the presiding officer: are there

any senators in the chamber wishing to vote or to change their vote? if not, then the ayes are 54, the nays are 44, and the nomination is confirmed. under the previous order, the senate will proceed to considering the following nominations en bloc which the clerk will report. the clerk: nominations, national labor relations board, nancy jean shiffer of maryland to be a member, mark gaston pearce of new york to be a member, harry i. johnson iii of virginia to be a member, philip andrew miscimarra of illinois to be a member. the presiding officer: under the previous order, the clerk will report the motion to invoke cloture. the clerk: we the undersigned senators in accordance with the provisions of rule 22 of the

standing rules of the senate hereby move to bring to a close the debate on the nomination of nancy jean shiffer of maryland to be a member of the national labor relations board, signed by 17 senators. the presiding officer: under the previous order, there will now be two minutes of debate equally divided in the usual form prior to a vote on the motion to invoke cloture on the schiffer nomination. a senator: madam president? the presiding officer: the senator from iowa. mr. harkin: i ask consent that time be yielded back. the presiding officer: is there objection? without objection. by unanimous consent the mandatory quorum call has been waived. the question is, is it the sense of the senate that debate on the nomination of nancy jean shiffer of maryland to be a maryland of the national labor relations board for the term of five years expiring december 16, 2013 --, 2014 shall be brought to a close. the yeas and nays are mandatory under the rule. the clerk will call the roll.

vote: vote:

is ca

vote:

the presiding officer: are there any senator in the chamber wishing to vote or wishing to change their votes? if not, on this vote, the yeas are 65, the nays are 33.

three-fifths of the senators dual chosen and sworn having voted in the affirmative, the motion is agreed to. mr. reid: move to reconsider, lay on the table. madam president? the presiding officer: mr. leader. mr. reid: can we have the attention of the senate. the presiding officer: order? the senate. mr. reid: we have three more votes. they're ten-minute votes. we give five minutes penalty time. we're employing to start wrapping these -- we're going to start wrapping these votes up. the first vote took 30 minutes. so let's try to stick to what we always said we would do. people wait around here. it's not fair everybody to else. so so as soon as we get enough votes here, we're going to move on if everybody is here or not. the presiding officer: thank you. under the previous order, all postcloture time yielded back. the question occurs on the schiffer nomination. is there a sufficient second?

there appears to be. the clerk will call the roll. vote:

vote:

the presiding officer: are there any senators in the chamber wishing to vote or wishing to change their votes? if not, the ayes are 54. the nays are 44. and the nomination is confirmed. under the previous order, the clerk will report the motion to invoke cloture. the clerk: we the undersigned senators in accordance with the provisions of rule 22 of the standing rules of the senate hereby move to bring to a close the debate on the nomination of mark gaston pearce of new york to be a member of the national labor relations board signed by 17 senators. the presiding officer: under the previous order there will now be two minutes of debate equally divided in the usual form prior to a vote on the motion to invoke cloture on the pearce nomination. the senator from iowa. mr. harkin: i ask consent that all time be yielded back. the presiding officer: is there objection? without objection. by unanimous consent the mandatory quorum call has been waived. the question is, is it the sense

of the senate that the debate on the nomination of mark gaston pearce pearce of new york to be a member of the national labor relations board for the term of five years expiring august 27, 2018, shall be brought to a close. the yeas and nays are mandatory under the rule. the clerk will call the roll. vote:

vote:

the presiding officer: any senator wishing to vote or to change his or her vote? on this vote, the yeas are 69, the nays are 29. 3/5 of the senators duly chosen and sworn having voted in the affirmative, the motion is agreed to. under the previous order, all postcloture time is yielded back, and the question occurs on the pearce nomination.

yeas and nays. is there a sufficient second? there appears to be. the clerk will call the roll. vote:

vote:

vote:

the presiding officer: are there any senators in the chamber wishing to vote or change their vote? if not, the ayes are 59, the nays are 38. the nomination is confirmed. under the previous order, the question occurs on the johnson nomination. all in favor say aye. all opposed, say nay. the ayes appear to have it. the ayes do have it. the nomination is confirmed. under the previous order, the question occurs on the miscimarra nomination. all in favor say aye. all opposed say nay. the ayes appear to have it. the ayes do have it. the nomination is confirmed. under the previous order, the motions to reconsider are

considered made and laid upon the tabling. the president will be notified immediately of the senate's action, and the senate will resume legislative session. mrs. murray: madam president? the presiding officer: the senator from washington. mrs. murray: what is the pending business? the presiding officer: the clerk report the pending business. the clerk: calendar number 99, s. 1243, a bill making appropriations for the departments of transportation and housing and urban development and so forth and for other purposes. mrs. murray: madam president? the presiding officer: the senator from washington. mrs. murray: madam president, i ask unanimous consent the following amendments be in order and the senate proceed to their consideration en bloc: flake number 1818, flake number 1772, mccaskill-blunt number 1800, bloom blumenthal, menendez 1812, and quok ran number 1814.

-- and cochran number 1814. the presiding officer: is there objection? the senator from maine. ms. collins: madam president, it is with great regret that on behalf of senator coburn, i am objecting. i want to point out that we've worked very hard to clear this list of amendments, and they include amendments from members on both sides of the aisle. it's a fair list, and i had hoped that we would be able to proceed tonight. regrettably, there is an objection on our side from senator coburn. i am, however, optimistic that with further work we will be able to deal with that objection, and my hope is that in the morning we will have an agreement that will allow me to agree on, as the manager on our side, to this list. but, unfortunately, at this

time, i do need to object fnl. the presiding officer: objection is heard. mrs. murray: madam president, i suggest the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

the presiding officer: the majority leader. mr. reid: are we in a quorum call? the presiding officer: yes. mr. reid: ask unanimous consent that we vitiate it. fer sph without objection. mr. reid: so s. 1243 is now pending? the presiding officer: sthear ts correct. mr. reid: i ask that the cloture motion be reported. the presiding officer: the clerk will report. the clerk: cloture motion: we, the undersigned senators, in accordance with the provisions of rule 22 of the standing rules of the senate, do hereby move to bring to a close debate on s. 1243, a bill making appropriations for departments of transportation and so forth and for other purposes. signed by 18 senators as follows: mr. reid: madam president, i ask that the reading of the

names be waived. the presiding officer: without objection. mr. reid: before i go further, i want the senator from washington and the senator from maine to hear what i'm saying. that is this: we would love to process amendments. we're going to do one in the morning which has held things up for sometime now. there are other amendments pending. there are going to be votes on those. no problem with that. i just think that this is a piece of legislation that we should pass. i heard the ranking member speak on the floor yesterday. could have been the day before. but i was so impressed because she said what is true. that's what we are. we're legislators. we pass this here. everyone knows what the number is if we pass it here. we go to conference. what happens in conference? the numbers change. that's the way things should happen around here. so i would hope that we don't have these lines drawn in the sand and that we can start being appropriators again. when i came here these many years ago, i was so fortunate --

