federal government provides some, the state provides some for medicaid. it's roughly about 60-40. some states it varies a little bit but that's roughly about it, 60-40. well, that means that a state now who -- that would do this would not have to come up with

their 40%. they would only have to come up with 34%. so it's an incentive for states to begin to implement the supreme court decision of over ten years ago, that people with disabilities have a right -- a right -- to live in the least restrictive environment. and so again, medicaid right now, as i say, i repeat, right now will provide only for nursing home care. states are obligated to pay for that, they must. now, again, this also is -- is a part of -- of what the seniors -- of what the elderly in this country are concerned about too. a lot of elderly say well, theyn they become disabled, they don't want to go to a nursing home,

but that's the only option under medicaid. and so it's -- it explains why the second biggest priority in poll after poll, the second biggest priority for seniors in this bill, after strengthening medicare, which we do, is changes to the health care system that will allow them to get help at home that they need to stay at home rather than going to a nursing home. and again, you might say, well, why is this so important? why is this so important? well, again, a couple stories of two women who brought the olmstead case, lois, curtis and elaine wilson. when asked at a hearing what had changed for them, because they were no longer institutionalized, they both spoke of things that we kind of take for granted. they had new friends. they could meet new people. they could attend their family

celebrations. and i like this one, they said, we could make kool-aid whenever we wanted to. simple, little things. they could go outside and take a walk in the neighborhood. they got a little dog. now they had a dog and they could take the dog for a walk in the neighborhood. something that they couldn't do in the nursing home. so that's another part of this bill, very closely aligned with the class act but it pertains to those people with disabilities right now. and we know -- again, we know from data and statistics that we have that by paying for personal care services and -- and home care services, you might say, well, that's really expensive, but we know from data that we get three for one. we can provide for everyone person in a -- for every one person in a nursing home, for what that costs, we can provide community and home-based services for three people. three people for every one in a

nursing home. so in a way, yes, it does cost money, but for every person -- every person we get out of a nursing home, we can pay for three living in the community. and, again, that's not to mention the kind of quality of life that i just mentioned about. so this bill for the first time creates what we call the community first choice option that gives states an extra share of federal money -- i mentioned earlier 6% -- if they agree to provide personal care services to all eligible people in their state. by eligible, i mean these are eligible for institutional care. if they provide that to them, then they get a bump-up. and only by making personal care services available on an equal basis to all those who are eligible can we satisfy the promise to the americans with disabilities act and really meet the supreme court mandate in the olmstead decision. so i just wanted to say to my

friend from pennsylvania, there's kind of two aspects of this bill. one is the class act, which looks ahead, provides for that peace of mind that people know that they can have that access. and then we provide for people with disabilities living out there today, fearful that the only thing that will happen to them is they'll have to go to a nursing home. now we're going to say to the states, you provide those community and home-based services, we'll give you more money to do so through your medicaid program. hopefully with that, we'll then begin to see states begin to move more rapidly to fulfill t the -- the mandate of that supreme court decision, i say to my friend from pennsylvania. and i thank my friend for yielding me this time to explain that. mr. casey: and, mr. president, i would yield the floor and note the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

mr. casey con. mr. president? the presiding officer: the senator from pennsylvania. mr. casey: mr. president, i would ask that the quorum call be vitiated. the presiding officer: without objection. mr. casey: thank you, mr. president. mr. president, first, i ask unanimous consent that on frid friday, december 4, after any leader remarks, the senate then resume consideration of h.r. 3590, with debate only in order until 11:30 a.m., with no amendments, motions to commit or any other motion other than a motion to reconsider a vote, if

applicable, in order during this period except those that are currently pending, with the time after the leader time equally divided and controlled between the leaders or their designees, with the majority controlling the first portion of time. the presiding officer: without objection. mr. casey: i ask unanimous consent the senate proceed to a period of morning business with senators permitted to speak for up to ten minutes each. the presiding officer: without objection. mr. casey: mr. president, i ask unanimous consent that the senate proceed to executive session to consider executive calendar number 1, treaty document number 114, protocol amending tax convention with france, that the treaty be considered as having advanced to the various parliamentary stages up to and include the presentation of the resolution of ratification and -- not and

but that any committee understanding, declaration or condition be agreed to, as applicable, that any statements be printed in the record. further, that when the vote on the resolution of ratification is taken, the motion to reconsider be considered made and laid on the table, the president be immediately notified of the senate's action. the presiding officer: without objection, so ordered. mr. casey: i ask for a division vote on the resolution of ratification. the presiding officer: a division vote has been requested. all those in favor of the resolution of ratification stand and be counted. all those opposed stand and be counted. two-thirds of the senators having voted in the affirmative,

the resolution of ratification is agreed to. mr. casey: mr. president, i ask unanimous consent that the -- let me do that again. mr. president, i ask unanimous consent that the senate consider en bloc executive calendar numbers 550, 555, 559, 562, 565 to and including 577 and all nominations on the secretary's desk in the air force, army, and navy, that the nominations be confirmed en bloc, the motions to reconsider be laid upon the table en bloc, that no further motions be in order, that any statements relating to the

nominations appear in the appropriate place in the record as if read, that the president be immediately not immediately e senate's action and the senate resume lenl laiivresume legisla. the presiding officer: without objection, so ordered. mr. casey: mr. president, i ask unanimous consent the judiciary committee be discharged from further consideration of s. res. 337 and the senate proceed to its immediate consideration. the presiding officer: the clerk will report. the clerk: senate resolution 337, designating december 6, 2009, as national miners day. the presiding officer: without objection, the committee is discharged and the senate will proceed to the measure. mr. casey: i ask unanimous consent that a resolution be agreed to, the preamble be agreed to, the motions to reconsider be laid upon the table with no intervening action or debate, and that any statements related to the resolution be placed in the record at the appropriate place as if read. the presiding officer: without objection.

mr. casey: i ask unanimous consent that the senate now proceed to the consideration of s. res. 369, which was submitted earlier today. the presiding officer: the clerk will report. the clerk: senate resolution 369, to permit the collection of clothing, toys, food, and housewares during the holiday season for charitable purposes in the senate buildings. the presiding officer: without objection, the senate will proceed to the measure. mr. casey: i ask unanimous consent, that the resolution be agreed to and the motion to reconsider be laid on the table. the presiding officer: without objection. mr. casey: mr. president, i ask unanimous consent that when the senate completes its business today, it adjourn until 9:30 tomorrow, friday, december 4. that following the prayer and pledge, the journal of proceedings be approved to date, the morning hour be deemed expired, the time for the two leaders be reserved for their use later in the day. and the senate resume

consideration of h.r. 3590, the health care reform legislation as provided for under the previous order. the presiding officer: without objection. mr. casey: mr. president, we currently have one amendment and one motion to commit pending to the bill. and senators should expect roll call votes throughout the day tomorrow. if there is no further business to come before the senate, i ask that it adjourn under the previous order. the presiding officer: the senate stands adjourned until 9:30 a.m. tomorrow.

>> up next on c-span 2, senate health care debate from earlier today. after that, defense secretary robert gates has devised about new u.s. military in afghanistan. and later, the director of the secret service testifies about the security breach at the white house state dinner last week. >> american icons, three original documentaries on c-span now available on dvd. a unique journey through the iconic homes of the three branches of american government. see the exquisite detail of the supreme court are the eyes of the justices. go beyond the velvet ropes of

public tours into those rarely seen spaces of the white house, america's most famous home. and export history, art, and architecture of the capital, one of america's most symbolic structures. american icon, a three disc dvd set. it's $24.95 plus shipping and handling. order online at c-span.org/store. >> new hampshire senator judd gregg or letter this week to republicans recommending a slow debate on health care legislation. senators discuss the communication on the senate floor for about ten minutes. you can read the letter at c-span.org/health care. >> madam president, this is the fourth day on this bill. and we are only late this morning coming to her first vote. even for the united states senate, this is a slow pace. i note that some have made plans

for delaying the spell even in a more extreme fashion. as the majority leader noted earlier today, on tuesday, one senator circulated a list of delaying tactics available under the senate rules. i presume that all senators know the senate rules already. so i've decided that letter to meet leaves the impression that senator would like to urge senators to use some of those delaying tactics stated in that memo. but i urge a more cooperative course. out of courtesy to other senators i urge my colleagues to allow us to reach unanimous consent agreements to order the the voting of future amendments in a more timely fashion. that's simply the only way that we can ensure that more colleagues would have the time and opportunity to offer and debate or amendment.

i think all senators. madam president, a couple requests. first i that senator harkin could make his forum. contents that stacey sacks detail leave the senate health committee. a majority health office granted for privileges for hh 3590. >> without projection. >> i ask consent that the order of december to be modified to delete all after the work table. >> without objection. smack i now ask consent that from 2:00 to 2:45 p. divided as follows in the order listed to the first 17.5 minutes under the control of senator mccain for his designee. the next 17 minutes under the control of senator baucus or his

designee. and the final ten minutes, five minutes each for senator mccain and senator ben and from colorado. >> without objection. >> thank you. senator from iowa. >> matter president, i heard the distinguished minority leader and his comments this morning say that one of the reasons they're kind of slowing to spill down and having all this debate is because i quote his words, a strictly partisan venture thus far. well, i beg to differ with the minority leader. nac are distinguished ranking member of our health committee here on the floor. in the health committee, the health committee, let me just again or the alignment of the senators, we have 13 days of markup, 54 hours, 788 amendments for file, 287 amendments were considered, debated, and voted on or accepted. 161 republican amendments were

adopted. 161 republican amendments adopted. no one was denied the opportunity to offer any amendment to discuss and debate it and get a vote or get it accepted, whatever the case may be. to me this is truly a bipartisan way of proceeding. it seems to me that the minority leader, his argument, basically goes to the fact that the people of this country overwhelmingly elected democrats to guide and make changes for the future. and one of the biggest changes is in our health care system. and so one of the responsibilities of being in the majority party is to propose. that's what we've done. we are proposing changes in the health care system in america. it seems to be the function of the minority is to offer amendments, instruct amendments, offer different ideas and if their ideas are better or get

the majority approval, then the bill is both changed. and that's happened in our health committee as i said 161 republican amendments were adopted. to me that is bipartisan. and that's what we've been doing. what is kind of not acceptable is this idea that things are just going to slow down for the purposes of delaying and eventually making sure that we don't have a bill. well, let me just say that after all that lengthy debates we got in the health committee, we passed a bill. the same will happen here on the senate floor. i don't care how many times a minority wants to drag it out and slow it down and try to kill this bill. this bill will pass the united states senate. we'll go to conference and will have it on the president desk early next year. >> madam president. >> senator from wyoming. >> i appreciate the comments. some need correction and some

from yesterday and some that have just been made. but a partisan bill. i sat there all the states in the health committee. that bill was rushed and put together. senator kennedy was not able to be involved in that part of it. his staff did it. they did it in a hurry. we turned in 161 amendments that were accepted. most of those were with typos and minor corrections. not very few of them actually have some substance to them. that bill was passed on june june 17th without a single republican vote. it wasn't published. we didn't get to see the final version of that until september 17. and you know what, the ones that were really something i could've made a difference were taken out without the permission of any republican senator. that's not bipartisan. we talk about how many hours we spent together. if you don't accept things from the minority party, it's not bipartisan, it's still partisan, just spending hours to make any

difference. to move onto a different topic, yesterday we were talking about cost and i hope that people take a look at a wall street journal article from yesterday that says that the bill that raises prices that lowers cost does other miracles. we heard all day yesterday that this bill is going to save people a lot of money. well, this article says we've now reached the stage of health care debate on all that matters is getting the bill passed the law news is good news, more subsidies means lower deficits and more expensive insurance is really cheaper insurance. the nonpolitical mind reels. consider how washington received the congressional budget office's study monday of how harry reid senate bill will affect insurance cost, which by any rational nature ought to have been seen as a disaster for the bill. cbo found that premiums in the individual market will rise by 10% to 13% more then if congress did nothing.