only two freshmen got on the aeption pros committee. i got on it and barbara mikulski. and i loved that committee all these years. it hasn't been much fun lately because we haven't had the eption pros committee that's been functioning decently. barbara mikulski and shelby are legislators. they want to do legislation. just like the manager -- the two managers of this bill here. so i would hope that we can move forward. i have no problem with the coburn amendments, the paul amendment. let's vote on them and move on. but the time has come that we have to try to get past -- the week is drawing to a close. we have a number of nominations. we have to move to things when we get back here. i'd like to do some more appropriations bills when we get bafnlgback. so i ask consent that the mandatory quorum under the --

required under rule 22 shall waived. the presiding officer: without objection. mr. reid: so i now ask unanimous consent that the senate proceed to a period of morning business with senators prime ministered to spink to ten minutes each. the presiding officer: without objection. the senator from colorado. mr. udall: madam president, i welcome this opportunity tonight to speak on the floor about the national security agency solves programs, their effectiveness and their future. and i have i'm proud to be joined which my colleague from oregon, senator wyden, who will comment as well after my remarks. he's been a stalwart leader on these issues, and it's been my honor to join forces with him to draw attention to this really important discussion that president obama recently welcomed. he call for a public debate on

finding the right balance between national security and privacy in the context of n.s.a.'s surveillance programs. and his call, madam president -- it's long overdue and it's an opportunity we should not squander. i've said time appeared time again to coloradans, and they've said back to me as well, we owe it to the american people to have an open, transparent debate about the limits of the federal government's surveillance powers and how we reconcile the need to keep our families safe while still respecting our hard-won constitutional rights to privacy. madam president, i would have preferred that this debate would have been kicked off by the more transparent actions by the white house instead of by unauthorized leaks. but we are nonetheless presented with a unique opportunity, an opportunity to finally have an open dialogue about the limits of our government's surveillance

powers, particularly those relating to the vast dragnet of americans' phone record recordsr section 2patriot act. 2patriot -- section 215 of the patriot act. mr. reid: will the senator yield? mr. udall: i would be happy to. mr. reid: i ask that the senator's statement not be interrupted in the record. the presiding officer: without objection. mr. reid: i ask that at a time to be determined by me ands the senate proceed to executive session to consider calendar number 220, thr that there be two hours for debate equally divided between the proponents and opponents. the senate proceed to vote with no intervening action or debate on the nominations the motions to reconsider motion to reconsider with no intervening action or debate, no further amendments be in order. that president obama be immediately notified of the senate's action and the senate then resume legislative session. the presiding officer: i

-- is there objection? without objection, so ordered. mr. udall: madam president, as i was saying, we have a unique opportunity to engage in an important discussion and debate about the power of the federal government to put in place the vast dragnet of americans' phone records under section 215 of the patriot act. this is a debate i feel very privileged to take part in. it's a debate that senator wyden has been a part of since before i was even elected to the congress and one that i have been engaged in for a number of years now. i want to be clear, i have acted in every possible way that i could within the confines of our rules that protect classified information to oppose these practices and bring them to light for the american people. i have fought against overall intrusive sections of the patriot act and the fisa amendments act and registered objections repeatedly with the administration. i believe that these efforts are critical for protecting our

privacy and also ensuring our national security. madam president, i serve on both the senate armed services committee and the senate intelligence committee, and in those assignments, i focus every day, every day on keeping americans safe at home and abroad. i recognize that we still live in a world where terrorism is a serious threat to our country, to our economy and to american lives. make no mistake, madam president, our government needs the appropriate surveillance and antiterrorism tools to combat the serious threats to our nation. but it is up to the white house and the congress to ensure that these tools strike the right balance between keeping us safe and protecting our constitutional right to privacy. this is a balance i know we can achieve, but in my view, the

patriots act bulk phone records collection program does not achieve that balance. and that's why i'm here on the senate floor with my colleague, senator wyden, to call for an end to the bulk phone records collection program as we know it today. two years ago, we were here on the senate floor. we were considering sending certain patriot act provisions, and at that time i argued that the sweeping surveillance powers we were debating did not contain sufficient safeguards to preserve the privacy rights of americans, and in particular i argued that the patriots act business records provision or section 215 permits the collection of records on law-abiding americans who have no connection to terrorism or espionage. as i said at that time, we ought to be able to at least agree that an investigation under the patriot act powers should have a terrorist or espionage-related

focus. we all agree that the intelligence community needs effective tools to combat terrorism, but we must provide those tools in a way that also protects the freedoms of our people and that lives up to the standard of transparency that our democracy demands. madam president, the bill of rights is the strongest document we have. another way to put it, it's the biggest, baddest weapon that we have. we need to stand with the bill of rights, and in this case the fourth amendment. following mr. snowden's actions and the subsequent declassification of information concerning the n.s.a.'s surveillance programs, americans in recent weeks are coming to understand what it means when section 215 of the patriot act says that the government can obtain -- quote -- "any tangible thing relevant to a national security investigation."

that is the foreign intelligence surveillance court's way of saying that section 215 permits the collection of millions of americans' phone records on a daily ongoing basis. as a member of the senate intelligence committee, i've repeatedly expressed concern that the fisa court's secret interpretation of this provision of the patriot act is at odds with the plain meaning of the law. this secrecy has prevented americans from understanding how this law is being implemented in their name, and in my view and in the view of many americans, this large-scale collection of information by the government has very significant privacy implications for all of us. what do i mean by that? well, information about our phone calls or as it's known metadata may sound pretty simple and innocuous, but i believe that when law-abiding americans

call up their friends, family, doctors, religious leaders or anyone else, the information on whom they call, when they call and where they call is from private information and should be subject to strong privacy protections. now, i've heard it said that the bulk phone records program collects nothing beyond what you can find in a phone booth, but let's be clear about exactly what this program does. it collects the very personal details of our phone calls, the who, where, when and how long and stores them in a database. and this just doesn't happen for those who are suspected of having some connection to terrorism. this program collects the phone records of literally millions of americans. this is a far greater intrusion into our privacy than being voluntarily listed in the yellow pages.

it's the reason why i'm calling on the white house and the congress to immediately reform this program. madam president, again, let me reiterate that it's absolutely possible to have both privacy and security, yet in the case of the bulk phone records collection program, senator wyden and i believe we aren't getting enough of either. not only does this program unreasonably intrude on americans' privacy, but it also does so without achieving the alleged security gains. for instance, in recent weeks, the intelligence community has made new assertions about the value of recently declassified n.s.a. surveillance programs, but in doing so, they have conflateed two -- conflated two programs -- section 702 of the foreign intelligence surveillance act regarding

foreigners' internet communications, and section 215 of the patriot act regarding bulk phone records. it appears, however, that the bulk phone records collection program alone played little or no role in disrupting terrorism plots. madam president, i say this as someone who has been fully briefed on these terror-related events. nor has it been demonstrated that this program even provides any uniquely valuable intelligence. therefore, saying, as the intelligence community has, that these programs together have disrupted dozens of potential terrorist plots is misleading. and while the intelligence community has been conflating these two programs, some of my colleagues in congress just in recent days have been going even further to say that the phone records program alone has been greatly successful. they have said it has saved