family policies under the status quo are projected to cost $13,100 on average, but under the bill that we're looking at it would jump to $15,200. nebulous news. no big cost rising u.s. premiums is seen in the study said "the new york times" while the "washington post" declared senate health care bill gets a boost. the white house crowed that the cbo report was more good news about what reform will mean for families struggling to keep up with skyrocketing premiums under the broken status quo. finance chairman, max baucus, chimed in with the health care reform is fundamental by lowering health care costs, lowering costs as with health care is designed to do. lowering costs will achieve the subject is. except it won't. cbo says it expects employer-sponsored insurance cost to remain roughly in line with the status quo. yet even this is a failure. by mr. baucus in the white house

on sanders. meanwhile fixing the individual market which is expensive and unstable largely because it does not favor the tax treatment given to the job-based coverage was supposed to be whole purpose of reform. instead cbo is confirming that the new coverage mandate will drive premiums higher. but the democrats are declaring victory. because of the opposite by new government subsidies. about 57% of the people who buy the insurance that will simply to these individual markets will qualify for subsidies and cover about two thirds of the total premium. so the bill will increase costs, goblin disguise this cost by transferring them to taxpayers from individuals. higher costs can be conjured away because they are suddenly on government balance sheet. the rebuild 371.9 billion new health tax is are also apparently not a new cost because they can be passed along to consumers or perhaps be hidden and lost wages.

this is a paleolithic of the brute force wealth and a very long way from the repeated white house claims that the reform is about ending the costs are. the only thing being dense here is the budget truth. moreover cbo is underestimating the cost increases based on county by county actuarial data. the insurer well point tabulated that mr. baucus would cause him to triple in middlemarch are. i assume it's going to happen in wyoming. the blue cross blue shield came to similar conclusions one is community rating which forces them to change rates regardless of health status or habits. cbo doesn't think this has much effect, but costs inevitably rise when insurers aren't allowed to price based on risk. and we have 35 states that give an example or not. at the white house decided to shoot the messengers like well point to avoid their messages.

william congdon of the brookings institute and mark showalter at brigham young have found similar results in the 2008 papers in the peer-reviewed forum for health economics and possibly see. as economist on the estate community rating months raise premiums and the individual market by 20.9% -- >> the senator has consumed five minutes. >> iso 30 manger of this editorial be published in the journal. >> without objection. >> i yield the floor. >> and you can read senator greg's letter at c-span.org/health care. the u.s. senate voted to protect coverage of mammograms and preventive screening test for women. the vote was the first in the senate of health care reform. it comes in the wake of controversy over a government advisory panel's recent recommendations on mammograms. here's part of that debate. this is 90 minutes. >> first, i have to respond to

my friend from wyoming about doing this in a hurry. mention that we done any hurry. actually it was last november, shortly after the election that i received a call from senator kennedy talking about doing a health reform bill, asking if i would take charge of section dealing with prevention and public health and wellness. i think then he asked senator murray to take over workforce development. senator bingaman did coverage. and senator mikulski did quality improvements. so that was in november. after that, i can't speak for the others that did the other sections. all i can say is on our side and when i did reified hearings. we have five hearings on prevention and wellness of public health and what ought to go into a bill. in those hearings, i think amidst an september and went through february.

and then we worked until june. we didn't start our markup until june. so it almost six months of hearings and putting things together in the bill before we started markup. i rather doubt that could be said to be rushing anything. but madam president, i want to focus on the vote that's coming up on the amendment offered by the senator from maryland, senator mikulski. which will strengthen provisions in the bill concerning preventative health benefits for women. as an initial matter, i'm proud of the significant investment this bill makes overall and wellness and prevention. it's not been talked about very much. if you read the public press out there, the popular press is about the only thing you think that's in this bill is a public option and abortion. and that's what this bill is about. those may be the high points in the flashpoint, and to make for good price, but i submit that while the most important part,

if not the most important part of this bill is what it does for prevention and wellness. trying to move our cost upstream, keeping people healthy in the first place. i've said many times what good does it do us if we're just going to pour more money into paying bills for a broken, dysfunctional, sick care system. not a health care system, a sick care system. but the good america today. this bill begin the transformation of moving us from a sick care system to a true health care system. and the senator from maryland has a very important amendment to make player, to make clear that what is included in this bill is to strengthen the preventative services that basically inured to the women took this country. mikulski is amendment gives recommendations of our bill and it also points out that the

recommendations that the united states preventative services task force is a floor, not a ceiling. it's a minimum. in other words, health plans are required at a minimum to provide first dollar coverage or preventative service is recommended by the preventative services task force, but that's just a minimum. the secretary of health and human services has full discretion to identify additional preventative service that will be part of the essential package offered by health insurance on the exchange. now, again there's been some talk here about this task force that the preventative services task force that somehow this is a bunch of bureaucrats. it's government-run task force. it is a political agenda. i've heard all the things he said on the floor in the life they are so. well, in fact come to preventative services task force is an independent body that evaluates the benefits of

clinical, preventative services. it makes recommendations. again, no decisions, just merely recommendations about which services are most effect is. who's on this task force? well, experts and leaders and primary care who are renowned internists, pediatricians, family physicians, gynecologist, obstetricians, and these professionals are not located in washington d.c. they're all over the country. some may be in one state and other states. they are all over the country. and they're the experts in these different areas. recognized by their peers. ditto said in an office that health and human services. they bring years of medical training and experience to the jobs they do. now does that mean that they never make a mistake? no. no one is perfect. no senator is perfect and

neither is any doctor perfect and neither is any task force always going to make what we might consider to be the perfect answer. but our bill does not grant the authority to tell insurance companies what not to cover. now that's clear. but do your it before you think you would be just the opposite that they can tell insurance companies what they can't cover. that's not true. our bill says that those recommendations that are a and b. categorized by the preventative services task force by this expert doctors around the country. these are the ones that they say really are key preventative services, have the most benefits. we say that in our bill that those services must be covered. without co-pays, without deductibles. that means that if the floor. that's the floor.

now again i might also add that preventative services that are rated by the advisory committee on immunization practices and by comprehensive guidelines supported by the health resources and services administration are also part of the recommendations to establish that floor. so again i would say it's a pretty big floor, when you put all those together. now, so again, it does not establish a ceiling and it doesn't say what can be done. it just says he got to do those basics as a floor. and i do understand the concerns of some of the task force has not spent enough time studying preventative services that are unique to women. now senator mikulski goes back a long way on this. and i can remember some years ago senator mikulski pointing out to me and my capacities and chairman of the appropriations subcommittee that funds nih --

>> senator sign has been expired. >> i ask for three more minutes. >> without objection. >> senator mikulski said if you look at the research done at nih it is all done on men and women. and i remember that some years ago when all of a sudden the light bulb went off in my head and i said you're right. so we have to start changing the focus of a lot of the research done to focus on the unique situation faced by women. well, this is also a concern that was raised in a house committee by senator mikulski and we included language to require all health plans to govern comprehensive women's government cared and screenings based on guidelines promulgated by the health resources and services administration. again, without any co-pays or deductibles. that was in our house bill, but unfortunately it was not included in the merged bill. but senator mikulski's amendment, which we are about to vote on brings us right to the

position that we had on the health committee bill. that was largely, i think, supported if i'm not mistaken on both sides at least in our health committee. at least no one offered any amendment to strike it. i assume it was supported generally by both republicans and democrats. so by voting for the mikulski amendment, we can make doubly sure that the floor that we're establishing a spell for preventative services that are unique to women also have no co-pays and no deductibles. and again, that's why this amendment is so, so important. now again, i note our friend senator murkowski has a different way of approach. i commend her for her involvement and her interest in this. she's been a great member of our committee in a deadlocked a great work with senator murkowski. but again her amendment misses

the mark in this way. it asks insurers to use guidelines from provider groups were making coverage decisions. well, that does not guarantee that women will get any of the preventative services they need. it's sad, and here's a statement here from the american heart association that says we are concerned that senator murkowski's amendment would take a step backwards by substituting the judgment of the independent u.s. preventative services task force with the judgment of private health insurance companies. and i ask that this letter from the american heart association, the statements being made here at >> without objection. and the senator sign has been expired here it >> again, the point is the mikulski amendment should be adopted.

>> i yield ten minutes. and the senator from florida. >> senator from florida. >> madam president. i met the mikulski amendment -- >> madam president, thank you. i come to the floor today to draw back the curtain a little and wide in the land to talk about the issue of the bill before us not just on this particular amendments but on what it's going to mean for my constituents in florida and for the people of this country. madam president, i had the opportunity last week to be back home in florida and south florida in south beach county, miami-dade county, where i talked to the hospital's aunt tran. as well as everyday floridians, specifically senior citizens. and the response is that i were near unanimous and that is grave

concern about the bill that's being debated on this floor. and the general confusion as to why the congress is pursuing on the path that it is. people of florida don't understand why we are going to cut medicare to create a new program. the people of florida don't understand why we are going to raise taxes to cut a new -- to create a new program. the people have spoken to in florida do not understand why we would undertake a new $2.5 trillion health care proposal if it wasn't going to reduce the cost of health insurance for the 170 to 180 million americans that have health insurance today. why are we embarking upon this measure if it's not going to affect most of everyday floridians and everyday americans who are struggling under the high cost of health insurance? health insurance premiums have increased 130% in the past ten

years. when the president but this proposal forward and when he campaigned on it, he said that his major goal was to reduce the cost of health insurance. when he addressed the nation in a joint session of congress on september 9, he said that his plan would reduce the cost of health insurance. but we find out for that at least 32 million americans it will raise the cost of health insurance 10% to 13%. so at least half of the goal, if not most of the goal, of his plan for most americans in this country will not be accomplished. yet were going to cut nearly $.5 trillion of medicare. we're going to raise taxes by half a trillion dollars and were going to spend $2.5 trillion on this program which was admitted to a senator baucus yesterday on the floor. which cannot be undermine understanding in any way budget neutral. not a president, i want to speak sympathetically about the cuts to medicare.