lives and prevented dozens of terrorist plots. as someone who has been presented with the same information as my colleagues on the much-discussed 54 terror-related events, i have to say that i disagree. again, i have seen no evidence that the bulk phone records collection program alone has played a meaningful role, if any role, in disrupting terrorist plots. i have yet to see any convincing reason why agencies investigating terrorism cannot simply obtain information directly from phone companies using a regular court order. it may be more convenient for the n.s.a. to collect phone records in bulk rather than asking phone companies to search for specific phone numbers, but convenience alone cannot justify the collection of the personal information of millions of innocent, ordinary, law-abiding americans, especially when the

same or more information can be obtained using less intrusive methods. a few hundred court orders per year would clearly not overwhelm the fisa court, and the law already allows for emergency authorizations to get these records quickly in urgent circumstance. senator wyden and i are not alone in believing there is a more effective and less intrusive way to collect this information. even before the nature of the bulk phone records program was declassified, there was support for narrowing the language of section 215 from many members of the congress of both political parties, and in fact, madam president, when the patriot act reauthorization passed the senate in 2005 by unanimous consent, it included commonsense language that would have limited the government's ability to collect americans' personal information unless there is a demonstrated link to terrorism

or espionage. that language was designed to, among other things, protect our fourth amendment constitutional rights and put a check on government power. now, while that language did not make it into the final conference bill, it demonstrated that bipartisan agreement on reforms to section 215 is possible. let's fast forward to 2011. the senate again took up an extension of a number of expiring provisions of the patriot act. i offered an amendment drawn directly from the language in the senate 2005-passed bill to narrow the application of this provision. that amendment unfortunately did not receive a vote, but in this congress, i introduced bipartisan legislation with senator wyden based on that same language and that same set of principles, and we are now joined by a strong bipartisan

group of our colleagues from across the country and all along the political spectrum, including senators durbin, murkowski, begich, tom udall, merkley, lee and heinrich, and our bill would responsibly narrow the patriot act's section 215 collection authority to make it less intrusive on the privacy of law-abiding americans. our legislation would still allow law enforcement and intelligence agencies to use the patriot act to obtain a wide range of records in the course of terrorism and espionage-related investigation, but it would require them to demonstrate that the records are in some way connected to terrorism or clandestine intelligence activities, which is not the case today. this past week, madam president, there was a strong bipartisan vote in the u.s. house of representatives to curtail

n.s.a.'s bulk phone records collection, and although the legislation didn't pass, the american people are demanding action, and those who share our concerns are on the march. it is time to take action. it's just common sense that our law enforcement agencies should have a reason to suspect a connection between the records they are seeking and a terrorism or espionage investigation before using these broad authorities to collect the private information of americans. if the government can use these powers to collect information on people who have no connection to terrorism, then where does it end? is there no amount of information that our government can collect that would be off-limits? what's next? are medical -- our medical records? we must be able to put in place reasonable measures that allow our law enforcement agencies to

pursue enemies who would try to harm us while protecting our rights as americans. that's why i believe that if an investigation cannot assert some nexus to terrorism or espionage, then the government should keep its hands off the phone records of law-abiding americans. these are the kinds of reasonable, commonsense limits on the government's powers that coloradans tell me are necessary to keep us safe while also respecting our privacy. and that takes me back to the statement i made at the outset. i believe it is time to end the bulk collection program as we know it. tonight i'm calling on the white house to begin to make the administrative changes to end the bulk collection of americans' phone records and conduct the program instead through direct queries to phone companies where there is a connection to terrorism or espionage.

under this more targeted approach, our government would retain its broad authorities to investigate terrorism while ordinary americans would be protected from overly intrusive surveillance activities. congress should support the administration's move in this direction by passing our legislation to end bulk collection. passage of our bipartisan bill would prevent unwarranted future breaches of americans' privacy rights and focus on the real threats to our national security. taking into account the serious privacy concerns raised by the bulk collection program, the lack of demonstrated unique value of the program and our ability through direct queries to the phone companies to collect the data in the same but less intrusive ways, i believe the administration, i hope the administration will see the value in working with congress to end the bulk collection of

phone records conducted under the patriot act's section 215 authorities. i pledge to work with the administration and all of my colleagues to see this through. madam president, let me end on this note: we need to strike a better balance between protecting our country against the threat of terrorism and defending our constitutional rights. the bulk records collection program as we know it today does not meet this balanced test and that's why i believe it must end. thank you, madam president. i yield the floor. a senator: madam president? the presiding officer: the senator from oregon. mr. wyden: madam president, before he leaves the floor, i just want to tell senator udall how much i've appreciated having him there in that intelligence room because he has been a strong advocate for making sure that our country can have security and liberty in those classified meetings just as he

has been here tonight, and is -- it's great to have you on the committee and to have you as a partner in these efforts. and you are so right when you state tonight that this is a debate that should have begun long, long, long ago, and it's a debate that should have been started by elected officials and not by a government contractor. i very much appreciate your remarks and i think you made this clear, that we're going to stay at this till we get it fixed, and i very much appreciate your leadership. madam president, as senator udall has made clear, these issues are about as important as it gets. when you're talking about how you can secure these bedrock american values, security and liberty, this is right at the heart of what americans care about most.

and for too long, madam president, my view is the american people have essentially been presented with false choices. americans have been told you really can have one or the other. you can have your security or you can have your liberty, but you really can't have both. and suffice it to say, madam president, in the last eight weeks as this debate has evolved, i think americans have come to understand that this set of false choices is not what this debate is all about, and they deserve better. as this debate has unfolded, whether you're in a lunchroom at work or a senior citizens center or you're looking at a political

opinion poll, madam president, madam president, the polls have changed something like 20 points just in the last few weeks with americans saying, particularly the bulk phone records collection program, is an intrusion on the rights of law-abiding americans. so whether it's what citizens say at town halls or what they say at the company lunchroom or in senior citizen centers, is americans have come to understand that these false choices are not what the discussion is all about. americans have really come to figure it out. and, frankly, a big part of the problem in the past -- and i documented it last week -- is leaders in the intelligence community have made misleading statements repeatedly. it's not just a question, madam president, of keeping the american people in the dark,

which was true. but the american people were actively misled on a number of occasions. senator udall and i have been walking everyone through that, the bulk phone records collection program is often compared to a grand jury subpoena approach. that's about as far-fetched as it gets, madam president,. -- madam president. even national security lawyers have made fun of that kind of argument in publications like "the wall street journal." very often when i talk to lawyers, the distinguished president of the senate is, of course, a particularly illustrious lawyer and taught in the field. i often say when i'm visiting with lawyers or asked for a show of hands, anybody know of a grand jury subpoena where you can go out and have the bulk collection of millions and millions of phone records of

law-abiding americans, come on up to me and tell me after the meeting is over. i don't exactly get swarmed, madam president. the reason is, there aren't any. and one of the reasons i wanted to touch on these misleading, you know, statements is that just in the last few days senator udall, you know, touched on there's really been an effort to take the two programs, one of them is called the fisa 7 0 -- 702 program, the prism program, which targets foreigners and has useful value. we've made that clear, it could be improved, and i came to that conclusion, madam president, when i was finally able to get declassified a finding from the fisa court that on at least one occasion the fourth amendment