192 billion according to the congressional budget office to medicare payment rate for most services. and i think we have to be clear here that if you cut providers, you are going to cut services. the very reason we talked about increasing.your payments in that quarter trillion of the dollar program was so that patients wouldn't receive less services. so that there would be ample doctors providing services for medicare. it is beyond logic to argue that cutting providers will not cut services. and what will happen when we cut providers,.yours, nursing homes, home health agencies, hospitals, less and less of them will provide benefits and less and less of them will take medicare. the chief actuary of cms believes that the cut in the bill that we have before us will

for providers constitute a substantial portion of their business. more they're not going to participate in medicare. the medicare payment advisory commission found in june of last year that 29% of medicare beneficiaries who remember *f who were -- who were looking for a primary care doctor had a problem finding one to treat them. this is of grave concern to the 3 million floridians who are on medicare. if a doctor won't see them, what kind of health care plan is this? these seniors, our greatest generation, have paid into this program their whole life, and it is i will illusory if they can'a doctor who will treat them. one of my constituents, earl bean, from sanford, florida, recently told cnn that he called about 15 doctors when he was trying to find health care, and

he was told they're not taking new medicare patients. so when we cut $500 billion out of medicare, is that going to improve health care for seniors or is it going to continue to decline health care for seniors? you can't get blood from a stone, madam president. it's going to make the situation worse. and for anyone to come to this floor and say that it won't is incredulous. incredulous. anyone to come to this floor and say that i won't is incredulous. we have to second-highest medicare population in florida. and when we caught on hundred $35 billion from hospitals in 21 billion from the disproportionate share fund, which is basically money that goes to these hospitals to provide health care for seniors how or they going to be to provide that health care? i spoke to the administrator of the north brought word hospital district and told him about the

cut to the dish funds and he told me it would be devastating on their provision of health care. and then we are going to take a theory popular program called medicare advantage, more than 900,000 floridians in my state and we are going to cut that as well. i recently revisited the leal medical center and their new facility in miami-dade county, where they are providing state of the art first class of care for seniors. not only normal health care, but eyeglasses, hearing aids, dental care, and the constituents that go there, they love it. they are getting the kind of health care you would hope for senior citizens and your family would get. and the principal of the company told me they've saved $70 million in the way that they from their system. and he told me if we continue on these packed with medicare advantage he will not be able to provide these good service is going forward. now there are some fixes to

grandfather folks in, but all in all people will be cut and all in all the program will not be as good, and will decline the health care of seniors in florida and across this country. we will cut $15 billion from nursing home care, $40 billion from home health agencies. i spoke to a provider of home health agency practice in florida. he said that these cuts will put half of the home health care agency folks out of business. at the time when we have 11.2% of men and women in florida, his health care bill is going to cost people their jobs and it's going to decline the quality of health care. i am also concerned about this medicare advisory board. this independent board of mauney elected folks are going to have the power to cut medicare by $23 billion over the next ten years and will be up to this body to reinstate those cuts.

these people are not elected. my constituents in florida don't know what they are. but they are going to be responsible for the decline of their medicare and health care. the greatest generation fought to protect this country is looking at this health care bill and wondering why. folks with health insurance in this country, more than 170 million who are not going to see their health care costs go down but up are wondering why. americans who are seeing higher taxes and penalties for not buying these health insurance programs under this bill are wondering why. if we are here to reform health care and we should be, if we are here to try to make sure the 45 million people in this country and the nearly 4 million floridians get health insurance, and we should be, why don't we take a step-by-step approach?

madame president, i am new to this body. my first date was september 10th so i've not even been here three months. but i can tell you the american people what if they knew what i know now and could see what all i see they would be baffled by this process. there isn't a give and take on this. we didn't sit down together in a conference room and work this out to have a bipartisan bill. their leader, the democratic leader worked on it with his colleagues but not with us. so now we have a program that cuts medicare, raises taxes that doesn't decrease the cost of health care for the majority of americans and will cost $2.5 trillion can't be budget neutral at a time, madam president, when we have a 12 trillion-dollar debt that requires each of us, each family to put $100,000 on our shoulders

to be a responsible for that debt. a debt where the third largest payment in the budget is for interest payments. in the next ten years those interest payments will go up by $500 billion. enough to pay for many of the budgets of the federal government -- >> you have used or ten minutes. >> -- including the war in afghanistan and iraq. i thank the senate, and i yield the floor. >> the senator from maryland. >> is this -- >> how much time for the senator? >> the senator from maryland controls the time. the senator from maryland has 33 minutes. >> madame president, i yield myself a firm ten minutes. >> without objection.

>> madame president, healthcare is a woman's issue. health care reform is a must do woman's issue. and health insurance reform is a must change issue. so many of the women and the men of the senate are here today to fight for change and to make sure that we have universal access to health care and we have universal access that it makes a difference in our lives which means that we have to have universal access to preventive and screening services. what my amendment does, and by the way it is a bipartisan and meant, it makes universal access to preventive screening services for women available. now, there is much discussion about whether or not you should get a particular service in particular age. we don't mandate that you get a

surface. we leave that up to a decision made with the woman and her doctor. but first of all you need to be able to have a doctor. so we are for universal access, and this is why the underlying bill is so important. and then when you have that there would also be universal access to preventive screening services particularly to the top killers of women, those things unique to women. if we take cancer we think about breast cancer, ovarian cancer and cervical cancer. also women are dying at an increased rate of lung cancer than there are these other silent killers that, and have had a lethal effect on women, and that's cardio and vascular disease. so we want to guarantee universal access to medically appropriate or medically necessary screening and preventive services.

many women don't get these services because first of all they don't have health insurance and number two, when they do have it it means that they either these services are not available unless they are mandated by states or the co-payment is so high they of the way of getting them in the first place. the main thing, the second main things about my amendment is that it eliminates deductibles and co-payments. so we even many of the biggest hurdle, the two big hurdles. bonn, having insurance in the first place which is the underlying bill, and also co-payments and deductibles. i know of no one in this room who would not want to be on our side on this issue. i want to acknowledge the role that the gentle lady from alaska has played. senator murkowski, senator kay bailey hutchinson, senator snowe

and senator collins. the women of the senate have worked on a bipartisan basis for years making sure we were included in the protocol said and i each increasing funding for an important research areas to find that tour, to race for the tour and at the same time to be able to have a mammogram standards. with the gentle lady from alaska's's amendment does, and by the way she is murkowski, i am mikulski. we soundalike and the amendments might sound like, but boy are they different. murkowski offers information. i think that's important. that is a threshold thing. you have to have information to make an informed decision. but it does not guarantee universal access to these services, and course it does not susan g. komen did does not eliminate the high payments and

deductibles. so her amendment is fault. my amendment is terrific to read my amendment offers key preventive services including the annual women's health screening that would go to a comprehensive assessment including the danger to women and heart disease and diabetes. we would hope when the senate makes its decision today that it would deal with the fact that for us women, the insurance companies also simply take being a woman as a pre-existing condition. we face so many issues and hurdles where we can't get health care, we can't get health insurance because of pre-existing conditions called ac section -- i'm going to be talking to someone whose company denied a woman a c-section and a letter from this insurance company said we are not going to

give you insurance unless you have a sterilization, a coerced sterilization in the united states of america. madam president that's going to be an amendment for another day but i just want to give the flavor and the power of what women face when we have to cope with the insurance companies or where there are barriers to getting these health care issues. so we want to be able to save lives and we want to be able to save money. we believe universal access, and if you utilize the surface it's because you've had the constitution with your doctor command at the end of the day because we do know early screening and detection does save lives, and at the same time it saves money and i will conclude if we look at heart disease and diabetes not only cancer early detection of diabetes means that in a

well-managed program under appropriate medical supervision you very likely will not lose your eye. you will not lose that kick me. you will not lose that flake and most of all of you will not lose your life so let's not lose the mikulski amendment. let's go with mikulski and thank schakowsky for the information but hers is too tepid and limited. madam president, i yield the floor. madam president, i ask my colleague, one of the great guys who supported senator cardin, how much time we have. five minutes to senator cardin. >> the senator from maryland. >> let me thank my colleague, senator mikulski for her leadership on this issue. i strongly support her amendment for the reasons she said. this is a very important point about providing health services to the women of america. a critically important part of our strategy not only to bring

down costs in health care but to have a health care system that is fair in america. and madame president, i've been listening to my colleagues on the other side of the i'll talk about the underlying bill. they talk about this as if it is a static situation. many of the criticisms i hear about the underlying bill or about the current health care system. i could tell you the people of maryland many of whom are finding it difficult to find affordable coverage today and are outraged at what is happening with the private and insurance companies, the attitudes they are taking as senator mikulski pointed out denying coverage on pre-existing conditions are pos and marjorie caps. and as has been indicated, if we are unable to get this bill passed what's going to happen in the future? we know that costs are going to become even greater, more people are quite to lose their coverage and insurance companies are going to continue their retreat practices and the health care of americans are in jeopardy. we are already spending so much economy on health care if we

don't take action will be a greater part of economy. but we have some good news. the underlying bill has now been analyzed by the congressional budget office. that's the independent scorekeeping. and what they tell us is if they pass the underlying bill for the overwhelming majority of americans they are going to find health insurance premium will either see the same or go down. and for the overwhelming majority of americans they are going to have a better insurance product that's been to cover the types of preventive services that senator mikulski is talking about it is in her amendment to read it so we are not only going to bring down the cost, the overwhelming majority of americans as to what will happen if we don't pass the bill, we are going to provide better coverage for those americans. the underlying bill will also reduce dramatically the number of people who don't have health insurance in america by 31 million. that's going to make our system much more effective. i've heard my colleagues talk about what's going to happen

with medicare. if we pass the underlying bill we are going to strengthen medicare. we already have a provision we pointed out. we've already pointed out that aarp endorses the bill. the understand it strengthens medicare. we've already printed out there will be additional preventive health care services to seniors and helped to start filling the so-called donato and prescription drugs. but let me tell you how it will also threat medicare by bringing down the cost of health care. when you reduce the number of uninsured, the amount of cost that medicare has to pay for health care in our hospitals is reduced. that's why we can reduce our payments to hospitals in america because the amount of uncompensated care they currently have will be dramatically reduced and i have heard my colleagues on the other side of the oil talk about medicare and advantage but let me tell you something, i remember when we used the private insurance companies that medicare a little less than we paid people in traditional

health care than we paid them the same. now we are paying more. that's corporate welfare. medicare part b premiums higher than it should be. taxpayer support is higher than it should be. and we know that these benefits that are being paid could be gone tomorrow. we saw it happen. we saw the private insurance companies leave the maryland market and leave so many markets. so, these are reforms that saved the taxpayer money and strengthen medicare for the future. at the bottom line is the bill is good for middle-income families. it will provide insurance reform so that they have insurance products that can cover their needs including the wellness and prevention programs. it's good for small business because it offers more trees and i can tell you chapter and verse a small company of maryland who today could not get an affordable product, who today are seeing 20, 30% increase in their premium. they need this bill in order to be able to preserve health care for their employees. and this bill with the mikulski

amendment will provide preventive health care for all americans to her so desperately needed that will reduce cost and improve quality and make our health system more efficient and effective for the future bringing down the cost by investing in wellness and prevention. on i urge my colleagues to support the mikulski amendment, i urge my colleagues to support the underlying bill and with that, madam president, i would yield the floor. >> the senator from south dakota. >> senator from south dakota. >> madame president, i appreciate the opportunity to speak on this important piece of legislation. i want to again point out to my colleagues and to anybody else who may be observing the volume of this. this is what to 100 pages, 2100 pounds which means it is about 1 pound per hundred pages. it is $1.2 billion per page. $6.8 million per whirred, create

70 new government programs and gives secretary of health and human services over 1600, 1700 incidences in this bill the opportunity to create, define and determine things in this bill. this is a big government bill. massive expansion of the federal government. to $.5 trillion when it is fully implemented. now of course to pay for all of the things in this bill not only those intended also the unintended consequences of this bill you have got to have revenue. where to get the revenue? the democrats' proposal, the senator read bill decided they were going to raise taxes on small businesses and individuals and families and that they are going to cut medicare by about half a trillion dollars. now what is ironic about that is that a few years ago, the republicans backing and the leadership in the united states senate tried to do a budget bill that actually achieved savings in medicare and medicaid to the

tune of $27 billion combined with the medicare savings in that bill were $10 billion. that was over a five-year period. $2 billion a year and i want to remind some of my colleagues on the other side of the comments they made about that. senate majority leader of the mind -- bear in mind madam president is is to reduce medicare by $2 billion per year. 2 billion over five. the majority leader's unfortunately republican budget is an immoral document. senator from west virginia this proposed eight morrill disaster of monumental proportion. a couple others of my colleagues in the senate, senator from michigan, people who rely on medicare and medicaid are going to be hurt by this bill. senator from wisconsin, irresponsible and pool budget. on your urge my colleagues to reject this bill and the former

senator from new york senator clinton at the time said this bill slashes, madam president, $6.4 billion of medicare over the next five years. actually it was $10 billion but my point simply is this colin co $10 billion over five years, $2 billion a year and these are the statements, you know, just the overstatements about the impact that $2 billion a year of medicare reductions were going to have on people in this country and we are talking about half the chilean dollars in medicare cuts. where are they coming from? 118 billion comes from medicare advantage which now we have 11 million americans infected by medicare advantage. every state has seniors to subscribe to medicare advantage programs whose benefits are granted a cut if this is enacted. you get it out of the hospital $135 billion reductions in reimbursements to hospitals.