had been violated in connection with the use of the 702 program. but even with that, i'm of the view that that provides useful value. but what a number of the leaders of the intelligence community have done is essentially commingled their advocacy of these programs so that 702 and the bulk collection program essentially ride, you know, together. when in reality 702, which senator udall and i have supported and i think we can improve it with these privacy reforms -- in effect 702 does all the work, and the bulk collection program, which does intrude on the rights of millions of law-abiding americans essentially is long for -- along for the ride. but you wouldn't know that when you hear these statements from a

number of the leaders in the intelligence community, when they just say these programs, of course, are what keeps us safe. now, in addition, madam president, i thought it was important to briefly start this evening by mentioning that over the last few days there have been a number of comments about whether the patriot act has violated the rights of americans with respect to this bulk collection program. and a number of commentatorrors and others have said where are the violations? haven't seen any, you know, violations. well, the director of national intelligence, madam president, said last friday in a letter to you and i and senator udall and 23 other of our colleagues, is yes, there have been violations

of the patriot act. when he said specifically that the government had violated court orders on the bulk collection of those phone records. madam president, i'm not allowed to discuss the classified nature of that, but i want to make sure that those who are following this debate know that from my vantage point, reading those documents that are classified, these violations are more serious than have been stated by the intelligence community, and mind you, are very troubling. so i do hope that senators will go to the intelligence committee and ask to see those classified documents. because i think when they read them, i think they'll come to the conclusion i've come, that not only is what was stated by the director of national intelligence in that letter that

was sent to you and i and senator udall and 23 other senators, not only was that correct, but i think that senators who read those classified documents will also come to the conclusion that the violations are more serious than i thought. than the intelligence community portrayed. so let me, if i might, talk a little bit more about why we spent several years examining this bulk phone records, you know, program. first, i think it's important for citizens to know that the ability to conduct this secret surveillance that lays bare the personal lives of millions of law-abiding americans, coupled with the ability to conjure up these legal theories as to why

this is acceptable, and then have such limited oversight through this yun sided adversarial fisa court, in my view is an opportunity for unprecedented control over the private lives of americans. that's really why senator udall and i have spent all this time focused on this issue. now, i thought also tonight -- and i haven't done this before -- provide a little bit more history into how we got to this particular place. when i came to the senate, you know, early on i had a chance to work with a number of colleagues who really saw the extent of these problems early

on. one of them was our former colleague, senator russ feingold. senator feingold saw the problems that the patriot act posed before they were apparent to many senators, and he and his staff took the responsibility to protect both american security and american liberties very seriously. so in 2007 the two of us came to understand that the patriot act was being secretly interpreted to justify the large scale bulk collection of ordinary americans' records, and we made it clear that we thought, first of all, that was something real different than what americans thought was going on, thought it was real different, for example, than the plain reading of section 215 of the patriot act, and we thought that the language of the patriot act had really been stretched beyond

recognition because the language in the patriot act really spoke to relevance and a sense that it was relevant to suspected terror activity rather than something that created this enormous leap from what was in the statute that called for relevance to collecting millions and millions of records on law-abiding people. so senator feingold and i dutifully set about to write classified letters to senior officials urging them to make their official interpretation of the patriot act public. and we said at the time that for intelligence activities to be sustainable and effective they have to be based on publicly understood laws and consistent with americans' understanding of their own privacy rights. this in our view was clearly not the case with the bulk records collection because, of course, the government's official interpretation the patriot act was a tightly guarded secret.

so back then in those early days we were rebuffed when we made these repeated requests that the intelligence community inform the public what the government had secretly decided the law actually meant. and, in fact, there was a secret court opinion that authorized massive dragnet domestic surveillance and the american people by that point were essentially in the dark about what their government was doing with respect to interpreting an important law. in 2009, as the expiration dates of the patriot act approached, senator feingold and i began to caution our colleagues and the public that our people were not getting the full story about the patriot act. at that time we had the good fortune of having our colleague, senator durbin, on the committee, and we all wrote

public letters. we authored various articles to the editorial pages, we raised issues about this to the extent we could at public hearings. but of course the senate rules regarding the protection of classified information limited what we could say. mr. president, one point that i've tried to make clear is the intelligence rules, the classification rules don't let a member of the committee tap the truth out in morse code. you have to comply with the rules, and they are very laborious, and if you don't comply with the rules, you can't serve on the intelligence committee and be a watchdog for some of these efforts which we think go right to the heart of protecting american security and american liberty. so we decided, those of us who

-- a small group of us who shared these views, we decided if we wanted to have that opportunity to play that watchdog role, we needed to work within the rules. so we did everything we could, recognizing that you can't tap out classified information in morse code to alert the public about what was going on. after a series of short-term extensions, the patriot act came up for a long-term reauthorization in the spring of 2011. by that time, senator fine dpoald had been replaced on the committee by senator udall. he, as colleagues know, shares these concerns about the bulk collection of phone records on millions of law-abiding americans, and we're lucky he's been a prominent leader in the cause of protecting security and liberty. so during that 2011 reauthorization, senator udall and i spoke to colleagues, invited colleagues to secure settings to really lay out what

was actually happening, and many of those colleagues joined us on the floor to oppose the extension of the patriot act for four more years. during that debate, mr. president, i came to the floor and said, "the american people find out how their government is has secretly interpreted the patriot act, they're going to be stunned and they're going to be angry." that week the senate agreed to extend the patriot act until 2015, but those who opposed the extension continued the fight in the months that followed. at that time the n.s.a. wags wao conducting a bulk e-mail records program in addition to the bulk phone records program that is ongoing today. senator udall and i were concerned about this program's impact on our liberties and on our privacy rights, and back in the intelligence committee we spent a big chunk of 2011

pressing intelligence officials to provide evidence of its effectiveness. turned out that the intelligence community was unable to provide any such evidence. intelligence agencies had made statements to both congress and the foreign intelligence surveillance court that they had significantly exaggerated the effectiveness of the bulk e-mail program when senator ow dale and i pressed them to back these staples up, they couldn't do it. the bulk e-mail records program was shut down that year. our experience with a the bulk e-mail records program showed us that the intelligence agencs' ssessments about the usefulness of a number of these programs, even big ones, are not always accurate. now, that doesn't mean that intelligence officials were deliberately lying. as far as i can tell, in a number of instances, they believed their claims that the bulk e-mail program was

effective, even though, mr. president, it was actually close to worthless. this was an important reminder that even if spel intelligence officials are well-intentioned, thethey can be dead wrong and ay policy-makers that simply diverse to intelligence agency conclusions without asking to see they are evidence is making a misstaifnlgt as we looked at that evidence, senator udall and i found claims about the effectiveness of the bulk phone records program also did not seem well-supported by the facts. in march of 2012 we wrote to the attorney general splesl expressh our concern. "in recent months we've grown increasingly skeptical about the value of this spell generals collection operation. wthis comes as a surprise to us as we were initially inclined to take the executive branch's assertions about the importance of this operation at face value. the department of justice, unfortunately, decided not to respond to our letter.