$15 billion in reductions to nursing homes and reimbursements to nursing homes. $40 million in reductions to home health agencies and a billion dollars in reductions to hospices. these are all the ways of this $2.5 trillion expansion of the federal government paid for and i didn't even get into the tax cuts will be a debate for another day the the medicare cuts in this bill, madam president are unlike anything we've seen past or present, and clearly when you compare to three, four years ago when we were trying to achieve $10 billion in savings and medicare or five years or $2 billion a year you thought the sky was falling. and so here we are trying to be for $2.5 trillion expansion of the federal government by cutting $500 billion out of medicare. now, the point i also want to make because it has been made by the other side this morning in fact by the most recent speaker that somehow this recent cbo analysis should be hailed as

good news. the courts are popping. celebration and people are crowing about the new cbo report because it has got such good news for this bill and the impact is going to have on people who buy health insurance in this company. what is it they are celebrating? the cbo in its report, madam president, he essentially said this: 90% of americans are going to see their premiums increased or see virtually the same increases as they do today year after. that, madam president is preserving the status quo not decrease in cost as was promised. president obama running for office in 2007 said when he gets the chance to do health care reform he's going to reduce cost by $2,500 for every family in this country and cover everybody. this bill after spending $2.5 trillion creating 70 new government programs doesn't cover everybody.

there's still 24 million americans who don't get covered under this bill according to the congressional budget office and furthermore, nobody, nobody at least the shouldn't say nobody, 90% of americans, those who don't get subsidies don't come out any better. they are still going to see the year-over-year increases in premiums they've been seeing the past several years and the cost of health care in this country is growing twice the rate of inflation so if you assume year-over-year increase similar to what we've seen the past several years you were looking at in the small group market annual increases of over 6% for the cost of health care to the point where a family today that is paying $13,000 a year for health insurance in the year 2016 will pay over $20,000 a year for health insurance. so nobody gets any better out of this except for the handful of people who are going to get subsidies. and if you were in the individual marketplace your premiums go up according to the cbo ten to 13% premium increase for people who live in the

individual market. if you're the large group market your premiums will go up like they have been almost 6% a year. if you weren't a small group market premiums will go up. over 6% a year. so we are talking about spending $2.5 trillion, cutting reimbursements to nursing homes, cutting reimbursement to hospitals, cutting reimbursement to home health agencies and hospices and raising taxes on health care providers, medical device manufacturers, prescription drugs, raising the medicare payroll tax which incidently doesn't go to preserve or extend the lives band of medicare or put it on a path toward sustainability but creates a whole new government entitlement. we are going to do all that for what? of the best the status quo for people today at the worst increase their premiums by ten to 13%. that's bottomline. that's what this is. that's the cbo report the other side saying this is great news.

when you're celebrating. great news. premiums are going to continue to go up at twice the rate of inflation just like they have in the past protecting and preserving the status quo as we know in america today this bill does nothing about the fundamental issue of cost and it doesn't matter what market or in small group market, large group market stayed the same at best in the individual marketplace where premiums go up ten to 13%. that's the news that is being hailed by the other side has validated the argument for why we need to pass a 2100 page, $2.5 trillion, 70 new government program monstrosity of the health care bill. so, madam president, not only are we here today, we are going to have a vote later on this amendment. senator mccain has an amendment ought recommit this basically to take the medicare cuts out of it, and i held all

of my colleagues to vote for it because it doesn't. they are giving it doesn't cut medicare. how can you say that? how can you with a straight face say that you are going to find $500 billion to pay for this bill out of medicare and say that it doesn't cut medicare? of course it cuts medicare. of course it raises taxes. you can't finance $2.5 trillion of new spending unless you find a way to finance it. and the way that they have chosen to finance it is to hit seniors squarely between the allies and cut reimbursements to the providers of their all across this country who are dealing with the of very serious health needs our senior citizens experience. my state of south dakota we have a lot of people who of course are in a point in the health care industry as i think is true in every state in this country believe in nursing homes, small towns in south dakota nursing home planet you're talking almost 600,000 employees. you're going to take $15 billion out of nursing homes,

$40 billion out of home health agencies, another $35 billion out of hospitals? what we are talking about, madam president, are huge reductions in medicare unlike anything we've seen and as i said to put it in perspective a few short years ago when we were in the majority in the budget try to reduce medicare by $10 billion over a five-year period it was referred to as an oral, as a monument to disaster, as cruel. $10 billion over five years. this has half a trillion dollars medicare cuts, medicare advantage and providers. madam president, i hope my colleagues will support the mccain amendment, and i yield the floor. >> who deals time? >> madame president? >> senator from maryland. >> i yield three and a half minutes to the junior senator from minnesota. senator al franken. >> senator from minnesota.

>> thank you, madame president. i rise today to express support for senator buckles the's amendment for women's health. this is crucial because it's about prevention. prevention is one of the key ways this bill will transform our system of sick care and to true health care. it's common sense you get the right screenings of the right time so you find diseases earlier. this saves lives and it saves money. the senate bill already has several provisions for preventive care which are strongly support for example callosities and screening for heart disease will be covered this is a good start but the current bill relies solely on the u.s. preventive services task force to determine which services will be covered at no cost. the problem is it is several crucial women's health services are omitted. senator mikulski's demint close is this gap and durham and

the health resources and services administration will be able to include other important services at no cost like the welshwoman visit, prenatal care and family planning. these preventive services will truly and prove women's health. flexible if all women got the recommended screening for cervical cancer, we could detect this disease earlier and prevent four out of every five cases of this invasive cancer. this will improve the health of our mothers and sisters and daughters. this bill and this amendment will make prevention a priority and not an afterthought also i respect the efforts of my distinguished colleagues from -- colleague from alaska the rakowski alternative falls short. the murkowski amendment does nothing to guarantee women will have improved access to coverage

and cost sharing protections for preventive services. rather than establish objective scientific standards about which preventive services should be covered this alternative only requires insurers to consult with medicare organizations when making coverage decisions. while we know that the u.s. preventive services task force recommendations do not cover all necessary services the and rakowski amendment entirely removes even this basic coverage requirement from the bill lefe enger wim and without any protections under health care reform for essentials preventive care. this means important preventive care for women including screenings for osteoporosis and for sexually transmitted infections may not be covered by insurance plans. in the simplest terms the murkowski amendment maintains the status quo. and we know the status quo is not working for millions of

women who are for going preventive care because they simply can't afford it. the murkowski amendment continues to believe prevention coverage decisions about health insurance companies. and that means there would be no guarantee any health plan and will cover basic preventive services at all. do we really want to leave these important decisions up to the insurance companies? the health of american women is too important to leave in their hands. that is why irish my colleagues to support senator mikulski's amendment and vote to make sure women can get a preventive services they need to stay healthy. most importantly, this amendment will make sure women have access to life savings means at no cost. mia lee request another 38 to 45 seconds? >> without objection. >> thank you. prevention is one of the ways this bill will approve women's health and it also ends

insurance company practice of charging women more just because they happen to be women or denying coverage based on the history of pregnancy, c-section or domestic violence. we need to pass a bill this year, this bill to ensure comprehensive affordable care for women throughout the country, and we need to include this amendment because i want to be able to look at my wife in the eye, be able to look my daughter in the i and my son, too and my future grand children and say that we did everything we could in this bill to improve women's health and we can't wait any longer and i urge all of my colleagues to stand with us and support this amendment. i yield the floor. thank you. >> -- to the senator from oklahoma. >> the senator from oklahoma. >> as a practicing physician who has actually cared for women, which nobody so far has been in on the state has ever done, i would congratulate the senator from maryland for her care about prevention because we all know

that is a key. the ms. characterization you heard about this bill is astounding. the reason we got in trouble with the task force, the pitch and to task force is because it did something that was inappropriate and didn't have the people have the appropriate professional groups on its task force when it made its recommendation on breast cancer screening. what the murkowski bill dies says we will rely on the professional societies to make the determinations of what must be available. and we have heard the senator from all i was a health insurance would decide that, that is absolutely not true. health insurance were undecided. the professional societies will decide what will be covered and the insurance must cover under the murkowski amendment. the second thing is that there won't be any objective criteria.

the objective criteria doctors practice under today is the guide lines of their professional societies. here is the difference between the murkowski amendment and the murkowski amendment to read the senator from maryland relies on the government to make the decision on what will be covered. she refers to the health resource services administration. she refers to the health resources service administration who has no guide points whatsoever on women's health care right now what you're in prenatal care and child care. that is the only thing they have. who does hrsa work for? secretary of health and human services. so the contrast between the two amendments couldn't be any more clear in terms of if you really want to solve the problems we just experienced on mammogram recommendations. we can let the government decide which got us into this trouble

and they will set the practice guidelines and their recommendations for screening or you can let the american college of obstetricians and gynecologists, you can let the american college of surgeons, the american college of oncologist set and use their guidelines. so the choice is simple. the government can decide what cared you get or the people who do care, the professionals who know what is needed who write the peer review articles and study the literature and make the recommendations for their guidelines. every month i get from the american college of obstetricians and gynecologists their new guidelines and i try to follow them at every instance. the fact is the mikulski amendment says government will

decide. that's what it says. the government will decide through hrsa. the murkowski amendment says the best practice is known by the physicians that are out there practicing what is different, how does it apply to you as a woman? it applies to you in as a woman the people who know best to make the recommendations rather than a government bureaucracy. that's the difference. and if you will recall under the stimulus bill that we passed would have a cost comparative effectiveness panel. which will be mixed into the mix associated with the recommendations. and if you look at what the task force on preventive recommendation said from a cost standpoint they were absolutely right. from the patient's standpoint they were absolutely wrong.

and the real debate on this bill, the mikulski is the start of the real debate is do we have the government decide based on cost or to we have the professional care givers who know the field decided based on what is best for that patient? that is the difference. and with the senator from alaska does, which is necessary, she says we will rely on the american college of obstetrics and gynecology. we will rely on the american college of surgeons. we will rely on the american college of oncologist to determine what should be the screening recommendations for patience. for qc what happens with the mikulski amendment is the government stands between you and your doctor. that is what is coming. that's what will be there. there is no choice under the murkowski amendment for an insurance company to have the

option either to or not to commit a must. it says shall do that. so the mischaracterization of the murkowski amendment actually says -- >> the senator's time is expired. >> i would yield the floor. >> who yields time? >> madame president? >> senator from maryland. >> how much time as our side have? 17 minutes and 15 seconds. >> yes. i yield -- is the gentleman from michigan on the floor? iowa yield five minutes to the gentle lady from michigan. >> madame president? >> senator from michigan. >> thank you, mr. president.