we continued our efforts to educate the public and to call out senior officials from intelligence agencies in the d.o.j. as they repeatedly made misleading statements about domestic surveillance. in june of this year, disclosures by "the washington post" regarding these revealed the bulk collection to the american people. this sparked a debate that is now ongoing about whether or not hoover up the personal records of ordinary americans is the best way to protect our security and our liberty. this debate, as i've indicated, and senator udall was on the floor, should have started a long time ago. but i'm sure glad, mr. president, that it is finally happening now. the fact of the matter is that americans' phone records can reveal a lot of private information. if you know, for example, that stime somebody called the psychiatrist three times a week and twice after midnight, you know a lot about that person.

and if you are vacuuming up when americans call and how long they tawrks you are collecting an astounding amount of information about a huge number of law-abiding men's. the intelligence agencies try to emphasize that they have rules about who can look at these bulk phone records and when. but, mr. president, i want to emphasize this, because i think after all of the talking on cable and the talkingheads on tv, i want to emphasize, none of these rules require the n.s.a. to go back to a court to look at americans' phone records, and none of these rules erase the privacy impact of scooping up all of these records in the first place. on top of that, as i indicated in the beginning, there have been a number of serious violations of those rules. for senators who got the letter last friday, you know that.

i want to tell all the other senators on both sides of the aisle about the violations that i've talked on tonight were a lot more serious than the public has been told. i believe the american people deserve to know more details about these violations that were described last friday by director clapper. mr. president, i'm going to keep pressing to make more of those details public. mr. president, it is my view that the information about the details, the violations of the court orders with respect to the bulk phone record collection program, the admission that the court orders had been violated, has not been, i think, fully flushed out by the intellectual p with generals committee, and i think a considerable amount of additional information can be offered without in any way compromising our national security. now, if the impact on america's liberties wasn't bad enough,

it's made even worse, mr. president, by the fact that this program, when we've asked and we've asked and we've asked, does not seem to have any unique value. value. and i'll explain briefly what it means. mr. president, i would ask for ... let's see ... how about seven additional minutes. i ask unanimous consent. the presiding officer: without objection. mr. wyden: all right. i will sea see if i can beat the clock here because i no he that colleagues are here as well. in fact, senator baldwin has been a great advocate for liberties and showing that liberty and security are compatible, both when she was a member of the other body and here when she was part of our group. i thank her for it. mr. president, the intelligence officials can only point to two cases where this program -- the phone records collection program -- actually provided useful

information about an individual involved in terrorist activity. in both of these cases, the government had all the information it needed to go to the phone company and get an individual court order, an emergency authorization, for the phone records they needed. in both of these cases the individuals who were identified using these phone records were arrested months or years after they were first identified. if government agents had felt that the situation was urgent, they could have used emergency authorizations to obtain their phone records more quickly. i'm glad both of these cases resolve the way they did. i'm proud that our intelligence agencies and law enforcement individuals were able to identify and arrest those who were involved in terrorist acts. in one case four men in california were arrested for sending money it a militant group in so mall yasm in the other case, a conspirator, mr. zadi, a few months after

zaz i's plot was disrupted, one of those individuals was arrested. these men are now being punished with the full weight of the justice system. what i don't see, however, mr. president, is any evidence that the u.s. government needed to operate a giant domestic phone record surveillance program in order to catch these individuals. i have seen no evidence -- none -- that this dragnet phone records program has provided any actual unique value for the american people. in every instance in which the n.s.a. has searched through these bublg phone records, it had enough evidence to get a court order for the information it was searching for. in getting a few hundred additional court orders every year would not overwhelm the foreign service surveillance court. they may argue that collecting the phone records in being is more convenient, but convenience

alone does not justify the massive intrusion. i believe it is vitally important to protect the safety and the liberty of our people. i don't see any evidence that this program helps protect either. that ought to be the standard of any domestic surveillance program. the bulk collection program doesn't protect privacy or security, then it ought to end -- plain and simple. the executive branch simply hasn't shown anything close to an adequate justification for this massive dragnet surveillance that has compromised the civil liberties of millions of americans. i'm not sure they ever could, but i'm confident that i haven't seen it as yet. mr. president, let me close by way of saying that over the last few weeks, we've seen extraordinary support for reform. last week over 200 members of the other body voted to end the

bulk phone records collection program, a understan and a numbe members who voted against it at that time made i it clear they have serious concerns they want to address. there are going to be more votes, about it, mr. president. make no mistake about it. there are going to be more votes about whether to end the bulk collection of phone records. there are going to be efforts to reform how the entire u.s. surveillance system works. one of the most important reforms will be to make the significant rulings. foreign intelligence scuferls court public, which is a goal that i've been pursuing for several years. additionally i believe that congress needs to reform the process for arguing cases before the court. right now the government lawyers walk in with an argument for why the government should be allowed to do something, and there is no one to argue the other side. that's not unusual if a court is considering a ru routine warrant

request but it is very unusual when they are doing constitutional analysis. i believe that congress needs to create a way to advocate for the public, a public advocate to argue cases before the court, because making this court more transparent and more adversarial is a way to ensure that americans can have security and liberty. and of course the relevant provisions of the patriot act itself will be expiring in 2015. i don't think there's any reason for the administration to wait for congress, you know, to act. the executive branch can take action right now. they can and should continue to obtain the records of anyone suspected of connections to terror or other suspicious activity. i'm very interested in working with the administration on these issues, but they can move of their own volition. so one way or another,

mr. president, we are going to stay at this until at this unique time in our constitutional history we have revised our surveillance laws so that we can have security and liberty and colleagues are coming to this cause. senator blumenthal has particularly recommended a number of constructive fisa court changes over the last few months. i hope colleagues will support that, and i hope they will see at this unique time in our history that it's critically important that these surveillance laws that i and senator udall have talked about tonight can be reformed. and we don't it so as to protect those bedrock american values, both security and liberty. with that, i yield the floor. mr. whitehouse: mr. president? the presiding officer: the senator from rhode island. mr. whitehouse: mr. president, may i ask unanimous consent that i and senator blumenthal from

connecticut and senator baldwin from wisconsin, and if he's able to join us, also senator murphy from connecticut be allowed to engage in a colloquy on the floor. the presiding officer: without objection. mr. whitehouse: thank you. mr. president, my colleagues and i have come to the floor today to talk about an issue that is at the heart of the discussion of our national debt and deficit, and that is health care spending. these days, around washington, there is a regular refrain echoing through the hallways -- in order to fix our deficit, we must cut medicare and medicaid benefits. well, that is wrong. that idea is according to the former c.e.o. of kaiser permanente, somebody who knows a little something about health care, and i'll quote him, so

wrong it's almost criminal, it's an inept way of thinking about health care. i could not agree more. it was put this way by from herrick, who is a columnist for my hometown paper, the providence journal. i'll quote her -- "the dagger pointed at america's economic viability hasn't been the existence of government programs like medicare. it's been the relentless rise in health care costs that plagues not only medicare and medicaid but everyone who uses health care. attacking medicare and medicaid ignores the fact that our health care spending problem is systemwide and not just unique to federal programs. our colleague, senator angus king, has used the colorful metaphor that to go after medicare and medicaid when the