i first went to thank senator murkowski on this issue, issues of health care for women across this country. we are honored to call her the dean for all of us as it relates to focusing on the issues that are so critical to women and their families. and i went thank senator reid for making this a priority, and making this the first amendment that we are offering in this debate. we all know, madam president, often women are the ones making health care decisions for their families as well as themselves. they are more likely to be a person making health insurance choices. and women of child-bearing age pay on average 68% more for their health care than men do, and we have so many instances in which insurance companies are standing between women and their

doctors right now in making decisions. decisions not to cover preventive services. like a mammogram screening or cervical cancer screening. decisions to call pregnancy a pre-existing condition so that women can't get health insurance. insurance companies making decisions not to cover maternity care so that women and their babies can get the care that they need so that babies can be successful in life, with prenatal care and postnatal care. so, women of this country have a tremendous stake in health care reform. we pay more now if we can find coverage at all, and there are too many ways in which insurance companies block women from getting the basic health services that they need. and so this amendment is critically important to make sure that women are able to get

preventive care services without deductible and without co-payments. this amendment recognizes the unique health needs of women and requires coverage of women's preventive services developed by women's health experts to meet the unique needs of women. and why do we stress that? we stress that because verge years we have struggled to in so many areas to make sure that women's health needs were focused on not just health in general, when we look at research through the national institute of health and what it took to get to the place where research would be done for women on women's subjects or on when and mice or rats, female rather than male subjects to make sure that the differences between men and women were considered in

research, and we have made important steps in that direction. and again, senator mikulski was leading the way as it relates to having a women's health research effort in our country. this is just one more step to make sure that we are covering women's preventive services, developed by women's health experts, unique needs of women. that's what this is all about. making sure women have access to preventive services like cervical cancer screenings, osteoporosis screenings, and you'll mammograms for women under 50. pregnancy and postpartum depression screenings, domestic violence screenings, annual checkups for women. we know that more women die of health care -- of heart disease than actually any other disease. this is something that i don't think is widely known. we have heard many physicians don't realize the extent to

which heart disease is prevalent in women, and as all of us have worked, all the women of the senate worked together on a women's heart bill part of that is for screenings. part of that is to make sure that we are screening for heart disease. heart disease and strokes, the number one killer of women. this would make sure those screenings would be part of health care reform, and we could go on to list all of the different prevention items but i would simply say, madam president, that when we are talking about women's health and we are talking about women's lives, this is an incredibly -- >> the center's time is expired. >> thank you. i yield the floor. >> madame president, i yield five minutes to the senator from texas. >> senator from texas. >> madame president? >> senator from texas.

>> i rise to speak on the mikulski amendment and the murkowski amendment because i feel very passionately about the women's issues in fact senator mikulski and i have worked throughout my time in the senate and rehearse before me on these various issues, assuring that women's health care concerns which are different from men's in many instances are a part of any health care coverage in our country and ongoing we must assure the same. i have been an advocate for cancer screening services for women, and i was dismayed when i saw the united states preventive service task force a few weeks ago issuing new guidelines for cancer screening for women, breast cancer screening for women. we all know that we have lived with breast cancer throughout of course the history of been in, but especially in the last

probably 25 years the strides that we have made in saving and survivability of when women with breast cancer is because we have early detection, we don't have a cure, we are fighting for that to work but until we get it, the first line of defense is early detection. so, now we have a new task force recommendation that says everything that we have had and have enjoyed the last 25 years, saving women's lives is no longer relevant because now before the age of 50 you don't really need a mammogram and after the age of 50 it's every other year. i know senator mikulski and i agree that we don't think that's right. neither did any other woman in the senate when that was proposed years ago by president clinton. we all stood up and said no and i am standing up saying no and

again and i am sure every woman in the senate is as many women in american art. but the mikulski amendment doesn't fully address the problem of having the task force which is relied on 14 times in the bill before us as the arbiter of what is necessary for our government program and then we will shortly become the private sector standard as well. and that task force even has money allocated to advertise its task force recommendations. so rather than the mikulski amendment severing of ties with the task force, the amendment now has another government agency that has the same capability to basically interfere between the woman and her doctor, which is where we

want the decisions to be made. coverage decisions will be dictated by both the task force and a new health resource service administration entry into the mix. while i certainly agree with senator mikulski about the importance of preventive services for women and insurance coverage decisions, i just can't support her amendment because we still have not one but two government task forces and committees that will be in the middle of these health care coverage decisions. i think the coverage decisions should be made by doctors and their patience. that's why i joined with senator murkowski and offering the alternative approach. this is what we should expect from any future health care reform and it is certainly what we expect today. if the murkowski amendment will leave the medical decisions to the guidelines established by

those who no medical treatment best which is our own doctors. in fact we have just received a cbo assessment of what the murkowski amendment would cost and it actually says there will be savings so rather indy 500 merkel ski amendment which would spend $1 billion over ten years, the murkowski amendment would actually save $1.4 billion over ten years. why? because the mayor kautsky amendment relies on the combined common sense and clinical judgment of american physicians. >> the center's time is expired. >> i urge a vote for the murkowski amendment and i know we have the same goal as senator murkowski and her amendment, but i don't believe mikulski amendment achieves the goal of having a woman and her doctor make the decisions for her. that is the key that i think is

so important in this debate. i year urge a vote for the murkowski amendment. >> thank you, madame president, and i yield the floor. >> who he'll time? >> madame president? alladi yield four minutes to the gentle lady from the state of washington he has been a real leader on these issues. by the way, madam president, before the senator speaks, i want to thank senator stabenow for the unique courtesy. this is her desk and as many of my colleagues know i broke my ankle and i can't get up to where my desk is at this point. i will in a matter of another few weeks. but she's giving me this desk on lonnae i want to thank her for the courtesy so i could stand on my own 2 feet to debate this. madam president, i also want to note something while the senior

senator from the republican leadership is here and the author of the amendment. we, the women of the senate on a bipartisan basis have worked for women's health. today we disagree on what is the best way to achieve it by these two amendments. i want to thank my colleagues for setting the tone of civility. i think this has been one of the most rational civilized conversations we've had on this, and i would like to thank them. from the early durham this side of the aisle in terms of the seniority, i would like to extend my hand in friendship that when this bill is done and the amendment is done we continue to focus on this wonderful work that we have done together and we have. we have done things that have saved millions of lives and we look forward to it. madam president, i now yield four minutes to the senator from the state of washington, senator murray. >> senator from washington. >> madame president, i thank my

senator from maryland. we're delighted you're here. thank you so much for your leadership on this critical issue making sure that women have access to quality preventive health care services. and screenings that are so critical to women across the country. madam president, the senator from maryland offered this amendment, and i worked with her on the committee. she has been a leader on this for many years and i echo her comments as well this has always been an issue for as long as i've been here since 1993 where the women in the senate from both sides of the ogle stood up to make sure that women's care is part of health care and understand that we have to stand shoulder to shoulder. it's unfortunate that this time we see this in a little different light. but i agree with senator mikulski. we will keep working together throughout our time here to make short women's preventive services are covered. i do support the mikulski and and and and the mikulski

approach. her amendment requires all health plans to cover comprehensive women's preventive care and screenings at no cost to women. i wanted to come to the fore and point out why this is important. when the economy is hurting, women on the whole tend to think of caring for their families first and not caring for themselves. they take care of their children, their spouses first and the end of the fleeing or skipping their own health care in order to take care of their families. in fact, we know that in 2007 a quarter of will women report skipping their health care because cost. may 2009, just two years later, a report by the commonwealth foundation found that more than half of women today are dealing avoiding preventive care because of its cost. that isn't great for the women, that's not good for the families, it's not good for their ability to be able to take care of their families and take

care of themselves. this, senator mikulski's amendment is extremely important especially in this economic time. we know that if women get preventive care and care for their needs than the are able to care for their families. yet the situation we find ourselves in today women are not taking preventive care. they are not taking care of themselves therefore when they get sick the ended in the hospital and then their families are in trouble. so we no preventive services can save lives and needs better health outcomes for women. we have to make sure that we cover preventive services and it takes into account unique needs of women. senator mikulski's amendment will make sure this bill provides coverage for important preventive services for women at no cost. women will have improved access to wealthy man visits important old. family planning services, mammograms, we've all talked that so many times to make sure they maintain their health.

and madame president, i want to emphasize that this amendment preserves the doctor patient relationship and allows patients to consult with their doctors on what service is our best for them. this has become an large topic of conversation over the last several weeks and senator mikulski's amendment makes sure it is a woman under 50 decides to receive an annual mammogram this amendment will cover it. she will be able to work with her own doctor and take care of herself. madam president i come to the floor today to strongly support the mikulski amendment to thank her for her leadership on this, and i would hope that we can get to a vote on this important issue and move on and pass health care reform. my constituents when i go home say move on, get this done. we've got to take care of this because of our economy and the impact on small businesses, because the rising cost of premiums because of the large number of people who are losing their health care coverage. it is a health care bill was going to make a major difference

when we get it passed and the american public can take a breath and say finally our government has moved forward so let's get past the summit. i support strongly the mikulski amendment. let's move on this bill and began major step forward for health care coverage for all americans and pass the health care bill. thank you. i yield the floor. >> madame president, i yield two minutes to the senator from kansas. >> senator from kansas. >> thank you very much, madame president. i rise in support of the senator from alaska's amendment, and i have talked with my good friend, the senator from maryland, senator mikulski about the issue of a side issue in this overall debate, but what is concluded in the definition of preventive care, and the senator from maryland has stated in a colloquy that there are no abortion services included in the mikulski amendment. she stated that in a colloquy. i have trouble that the future

bureaucracy could interpret it differently. i asked my friend from maryland if she would include clear legislative language in this saying simply nothing in this act shall be construed to authorize the secretary or any other government or quasi governmental entity to define our classified abortion or abortion services as preventive care or as a preventative service. i think that clarifies the issue it would be my hope that my colleague from maryland would include that in her language. it isn't in their even though there has been statements on the floor but as we all know as legislators it is one thing to say something on the floor and one thing to have a colloquy it is far different to have it written into the slot. this is not in the case law. so i would urge my colleagues, the senator from maryland to include this language and absent that. i think there's too much room for a broader definition of what

preventative care means but it could include abortion services as well and i would urge my colleagues to vote against the mikulski amendment if that is the case on that ground i think there are other issues involved. it's why i believe the senator from alaska's capricious superior on maintaining the doctor-patient privilege. this is a good debate to have given the recent discussions but this change there is another issue that is involved here and i would urge my colleagues to consider. i want to yield back to maintain time to the senator from wyoming to be able to speak so i would yield the floor. >> who yields time? >> madame president, we are

waiting for senator boxer to come to the floor, and if the other side of the ogle has another speaker i know whether the and we hope that senator lisa and senator barbara, because our last names sound the same, could wrap it up. how would the senator from wyoming like to proceed? we are waiting for boxer or bachus? >> madam president, i would yield ten minutes to the senator from alaska so that she can actually propose her amendment that we've been debating and take up to ten minutes. >> and then i will wrap up. >> that would still leave us with two minutes. it does leave us with two minutes, and i would have the senator from wyoming used that two minutes. >> whatever way we can work while we are lining up to see where our speakers are. >> mr. president? >> the senator from alaska.

>> mr. president, maryland, and accept her gracious offer to continue to work on this issue as it relates to women's health and women's health services. as has been noted by the senator from maryland and senator from washington this is an issue that we women of the senate have come together repeatedly to work cooperatively, and while we do have some would say duelling amendments if he did is important to recognize that the goal we are both seeking to attain are certainly right in alignment. we are just using different means to get their. but i appreciate it and the civility and the cooperation from all only senator mikulski but the women on the important senator from maryland.

ms. mikulski: mr. president, i ms. mikulski: mr. president, i ms. murkowski: let me try it here. ms. mikulski: that's so much better. i want to hear the amendment and continue our conversation. ms. murkowski: and you just missed all the kind remarks that i addressed to your attention. ms. mikulski: could i ask unanimous consent that she be extended for two additional minutes. no, no, i draw. thank you. ms. murkowski: i'll make sure that the comments that were made in the record are delivered to you personally, senator mikulski. but i want to reiterate a couple of points i made yesterday about my amendment and to also share with my colleagues, and i know that the senator from texas mentioned it as well, the c.b.o. score that we received yesterday -- actually late last evening. it provides us with a score it provides us with a score actually late last evening provided us with a score showing a cost savings of $1.4 billion over the next ten years and i

think that this is significant, as members certainly from the other side have raised the importance of fiscal discipline and our financial fiduciary responsibility there. i think importantly the cbl indicated that the provisions on the second page which prevent the secretary from using recommendations to deny care what cost money which means that we are in fact protecting certain benefits and that is very important. the amendment that we have before us, the murkowski amendment, it is one that really allows four or requires a level of transparency with the recommended health screenings, the prevention services that are deemed necessary, not by some task force that is appointed to buy folks within the administration. not by some commission that has political relationships.

what we are urging is that the screenings, the health screenings, the preventive health services, that these be determined by those who are actually in the field, those practitioners, those who are engaged in, in oncology, ob-gyn. we need to be looking to the experts. we need to be looking to that peer-reviewed science. we don't need to be looking to those entities that have been brought together by a government entity or by the secretary. we need to be looking to the likes of the american society of clinical oncology, the american college of surgeons, the american college of radiation oncology, the american college of obstetricians and gynecologists. we need to look to their recommendations and again as i mentioned yesterday, in my

comments, if you go to their web site, if you look at their specific recommendations, they will give guidance, the guidance that again is based on their practice in oncology, their practice as an ob-gyn. what to what they set out as the guidelines for cervical cancer screening for mammograms and let that information be made available, made available publicly through the, the plans that come together from the insurance companies, but allowed them, allow me as a consumer of health care, me as the consumer looking for the best plan for me and my family, to know what those guidelines are not from a government task force but from those that are the real experts.

i think this is the transparency that health care shoppers are looking for. now, some have suggested that well your amendment doesn't require the insurance companies to provide any prevention or screening services. there is no mandate in there and if we don't have a mandate than the insurance companies aren't going to provide health care prevention and screening services. i think we need to ask a question here, what is the point of prevention? if it is to prevent more expensive care and the future by preventing the chronic in a more acute illnesses so shouldn't the insurance companies want to utilize more preventive services and utilize more screenings, more will the services in order to keep down the cost of care based on the judgment of the doctors, based on the judgment of the professionals and not necessarily those that again are appointed as part of a government entity. i know within my staff, i have a

staff member, she is on the fehbp plan but they contact her on a somewhat regular basis about her diabetes care insuring that she is taking medications, getting the necessary preventive services offered by her insurance for her particular condition. it has been mentioned by several of my colleagues that well, the u.s. tfr not such a bad bunch of guys. they are not just these nameless faceless bureaucrats. it is important to recognize and even the american heart association has recognized the preventive services task force is limited to only primary-care doctors and not specialists like the oncologist to see patients every day for battling cancer. shouldn't the doctors that are providing americans with their suggestions on what services are necessary for cancer screenings but yet these doctors are not part of this task force that has

really again shown the spotlight on what happens when you have a government entity or a government task force that is basically the one that is saying this is what is going to be covered, this is what is not going to be covered. in my amendment we specifically provide that the recommendations from usps t.f. cannot be used to deny coverage on an item or service by a group health plan or health insurance offer. i think that is very important. i think it is also important to recognize that what we do in my amendment is to make sure that the health plans consults the recommendations and guidelines of the professional medical organizations to determine what prevention benefits should be covered by all of these health insurance plans throughout the country. we also require plants to provide the information directly to the individuals. you get to see it for yourself and you get to make that

determination, so what that means is it is not the doctors or the specialist. at meaned, does mean the doctors and specialists will be recommending what preventative services to cover, not those who in washington d.c.. my amendment ensures the secretary of health and human services cannot use any of the recommendations again, made by the task force to deny coverage. we also include broad protections to prevent pure cresse the department of health and human services from denying care to patients based on comparative effectiveness research and finally have a provision that ensures the secretary of health and human services may not define our classify abortion or abortion services at preventive care or as preventive services. i appreciate that mr. president. i think my amendment is straightforward. i think it is a good compromise and again i think it is a clear differential between what we are trying to do to allow a woman to

have full choice whitford dr. as opposed to government telling him of us who we should be seeing and with that mr. president i yield the floor. >> this senator from-- >> to ask consent to call up my amendment number 2836. >> the clerk will report the amendment. >> the center from alaska ms. murkowski for herself and others proposes a amendment 28362 amendment number 2786. >> i have further reading of the amendment be dispensed with. >> without objection. >> the center for montana. >> i have ten unanimous consent request for committees to meet during today's session and senate and the approval of the majority and minority leaders and i ask consent these requests the agree to andy's request be put in the record. his. >> without objection.

>> mr. president i'm going to speak very briefly on the pending subject and let the sponsor of the amendment, that is the mikulski amendment, finish up here. it is very telling. i know this point it's been made before but i think it bears repeating. the american heart and association or the stroke association has written a release to the senate and i will just read the most important parts here. basically they say coverage for clinical preventive services that are evidence-based and necessary for the prevention and early detection of an illness or disability. we all agree with that. they go on then to comment on the murkowski amendment, saying that they appreciate the murkowski a amendment recognizes

the recommendations but they do want to say that even these guidelines must be held to a standard of being evidence-based. i might say that this is, i run across this over and over again and the medical profession and medical experts, we just need to keep moving more and more towards the evidence-based medicine. the statement from the american heart association and the american stroke association goes on to say we are concerned that senator murkowski's preventative health services amendment takes a step backwards by substituting the judgment of the independent service task force to the judgment of private health insurance companies. that is a point i would very much agree with an. i don't think we want the judgment of private health insurance companies making these decisions and i would like now to recognize, appropriate the sponsor of the main amendment to finish up and she is doing a very good job.

>> i would yield the final amendment to the center of wyoming. >> without objection. >> mr. president. >> the senator from wyoming. >> thank you mr. president. mr. president my wife was diagnosed with breast cancer by screening mammogram in her 40's who. it is that screening mammogram that is saved her life. by the time of the mammogram the tumor had spread and she is had three operations, to full bouts of chemotherapy. i do not want a government bureaucrat making a decision for the women of america and they should be allowed to have a screening mammogram. it saves lives, one in 1900 women in their 40's. the bill empowers bureaucrats to decide what preventive benefits will be allowed for american women. the amendment from the senator from maryland does the same. bureaucrats, not the physicians who are doing the trading and that is why i support the amendment from the senator from

alaska because that amendment says the federal government cannot use recommendations of the u.s. preventive services task force, recommendations from bureacrats to deny care to anyone including seniors on medicare, anyone in america. that is how decisions should be made, not by government bureaucrats for the thank you mr. president and i yield the floor. >> mr. president? >> the senator from maryland. >> mr. president how much time is left on our side? >> three minutes. >> mr. president i yield myself three minutes. as we get ready to conclude the debate on both the mikulski and as in barbara mikulski and murkowski as in lisa murkowski amendment, i want to first say a word about the senator from alaska. we have four together on the health education committee. we have worked together as women of the senate to provide him

access to women's health services and not too long ago when i had my awful fall, she gave me much wisdom and counsel with practical tips because she herself had broken her ankle, so to us that, we say to senator lisa or two senator barber, break a leg, it has a whole different meaning to us and i again want to thank her for all of her work and i have great respect for her. and look forward to our continued working together but i do sincerely disagree with her amendment, because what her amendment does is it guarantees really only information. it does not guarantee universal access to preventive and screening services and it also does not remove the cost barriers by eliminating the high deductibles or co-payments when you go to get rid a preventive

for screening service. it tells insurance companies to give them permission on recommended preventive care. that is a good thing but it is a threshold thing. you need to have universal access to this service. also, we do not mandate that you have the service. we mandate that you have access to this service. the decision to whether you should get it will be a private one. unique to you. sold in the case we have heard about, the senator from wyoming's wife, that would have been up to the doctor and the physician to get her this service that we need. and it is not only a i or one side of the aisle that is opposing the murkowski mnf. >> at the american cancer society, the american heart association and the american academy of ob/gyn services to

it. my amendment is a superior the amendment because it guarantees universal-- it also eliminates what are the major barriers to excessing care by getting rid of high payments and deductibles. what does a mean? it does not say he will have a mammogram at 40 because again, we are substituting ourselves with the task force. >> all time has expired. >> you will have universal access to that mammogram if you and your doctor decided is medically necessary or medically appropriate. mr. president eyes szabo for mikulski, don't four murkowski and please, on this one get it straight. >> senators are continuing their debate of the health care bill for the weekend. our regular booktv schedule will be pre-empted during. >> rare senate sessions. wit booktv programs reece demming after the debate. watch the senate debate on

health care live gavel-to-gavel here on c-span2, the only network with the full debate on edited and commercial free. >> senators voted on a number of amendments today. the improved increased access to preventive health care in cancer screenings for women. the vote by maryland center barbara mikulski was an 61-39. the senate is back tomorrow morning at 9:30 eastern. the chamber will debate the medicare advantage program a private government subsidize supplemental health care program for seniors. watch live senate coverage on c-span2.

>> as we get a veteran veterans what we do we run an ever-increasing risks of overconfidence and yurgens. >> fork malcolm gladwell's books that on the "new york times" bestsellers list including its latest with the dogs saw. as he is our guest on c-span's q&a. >> now another in a series of hearings on the president knew afghanistan strategy part of the witnesses are defense secretary robert gates in joint chiefs of staff chairman my molin. john kerry of massachusetts chairs the senate foreign relations committee. this is almost three hours.

her. >> the hearing will come to order. secretary clinton, secretary gates and admiral mullen we welcome you here today. thank you very much for joining us. and we appreciate your coming to share more details of the president's plan and for consulting and partnering with congress on the decision obviously of enormous consequences for our soldiers, our security and our country. this is a decision that the president of the united states has made but ultimately all of us share responsibility for its consequences. given the complexities of our challenge in the seriousness of the sacrifices the head and the absence of strategy over much of the last eight years, i believe the president exercised importantly leadership by taking the time he needed to make the

right decision even as political pressure mounted in different directions. his words and your testimony showed that the administration has confronted tough realities, carefully weighed all of the options and a right that a comprehensive, considered path forward. i believe that the president appropriately narrowed the mission in afghanistan when he presented to the american people is not an open-ended nation-building exercise or a nationwide counterinsurgency campaign and nor should it be. the president was right to free my commitment to afghanistan in the context of all of our national priorities from the drawdown in iraq who are urging challenges at home and he was correct to consider our mission there in terms of our enduring interest in pakistan. over the last days i have for the number of people say that we are in afghanistan today because that is the place from which we were attacked.