problem is our health care system would be like attacking brazil after pearl harbor. wrong target. it ignores the fact that we operate a wildly inefficient health care system. 18% of our g.d.p. compared to only 12% for our least efficient international competitors. so how can we continue to stem the rise in costs and improve our wildly inefficient health care system? well, thankfully, many of the tools necessary to drive down costs have an interesting collateral benefit. they actually improve the quality of care for patients. the affordable care act included 45 different provisions dedicated to redesigning how health care is delivered, for the benefit of patients and taxpayers. these reforms support and encourage an ongoing delivery system reform movement, and

there really is a movement out there driven by dedicated providers, payers, employers, and even some states that have worked for years to improve the quality and the safety and the effectiveness of health care. we're not discussing hypothetical improvements. we're not discussing theoretical cost savings. today, mr. president, i'm joined on the floor by colleagues who have seen how delivery system innovators in their states have achieved real improvements to quality, real improvements in patient outcomes and real cost savings. here in congress, we can't get over yesterday's quarrels about repealing or defunding obamacare, but out there in the real world, health care leaders across the country are innovating forward. places like the cleveland clinic in ohio, intermountain health in utah, geisinger health system in

pennsylvania, palm palmetto health in the carolinas, and in rhode island, among other places, our own coastal medical. one rhode island practical example -- when intensive care unit staff follow a checklist of basic instructions, washing their hands with soap, cleaning a patient's skin with antiseptic, placing sterile drapes over the patient and so forth, rates of infection plummet, and the costs of treating those infections disappears. no infection, no cost. these reforms have the triple benefit of protecting medicare and medicaid, improving patient outcomes and dialing back health care spending for all americans. how big is it? well, the president's council of economic advisors has estimated that we could save approximately $700 billion -- that's billion with a b -- $700 billion every

year, every year in our health care system without compromising health outcomes. the institute of medicine took a look at the same question. they put the savings number at $750 billion. other groups are even more optimistic. the new england health care institute has reported that $850 billion could be saved annually. and the lewen group and former bush treasury secretary paul o'neill, who as the c.e.o. of alcoa, was deeply involved in the reform efforts in pennsylvania that have been very successful, he knows a fair amount about this. they estimated annual savings of a staggering $1 trillion. whatever the exact number is, what's clear is that there is huge potential for savings in our health care system while improving or maintaining the quality of care. and since the federal government does 40% of america's health care spending, when you get that

right, taxpayers as well as patients become big winners from these reforms. i'll close with two points. first, many of us are asking the obama administration to set a hard cost savings target for these delivery system reform efforts. if it's $750 billion, pick a number that will be your target to be actually achieved. a target, a measurable goal will focus and guide and spur the administration's reform efforts in a manner that vague intentions to bend the health care cost curve simply cannot. second, we need to put the full force of american innovation and ingenuity into achieving that serious cost savings target for our nation's health care system. it's hard to do that without that target to strive towards. this is an issue where our

republican colleagues should be able to join us to accelerate these reforms in our health care delivery system and to move forward beyond tired out calls to repeal obamacare so that we can deal with the ongoing reality of health care reform. so let's give american families the health care system they deserve instead -- deserve. instead of waste and inefficiency, poor outcomes and missed opportunities, let's give them a health care system that is the envy of the world. i yield to my colleagues. senator baldwin. ms. baldwin: i thank my colleague for convening us and for giving us an opportunity to discuss the important topic of delivery system reform and to highlight some of the innovations that are occurring in our own states. i heard senator whitehouse talking about moving forward. it's actually the motto of the state of wisconsin, one simple

word, forward. throughout our state's history, that motto has, i think, well represented our leadership in extending high-quality and affordable health care. our health care providers and payers have pioneered forward-looking reforms that improve the quality of care and lower costs for families and for businesses. we are home to world-class, highly integrated health care systems. we make quality and outcome data widely accessible to providers so that they can measure their success against their peers, and we stand at the forefront of using and advancing health care information technology. all of this affords some of the highest quality care in the country at a competitive cost. congress has a lot to learn from wisconsin's health care delivery systems. a recent institute of medicine

report reinforced what we have known for a long time, that geographic variation in health care spending and utilization is real and that variations in health care spending are not consistently related to health care quality. for every state like wisconsin with higher quality outcomes and lower costs, there are five other states faring worse. even within states, the regional variation in health care spending and quality is troublesome. unfortunately, instead of advancing and fostering forward thinking innovations like those working in wisconsin, far too many of my fellow lawmakers are looking backward when it comes to health care. in the house of representatives, the republican leadership has scheduled votes to repeal or defund the affordable care act almost 40 times. some state governments,

including, unfortunately, my own, have refused to move forward with america's new health care law and are undermining its effectiveness at every chance possible. now some of my colleagues in the senate are threatening to shut down the government if investments in our health care system are not stripped out of our budget entirely. families and businesses in wisconsin and across the country are tired of these political games. for as long as some of my colleagues and some of the governors across this country remain glued to the past, waging political fights based on pure ideology, we lose golden opportunities to move health care reforms in our country forward. we should all be focused on building a smarter and more affordable health care system, not trying to tear down the law of the land. that's why i'm so proud to stand on the floor with my colleagues

tonight committed to moving our nation's health care system forward by building on the best reforms to our health care delivery system that are embedded within the affordable care act and making new improvements as to how we deliver care in our country. we will lower health care costs, improve quality and strengthen our economic security and reduce the deficit. better yet, we will have more states with health care systems like wisconsin's, and wisconsin's system will be improved as well. you know, the possibilities are exciting, and i think one of the things that senator whitehouse just mentioned bears repeating -- there is widespread agreement that significant savings can be achieved in our health care system without compromising the quality of care. and the figures that he cited bear repeating. the lewen group and the former treasury secretary paul o'neill

have estimated that we could save $1 trillion per year without affecting health care outcomes by enacting smart, targeted health care delivery reforms. the new england health care institute had that number at $850 billion annually. the institute of medicine estimated this number would be $750 billion. and the president's council of economic adviseers foresees saving $700 billion a year. no matter the exact figure, these are impressive savings that would strengthen our entire nation. the affordable care act has sparked this hard work of transforming health care delivery. the law provides health care practitioners with incentives to better integrate care, increase quality and lower cost, and these efforts are producing impressive results in wisconsin.

for example, the pioneer accountable care organization program has offered financial incentives to meet quality and medicare savings benchmarks. belle and theta care, health care partners in northeast wisconsin, has excelled in this program. in its first year of participation, they earned $5.3 million in shared savings and lowered costs for its 20,000 medicare patients by an average of 4.6%. while not every pioneer a.c.o. has been as successful, the c.m.s. office of the actuary believes that this program could save medicare up to $1.1 billion over five years by simply better coordinating care. wisconsin boasts six additional health care providers participating in the law's

traditional accountable care organization program. which the department of health and human services estimates could save up to $940 million over four years. wisconsin health care providers are also taking part in the affordable care act partnership for patients to improve health care quality. this public-private partnership engages hospitals and businesses, consumer groups, with the goal of preventing injuries and complications in patient care. including hospital-acquired conditions. the administration estimates that reducing medical errors and preventing conditions will save up to $35 billion in health care costs. another public-private partnership, the affordable care act's million hearts initiative, is preventing heart attack and stroke.