frankly, eight years later that is simply not good enough. we have largely expelled al qaeda from afghanistan. today it is the presence of al qaeda in pakistan, its direct ties to and support from the taliban in afghanistan and the perils of an unstable nuclear arms pakistan the drive our mission. what happens in pakistan particularly near the afghan border, will in my judgment do more to determine the outcome in afghanistan that any increase in troops are shift in strategy. congress has provided 7.5 billion in nonmilitary aid of the next five years to help address the crucial pakistani dimension of the president's plan. that is the beginning but i believe and i think other members of the committee share the belief that there is more that we can and must do with the pakistanis all of which can alleviate the pressure in afghanistan, indeed even determine the outcome in afghanistan. i believe it is important for

the pakistanis to understand that our commitment to them and to the region is long-term even as troops are reduced in afghanistan. in fact, conditions that permit a reduction in american troops in afghanistan are a benefit to pakistan. the president was correct in defining success in terms of our ability to empower and transfer responsibility to afghans as rapidly as possible, while simultaneously achieving the sufficient level of stability to ensure that we leave behind in afghanistan that is not controlled by al qaeda. or the taliban. as i have said before, to each extra family that is asked to send a husband, wife son or daughter into harm's way, the deployment of a single additional soldier makes all the difference, but a public debate that reduces the difficult mission in a complex region to a simple headline read the number of troops does this ali this

service. what will matter most are in the ground in afghanistan is not the number of troops but what they will do and how they are integrated into a broader civilian military strategy. i returned from afghanistan and pakistan in october with serious concerns that even if additional troops are able to clear the enemy and holden area, even in limited areas where we will operate, unless we are able to build the transferrer leadership to local afghans, unless the government is in place where risks squandering time and time again. and right now our military will tell us in many places that tripartite capacity is not there. there are three principal conditions that i still believe must guide the tasking of additional troops. first, are there enough reliable afghan national army and police forces to partner with american

troops and eventually take over responsibility for security? the president has recognized the critical importance of speeding up training and mentoring and to date we have struggled to do so on the skill required and i look forward to hearing your plans today to increase that training capacity and quickly moved afghan security forces into the center of the fight. second, or their local lafta and leaders with whom we can partner? we have to be able to identify and cooperate with tribal districts and provincial leaders who command the authority to help deliver services and restore afghans' fate in their own government. beared, is the civilian side ready to follow swiftly with development aid and bring tangible benefits to the local population? the president has outlined a surge in submitted personnel which will be crucial to locking in any of our military gains and bring stability to afghanistan and i know secretary clinton that you've been working on that task and we look forward to exploring it with you today. i would hope that just as the

exit strategy is based on the conditions on the ground, so too should our strategy of any escalation be based on conditions on the ground. i continue to believe that absent the urge and security need we should not send american troops into clear places unless we are confident that we have the afghan partners and resources in place to build on those victories and transfer both security and government function to legitimate afghan leaders. i still remain concerned that additional troops will tempt us beyond a narrow focused mission. with 30,000 troops rushing into afghanistan at the weekly will be challenged to have the civilian government's capacity in place quickly enough to translate their sacrifice and to lasting gains. there conversations with the president and vice president recent days on the president's speech i have been assured that the administration recognizes the need to meet these conditions. how we answer these challenges will go a long way toward determining our overall prospects for success and we are

all eager to hear in detail how we can do better than we have done on each of these components everyone understands the president karzai's diverse depaulo through will be critical to the outcome and we all understand our ultimate goal and cornerstone of our strategy is to empower and transfer responsibility to the afghans. some are trying to make much of the president's target deadline. i think we learned in iraq that when our policy is to be in another country with troops for "as long as it takes" our clothes are very good at taking as long as they want. the president is correct in setting a target and it will help create a sense of urgency for the afghans to chafe at four in boots on their soil and it sends a message to while america will remain committed to the afghan people we are not interested in a permanent occupation. we can all agree the next 18

months are crucial to reverse the momentum and lay the groundwork for a stable afghanistan one where the police and army can play a greater role in serving their citizens and his government focus is squarely on reclaiming legitimacy with the afghan people and where we have the intelligence in place to engage in the counterterrorism missions that for years ahead we will need to be able to engage in. we should all recognize that americans, all of us fundamentally share this challenge. the senate voted unanimously to go to war in afghanistan. oe jim humble all of us that today there are simply no easy options. we have no choice but to grapple with complexities, reached the conclusion that best serves the american people and work in partnership with other branches of government and that is sally democracy fights a war. the president's speech offered a vision of a path forward by the great many questions remain.

including, house simply beyond adding more resources the u.s. and afghan civilian strategy will improve, what balance we will strike between security population centers and entering into the afghan countryside, how we intend to finance this increase commitment and crucially how we intend to improve our partnership with pakistan. we look forward to the conversation this morning. >> mr. chairman i join you in welcoming secretary clinton, secretary gates and admiral mullen. we appreciate very much that he well-funded-- come to the foreign relations committee. the presence of the three of you underlies depends on military and civilian programs. we must sustain the civil military approach, given the interlocking elements for the newly announced strategy. as we consider our courts in afghanistan we should evaluate options according to how well

they contribute to the united states national security. the ultimate purpose in committing tens of thousands of new troops and tens of billions of additional dollars to the war effort in afghanistan must be to enhance the united states security and our vital national interest in the region. this may seem to be an obvious point, but during long wars, specific tactical objectives have become ensign themselves. disconnected from the broader strategic concept or accounting finite resources. verse stilling al qaeda or the taliban and improving governance and economic opportunity in afghanistan are important, but when our country commence the level of forces contemplated by the president to a sustained war, the objective must be absolutely fundamental to the united states security. this is especially true at a time when our armed forces are restrained by many years of high

deployment rates, our capacity for new government debt is limited and our nation has not fully emerged from the severe recession. the president made the case on tuesday that what happens in afghanistan can directly impact the safety of americans. i believe that most americans accept this point based on the reality that the 9/11 attacks were conceived in afghanistan and that the taliban forces to protect the al qaeda are likely to become more resurging schifley go but much more discussion is warranted on whether the afghanistan mission is so central to our core national security that it necessitates a huge spending increases and the deployment of a large portion of our finite combat capability. in essence we have to ask whether the costs of this deployment are justified and our

overall national security context and whether we are mistakenly concentrating our forces to fight a terrorist and the need in a specific location. even as the global terrorist threat is becoming increasingly diffuse. terrorist cells associated with or sympathetic to al qaeda exists in numerous countries, in africa and the middle east. terrorist attacks for perpetrated in europe by homegrown cells. kelling taliban fighters and training afghani soldiers and policemen are unlikely to substantially diminish these broader terrorist threats. moreover, the results of even the most skillful civil military campaign in afghanistan are likely to be imperfect in the long run. i do not doubt that the application of additional united states allied forces will result

in a military setback for the taliban. during this time, it is hoped that progress can be made in building afghanis security forces. but over the long run we should recognize the problems stemming from tribalism, corrupt governance and lack of economic opportunity in the country of afghanistan are almost certain to persist, complicating efforts to ensure the central government can effectively govern the country. and resist the taliban when allied troops are withdrawn. even if the president's plan achieves the best in the stabilization scenario allowing for u.s. withdrawals on the schedule the -- contemplates may be responsible for the most afghan defense and police in budgets indefinitely and our budget. perhaps most importantly it is not clear how an expanded military effort in afghanistan addresses the problem of taliban

and al qaeda's save havens across the border in pakistan. if these safe havens for sis, any strategy in afghanistan will be substantially in complete. specifically, what will pakistan work with us to eliminate the leadership of osama bin laden and other major al qaeda officials? as hearings in our committee have underscored, the potential impact of instability and a nuclear arms pakistan doors anything that is likely to happen in afghanistan. the future direction of governance in pakistan will have consequences for nonproliferation efforts, the global economic stability, the relationships with india and china and the security in both the middle east and south asian

regions among other major issues. the president does not dwell on pakistan in his speech on tuesday evening. perhaps because sensitivity in that country to american influences and tensions are extremely delicate. but the president and his team must justify their plan not only on the basis of how it will affect afghanistan but also on how it will impact our efforts to promote a stronger alliance with pakistan that embraces vital what common objectives. having made these observations, i want to recognize the president has been confronted with extremely difficult choices in afghanistan and pakistan. he and his team have worked to the problem carefully and deliberately to reach their conclusions. there are no options available that are guaranteed to succeed and every conceivable course from complete withdrawal to

maintaining the status quo to the plan outlined by the president to one unrestrained, unlimited counterinsurgency campaign has its own set of risks and costs for the united states. the president deserves credit for accepting ownership of this difficult problem as we go forward and for his clear advocacy expressed in his speech on tuesday night. congress and the american people now must evaluate whether this course has a reasonable chance to succeed. if success can be defined, and with the objectives outlined are worth the expenditure of american and afghan lives and treasure. this situation, the advocacy of a president and his national security team must be broadminded and theroux as his policy review appeared to be. within months the president is likely to ask congress for additional funds related to

afghanistan. in the meantime the administration must be prepared to answer many difficult questions about his strategy as the american people study the potential consequences of the president's decision. once again i thank our distinguished witnesses for their leadership, a very substantial leadership and i look forward to hearing their testimony today. thank you mr. chairman. >> thank you very much senator lugar. let me just say senator dodd may have to leave at some point during the testimony because he has to chair the bernanke commination cairnes today so we suspect that maybe the reason you have to go. >> i have-- with. >> madam secretary thank you for being here. mr. secretary if he would follow the secretary of state and admiral mullen if you want to summarize the can put your full

testimonies in a record. >> thank you very much chairman kerry and ranking member lugar and to all the members of this committee. it is an honor for me to be here to testify before you and also to continue the dialogue. both the chairman and the ranking member's statements as would be expected, were extraordinarily thoughtful, raised a lot of the hard questions we are grappling with an's the challenges that we have to meet on both the administration and congress together and i want to thank the committee for their constructive role it has played in helping us to address the difficult issues raised in their region of the world we are focused on today. win president obama addressed the cadets at west point, he set forth both the rationale and the

difficult choices that his policy represents. at the end of a very long and thoughtful process that consisted of ten meetings with the president and his national security team and probably three times that many among the rest of us without the president, the president concluded that among a range of very difficult decisions, this is the best way to protect our nation now and in the future. extremeness, who have taken root in the border area of pakistan and afghanistan have attacked us before. they have attacked our allies. they are now attempting to destabilized if not overthrow the pakistani government and take back in of control, if not the entire country of afghanistan. we believe that if we allow

afghanistan to become a failed state, if we allow extremists to have the same safe havens that they used before 2001, they will have a greater capacity to regroup and attack again and also to continue to provide the leadership the operational and logistical support that they currently provide to global extremism. we believe they could drag an entire region into chaos, and we know that based on the reports from our military and civilian leadership, this situation in afghanistan is serious and worsening. now i know we don't want to go back in history and anchor our decision totally on what happened on september 11, 2001, but i think it does have to be part of the national debate. the damage done with those

attacks against our economic and military power centers was also an attack on my constituents because at that time i had the honor of serving as the senator from new york. i witnessed the tragic consequences to the lives of thousands of innocent families, the damage done to the economy and the damage to our sense of security. so i feel a personal responsibility to help protect our nation from such violence and i entered into the very intense consultations we have been engaged in with that is my overriding goal, but without any preconceived notion of exactly the best way to meet that goal. the case for action against al qaeda and its allies has always been clear, but the united states's course of action over the last eight years has not.

the fog of another war obscured our focus and while our attention was focused elsewhere the taliban regained momentum in afghanistan and the extremist threat in pakistan. a country as you know well but 175 million people, a nuclear arsenal in more than its share of challenges. so it was against this backdrop that the president called for this careful, thorough review of our strategy. our objectives are clear. we will work with the afghan and pakistani governments to eliminate safe havens for those plotting against us, our allies and our interest. we will work to find reliable partners in the region to help us stabilize it, which we think is fundamental to our national security. we will develop a long-term sustainable relationship with afghanistan and pakistan so that we do not repeat the mistakes of the past, primarily our abandonment of that region. a duration of our military presence will be limited on

there's a million commitment must continue even as our troops began coming home. now accomplishing this mission and insuring the safety of the american people is not easy. it does mean sending more civilians, troops and assistance to afghanistan and significantly expanding our civilian efforts and pakistan, which we have begun to do on to the leadership of the chairman and the ranking member of this committee. the will be asking the young men and women who not only serve in the military but are part of our civilian service team to be taking great risks and facing extraordinary sacrifices. i want to assure the committee that we will do everything we can to ensure that their sacrifices make our nation safer. the situation in afghanistan and pakistan in serious but it is not in my view as negative is frequently portrayed in the

public. the beginning of president karzai's second term has opened a window of new opportunity. we obviously have real concerns about the influence of corrupt officials and the afghan government and we will redouble our efforts to pursue them but it is-- in his inauguration speech i witnessed president karzai's call for the afghan people and the international community. he pledged to combat corruption improve governance and deliver. his words were long in coming but they were certainly welcome. they now must be matched with action. the afghan people, the united states and the international community must hold the afghan government accountable. we will help the working with their afghan partners to strengthen institutions at every level. the president has outlined a timeframe of transition to afghan responsibility. as he said in his speech the additional american and international troops will allow us to accelerate our handing over responsibility to afghan forces as we began to transfer

our forces out of afghanistan in july of 2011. just as we have done in iraq, we will execute this transition responsively taking into account conditions on the ground. this is not a cliff. this is a transition. the timeframe for the transition provides a sense of urgency in working with the afghan government. but it should be clear to everyone that unlike the past, the united states and our allies will have an enduring commitment to afghanistan. are resolved in this fight is reflected in the commitment of troops since the president took office and in the significance of the commitment that will continue long after our combat forces began to leave. our civilian effort is already bearing fruit. civilian experts and advisers are helping to craft policy inside government ministries. we are engaged in the process of certifying those ministries that we feel confident providing funding and people not provided if we cannot certify them.

when armories went into-- we had civilians on the ground with them to coordinate assistance the very next day. as their operations progressed our coordination is growing even stronger. we are on the track to triple the number of civilian positions in afghanistan to 974, by early next year. when we started there were about 320. they had six month rotations. are checking of their duly roster showed a lot of them spent more than 30 to 60 days inside afghanistan even though they had been assigned there. we have totally revamp how we are providing assistance and may believe we are beginning to make a difference. each of the civilians leveraged not only on average ten partners of locally employed staff to experts with u.s. bonded ngo's but what we are finding most interestingly is the leverage expertise within the united states military. when you put in agricultural

experts embedded in a battalion and along with the commanding officer of that battalion they go looking for soldiers with ranching and farming experience. we have a force multiplier and when i was in kabul two weeks ago meeting with our sentinel teams, those were in exactly the kinds of stories i was told in the military who are responsible for the clearing phase bekka of our military operations told me repeatedly how important this civilian presence was. as one said to me, i am happy sis supply would never support these valuable civilians need and we need more of them. this strategy will make that possible. not only do we believe we have the right people to achieve our objectives, we believe we have a sound strategy. we will be delivering high impact economic assistance and in bolstering afghanistan's sector of the core of the afghan

economy. a number of my former colleagues have talked with me in the last month about the importance of agriculture and how they tried for eight years to help create jobs, reduce the funding the taliban received from poppy cultivation, in effect draw resurgence of the battlefield well moving them from poppy to pomegranate. we also will support it effort to open the door to those taliban that were willing to renounce the al qaeda, abandoned violence in which to reintegrate into afghan society. we understand that some of those the fight with the insurgency did not do so out of ideology, theology or conviction but frankly do to coercion and money. the averaged taliban fighter is our information received two to three times the monthly salary than ever jet cancels your police officer. our regional diplomacy complement's this political approach by seeking to mitigate external interference in

afghanistan and working to ship the calculus of neighboring countries. that of course leads me to pakistan, a strong, stable democratic pakistan must be a keyboard and for the united states and an ally in the fight against violent extremism. we have seen progress of this past year as people in pakistan increasingly come to the view that we share a common enemy. i heard that repeatedly during my recent visit but we have a long way to go. we will significantly expand, support to develop the potential pakistan and its people demonstrating a long-term commitment. i spent three days in pakistan last month and most commonly i heard over and over again, you left us before, will you do it again? he walked away. you left us holding the problem you helped to create. we want to send a clear message as the kerry-lugar berman legislation does that we intend to be committed over the long term. we will not be facing the

challenges alone. we have 42 other troop contributing countries. car nato allies the party made significant contributions. after this hearing i will leave for brussels to begin the process of securing additional afghan commitments. ambassador holbrooke is already there consulting with our allies. we have had a very encouraging response and the conversations we have thus far and we are looking beyond nato to build the strongest, the broadest possible local coalition. japan just announced a 5 billion-dollar commitment to afghanistan. we think other governments are beginning to recognize that this is a common fight against the common in many so let me conclude where i began. we face a range of difficult choices but the president's plan represents the best way beano to protect our nation today and in the future. the task we face is as complexes in the national security

challenge in our lifetime. we will not succeed if people view this effort as a responsibility of a single partner, a single agency within our government or a single-- we'll it to our troops and civilians will face these dangers to come together as americans and come together with our allies in the international partners to help accomplish this mission. i look forward as always to continuing to work with you to achieve that goal. thank you. >> thank you madam secretary. secretary gates. >> mr. chairman, senator lugar, members of the committee i would like to provide an overview of the strategic thinking and context behind the president's decisions. in particular the nexus amman al qaeda, the taliban, pakistan and afghanistan and our objectives in how the president's strategy clint-- as the president's stated in march and mythicize to's tonight the goal of the united states and

pakistan is to disrupt dismantle and defeat the al qaeda and its extremist allies. and prevent its return to both countries. the international military effort will stabilize afghanistan as necessary to achieve this overarching goal. defeating al qaeda enhancing afghan security are mutually reinforcing emissions. they cannot be untethered from one another as much as we might wish that to be the case. well al qaeda is under great pressure now and dependent on the taliban and other extremists, groups for sustainment its success of the taliban would vastly strengthen al qaeda's message to the muslim world that island extremists are on the winning side history. but simply the taliban and al qaeda have become symbiotic, each benefiting from the success and-- al qaeda leaders have stated this explicitly and repeatedly. the lesson of the afghan taliban's revival is the time

and will on their side. that with the western defeat that they could regain their strength and achieved a major strategic-- as long as their senior leadership lives and can continue to inspire and attract followers and funding. rolling back the taliban is now necessary even if not sufficient for the ultimate defeat of the al qaeda. at the same time, one cannot separate the security situation in afghanistan from the stability of pakistan, a nuclear-armed nation of 175 million people now also explicitly targeted by islamic extremeness. giving extremeness breathing room in pakistan led to the resurgence of the taliban and more coordinated sophisticated attacks in afghanistan. at the same token providing sanctuary for extremists in southern and eastern afghanistan would put yet more pressure on the pakistani government already under attack from groups operating in the border region.

indeed the pakistan taliban in just the last year or so has become a real threat in pakistan's domestic peace and stability, carrying out with al qaeda's help deescalating bombing attacks throughout the country. failure in afghanistan would mean a taliban takeover of much of mcnaught most of afghanistan and likely renewed civil war. taliban vreen, taliban ruled areas could in short order become once again a sanctuary for al qaeda as well as a staging area for research and militant groups on the offensive in pakistan. success in south and central asia by islamic extremists as was the case 20 years ago, would the get success on other fronts for goldenson quimby al qaeda narrative, providing opportunities for recruitment, fund-raising and more sophisticated operations. it is true that al qaeda and its followers simplot unexecuted

sacks from a variety of locations from munich to london to denver, but what makes the border area between afghanistan and pakistan uniquely different from any other location including somalia, yemen or elsewhere is that this part of the world represents the epicenter of this extremist jihadism. the historic place where native and foreign muslims defeated one superpower and in their view cossets collapsed at home. for them to be seen to defeat the sole remaining superpower in the same place would have severe consequences for this country and the world. some say this is similar to the domino theory that underpinned and ultimately muddy the thinking behind u.s. military escalation in vietnam. the difference however is that we have very real and very recent history that shows just what can happen in this part of the world when extremists have breeding space, safe havens and government complicity with and supportive of their mission. less than five years after the

last soviet tank crossed the bridge out of afghanistan in 1993 islamic militants launched their first attack on the world trade center in new york. we cannot afford to make a similar mistake again. the president's new strategic concept aims to reverse the taliban is momentum and reduce its strength while providing the time and space necessary to the afghans to develop enough security in governance to stabilize their own country. the essence of our civil military plan is to clear, build and transfer. beginning to transfer security responsibility to the afghans in the summer of 2011 is critical and in my view achievable. july 2011, the time at which the president said the united states will begin the drawdown of our forces will be the beginning of a process, and inflection point if you will, of transition for afghan forces to begin to assume

greater responsibility for security. the payson character of that drawdown, which district in provinces are turned over, will be determined by conditions on the ground. it will be a gradual but the inexorable process. it will be similar to the gradual but steady conditions bates drawdown that began to take place in iraq about 14 months after the surge began there. as lisl many issues on the national security and defense arena the real challenge in afghanistan is finding the right balance. the prompt dispatch of some 30,000 u.s. combat troops on top of the 21,000 already ordered by the president earlier this year sends a certain message that the president's resolve to both our partners and our adversaries in afghanistan and pakistan. when this buildup is complete, u.s. force levels in afghanistan will have more than doubled under president obama's orders

to about 100,000 troops. whether you agree with what we are doing are not there should be no doubt at home or abroad, this president's commitment to the success of this mission. on the other hand we have to send in equally strong message to the afghan government that when all is said and done the united states military is not going to be there to protect them forever. that the afghans misstep up to the plate and do the things necessary that will allow them to take primary responsibility for defending their own country and do so with a sense of purpose and urgency. this is the balance were trying to achieve and i believe the president's plan provides both the resources and the flexibility to do so. making this transition possible requires accelerating the development of a significantly larger and more capable of afghan army and police to intense apart during with isaf forces sis wrestling combat. even after we transfer security responsibility to the afghans to

drawdown our combat forces, united states will continue to support the development as an important partner for the long-haul. we must not repeat the mistakes of 1989 when the band in the country only to see a descent into chaos and then into taliban hands. that we offer a couple of closing thoughts. the president believes as i do, that in the end we cannot defeat al qaeda and its toxic ideology without improving and stabilizing the securities they situation in afghanistan. the president's decision offers the best possibilities to the sizably change the momentum in afghanistan and fundamentally hold the strategic equation pakistan in central asia. all necessary to protect the united states, our allies and our vital interests. has always the heaviest burden will fall on the men and women who have volunteered and reed volunteered to serve their country in uniform and i know they will be uppermost in our

minds and in our prayers as we take on this arduous but finally import mission. thank you. >> thank you very much secretary gates. admiral mullen. >> chairman kerry, senator lugar and distinguished members of this committee thank you for your time today. i also like to express my appreciation for all the work this committee has done to get the kerry the flu gruebel past and these discussions that can be easily lost on the 7.5 billion candidates actually nonmilitary aid, which i think having spent a lot of time in that part of the world is absolutely critical, and the other part of it is that it is an over an extended period of time, for too long in pakistan as many of you know. it is tenure to years of that five year commitment is really significant. and i want to ensure you in the debates in the deliberations that we have had ith