cardiovascular disease costs this country $440 million per year in medical costs and lost productivity. the initiative seeks to deliver better preventive care, to stop one million strokes and heart attacks by the year 2017. in part by utilizing innovative technology. wisconsin's own marshfield clinic designed a winning mobile application for the initiative. the app will encourage patients to get their blood pressure and cholesterol checked, and to work with their health care providers to improve their heart health. finally, the affordable care act has empowered the c.m.s. innovation center to develop new ideas to improve health care quality and lower costs for people enrolled in medicare, medicaid, and the children's health insurance program.

a number of the center's projects are currently underway in wisconsin. for example, the children's hospital of wisconsin, aurora health care, and the wheaton franciscan health care system have created a model to decrease emergency room visits for children. the estimated three-year savings of that project is almost $3 million. in addition, the pharmacy society of wisconsin in utilizing a provision in the affordable care act, is better integrating farm assists into -- pharmacists into clinical care teams. that initiative is set to save over $20 million in three years. this just represents a small sampling of the delivery innovations being promoted through the affordable care act that are saving us money right now. these parts of the law are empowering wisconsin health care providers to provide higher

quality care at reduced costs. public officials who advocate for repealing the affordable care act would end these impressive initiatives as well. instead, we really must build on these delivery reforms as so much more can be done. to name just two priorities, wisconsin cardiologists have developed an innovative, network called smart care to deliver better, more efficient care for a vulnerable patient population. the department of health and human services should encourage this coordinated care model by investing in it and measuring its results. and we should improve the law to increase access to medicare claims data. the wisconsin health information organization currently holds over 65% of health insurance claims data in the state.

from private insurers and from medicaid. the organization shares that data with health care providers so that doctors can compare their performance in terms of quality and cost against their peers. this data sharing promotes competition and it lowers cost. but due to current law, the organization cannot access medicare data. if we open up medicare claims data, we will further improve quality and we will lower costs. lawmakers have a clear choice. go backwards and try for the 40th time to repeal the affordable care act or put progress in our country ahead of politics. we welcome our colleagues to join us in moving our country and our health care delivery system forward. and i would now yield to senator murphy.

mr. murphy: thank you very much, senator baldwin. thank you to the state of wisconsin for in a lot of ways leading the way and showing us what's possible when it comes to delivery system reform. it's pretty amazing some of the statistics that you used, senator baldwin, when you talk about how much waste there is in the system today. you know, the estimates are from the council of economic advisors $700 billion from the new england health care institute, $850 billion, to put that in context, even if the, you know, median of the two is right, somewhere in the high $700 billion, that's $100 billion more than we spend every year on the military. that's enough money to provide coverage for 150 million more americans. that's enough to pay the salaries of every single first

responder personnel in the country including firefighters, police officers, and e.m.t.'s for over a decade. it's an enormous amount of money that we are wasting today because we have a reimbursement system, as senator whitehouse said as well, that essentially rewards providers and hospitals and health care systems for providing volume rather than providing quality. now, we understand there's not a single health care providers in the country that doesn't get into this if not for their desire to provide quality health care. there's no malevolent motives involved here, but ultimately when you've got to keep your doors open as a medical practice, as a hospital, as a nursing home, and you get paid more the more medicine you practice and the more treatments that you order and the more

tests that you have your patients undergo, then you're going to follow the money. and it's time that we reorient our reimbursement model under medicare and medicaid and in partnership with our private insurers so that we're reimbursing based on the quality of medicine and the quality of the outcomes that you provide, rather than just on how much stuff that you order or prescribe. let me talk about three examples of how we've succeeded already when it comes to changing the model of reimbursement. first, the issue of readmission rates. so when you go into the hospital for a surgery, that hospital is going to get a set fee for the surgery and for the amount of time that you spend in the hospital afterwards. it's called a bundled payment.

bundled payments are a good thing because what it does, it encourages you to essentially use your resources wisely because you're not going to get paid more if you keep the person in the hospital for ten days than if you keep the person in the hospital for five days. but here's the problem when it comes to the care that people were getting after a particular surgery. because the hospital got a set payment for that period of time, they had an incentive to push the person out of the hospital as quickly as possible. and that was an incentive not only because the payment itself didn't get bigger the more amount of time that you were in the hospital but it also was incented that way because if the person went home too early and then they came back again to the hospital, the hospital got a second bundled payment when they came back. and if they came back what a third time and fourth time, they got another payment. so what was happening is that there was an incentive to send

people home before they were ready because not only would that save you money on the first bundled payment but it actually made the hospital or the health system money in the long run because the person came back the second, third, fourth time. i don't think there was a single hospital in the nation that was deliberately misaligning their care so that they would have people coming back to the hospital a second or third or fourth time. i'm not suggesting that people were trying to game the system in that way. but what certainly was happening is that without an incentive that pulls you the other way, get the care right the first time, that there was, unfortunately, insufficient care being provided. and so the health care bill says listen, we'll pay you for maybe the first readmission, maybe for complicated procedures we'll pay you for the second readmission but at some point there's got to be an end to this

model. at some point it's got to be up to you as the hospital or as the health care provider to get the care right the first or the second time so that we aren't on the hook for readmissions occurring times three or times four. that's a pretty simple change. but it can save hundreds of millions of dollars. second example is accountable care organizations. we set up pioneer accountable care organizations. these are bigger systems of care where you've got primary care doctors networked with specialty care providers working under one umbrella to coordinate the care of the sickest patients. there are different numbers but they all tell the same thing which is that the sickest 5% or 10% of patients in the country are taking up about 50% of annual medical expenditures so if you do a better job of coordinating the care of that small percentage of medical

population, you're going to save a lot of money. and accountable care organizations can do that. instead of having siloed care where a comorbid patient goes to a primary and a specialist here and a specialist there, if they're under one roof and are talking to each other you can save a lot of money just by coordination. that's the theory. and so the health care reform act put that theory into practice. it set up a pilot program where pioneer accountable care organizations, essentially a beginning set of accountable care organizations would be set up under a model through which medicare would say if you save money, we are going to deliver back to you some of those savings. so that, in fact, there's not a disincentive to practice less medicine because you could pras less medicine, medicare will take the savings and share with you some of the savings. we'll we've only had a year or

so of returns from this model, but the results are pretty stunning. the average increase in cost per beneficiary has been in the pioneer a.c.o.'s less than 50% of that for non-pioneer a.c.o. models. that's a pretty significant savings. in addition go back to this question of readmissions. in 25 of the 32 pioneer a.c.o.'s there was a lower risk adjusted readmission rate than in non-pioneer a.c.o.'s. coordinated care where you are reimbursing an organization as opposed to just the individual physicians, actually savings you a lot of money. -- savings you a lot of money. and third, the issue of outliers. what you find when you look at the data and it may be that senator whitehouse talked about this, is that sometimes 60%,

70%, 80% of the system is practicing good medicine at the right cost. and it really is only a small handful of providers that are way outside of the median. and all you have to do when it comes to some subsets of reimbursement is bring back those outliers into the median. home care was a great example. in the accountable care act, we said that for home care providers that had utilization rates that were far outside the median we were going to stop reimbursing for those episodes far outside the median. c.b.o. wasn't sure how to score it wasn't because they didn't know that was going to change people's practice but it did. and it's estimated that that single change in controlling for the handful of outliers when it

comes to high utilization rates in the home care line item is going to get us almost a billion dollars in savings over a ten-year period of time. and when you look at home care actually it's only a handful of areas in which you have these outpaced utilization rates compared to the rest of the country. it's places in texas, it's places in certain counties in florida, most of the country is, you know, right where you should be. and so part of reforming our delivery system is also taking care of these outliers. we've seen savings, whether it be in controlling readmission rates, setting up accountable care organizations, or taking on outliers within our home care system. and now it's time to do more. because, mr. president, before i turn it over to my good friend, senator blumenthal, here's where the rubber hits the

road. in about ten years, medicare starts taking in less money than it sends out. it doesn't go bankrupt all of a sudden but it starts to become fiscally insolvent. there's only a handful of ways to stop that reality from happening. you can either ask beneficiaries to pay more out of pocket, you can cut their benefits, give them less, you can ask people to pay more into the system while they are working, or you can make the system more efficient. it may be that we have to do a mix of those. but clearly the first three are not that palatable. reducing benefits, increasing co-pays, or increasing taxes. this isn't a partisan issue. both sides agree that in ten years we have an accounting

problem in medicare. both sides agree we have to make changes today in order to stop that crisis from occurring. and it strikes me that if the most conservative republican and the most liberal democrat sat down at a table and looked at those four options, increase co-pays, reduce benefits, increase taxes, or increase -- increase efficiencies, we would all agree, the conservative democrat and -- the conservative republican and the liberal democrat would agree, along with probably every other member of this body the first place you should go is to reduce inefficiencies. that's what a delivery system provides. so we've set up a working group here in the senate which is beginning its work this week -- this week that senator baldwin, senator blumenthal, i and others will be building over the course of the late summer and

fall. we hope that it will draw interest from he both sides of the aisle so we can start to put some meat on the bones when it comes to the changes in our delivery system that can be made to increase efficiencies so as to forestall the need to balance the medicare books on the backs of taxpayers, workers, or beneficiaries. with that, let me yield the floor to my great friend from connecticut, someone who both as a senator and as our state's attorney general, has been fighting for health care consumers for a long time. senator blumenthal. mr. blumenthal: mr. president? the presiding officer: the senator from connecticut. mr. blumenthal: thank you, mr. president. i want to thank my colleague, chris murphy. senator murphy has been a longtime champion on this issue. my colleagues may wonder why two senators from connecticut, both of our united states senators here on the floor and part of

this working group seeking to lead on this critically important issue of health care delivery reform. and the answer is that we come from a state where it is working. we've seen the future in connecticut's health care delivery system. it's still a work in progress. a lot of work still to be done. but connecticut hospitals and providers and insurers and patients know that it has to be our future, that cutting costs is essential to preserving and enhancing quality. let me emphasize how important that basic principle is, because a lot of our colleagues believe there is a choice here between cutting cost and quality, that quality can't be enhanced if we

cut cost. in fact, the opposite is true. cutting the cost of health care is key to enhancing and improving quality. i.t. the wait's the way that wes premature discharges -- we will reduce premature discharges from hospitals, that we'll diminish the number of discharges from hospitals without proper rehabilitation plans, and cut the number of hospital-acquired infections. it is not only possible to do, but it is essential. and it is a way that we avoid the false choice -- and it is a false choice -- between presesqui medicare, on the one hand, and avoiding increasing co-pays, cutting benefits, or increasing taxes, as my colleague from connecticut has just said.

i reject every one of those options as necessary to preserve medicare. increasing co-pay, decreasing benefits, increasing taxes are not the way. in fact, it is increasing efficiencies and avoiding unnecessary, wasteful, and indeed harmful costs. now, my mother taught me a number of things. she said, number one, if you don't have something nice to say about someone, don't say anything. so i'm not here to say not-so-nice things about the folks who say we ought to cut medicare benefits. but i would oppose those kinds of cuts, as are necessary and harmful. she also said that an ounce of prevention is worth a pound of cure. and, in fact, that basic truth is what will help to save our health care system.

prevention of cost, prevention of illnesses, prevention of obesity and smoking and other kinds of diseases and conditions that lead to increased health care costs is essential to this effort. my mother said also, listen to your younger brother. my brother, dr. david blumenthal, has been a pioneer and expert in this area. and as much as it pains me to being acknowledge that my youngr brother knows more about this than i do -- in fact he has been here to enlighten me and many of my colleagues here on this point. i mention him and the others who are experts and pioneers in this effort, and he is one of many who have advised and provided that kind of enlightenment.

because there's no more kind of guesswork as to whether advances can be made in this area by cutting costs and raising quality. it's been documented. there are projections. it can be costed out. and it can be scored, in my view. and it can be the basis for actions by my colleagues here in seeking to cut costs that are skyrocketing out of control. and i've seen these reforms at work throughout the state of connecticut. this issue is of national importance, but it hits hospitals and providers in every one of our states. i've seen it and listened to folks who work at places like st. vincent' vincent's and brids hospital, yale-knenew haven, middlesex hospital, all around the state of connecticut i've seen the checklist at work, the

protocols for hand washing, the increased attention to quality care that also has helped -- hed reduce costs. they have helped improve patient care while reducing cost. and they reject this false choice between quality and cost cutting. both are possible. both are essential. we hear so much rhetoric about the affordable care act in washington, but in connecticut we see tangible examples of how it's working and making a difns. the implementation of the affordable care act is an historic opportunity for continuing this work and expanding it nationwide, and we need to continue our dedication to health care reform. my colleagues and i have come to the floor today to call for smart reforms that help patients

and avoid harm to them and do not discourage providers from being a part of the federal health care programs. in fact, we need to identify areas of reform within the health care system that we can address that will strengthen health care in this country and address these serious concerns about the sig skyrocketing costf health care. now, we've seen a slowdown in the growth of national health care expenditures over the past years, but slowed growth certainly doesn't mean a decrease in overall expenditures. smart policy decisions require that we address the ongoing problem of health care spending in this country and turn a corner for good by reducing the current costs. i'm concerned that there are shortsighted strategies such as

taking money from the prevention and public health care fund established under the a.c.a., which has been a tactic unfortunately by both parties in financing programs. that tactic will undermine our long-termests at reducing -- long term efforts at reducing health spending. the prevention and public health fund is used in connecticut for programs like mental health services and substance abuse prevention, as well as public health research and solves. -- and surveillance. these measures will ultimately result in lower health care spending through prevention and preventive health care. but wands to sta we need to stad and stay the course. what we need to do now is continue work toward developing a sustainable health care system through structural reforms such as the accountable care organizations, health

maintenance organizations, patient-centered medical homes that have provided advances in this area and have created provider organizations that lead to greater provider acceptance of responsibility for health care outcomes in their patients. measuring the success of these organizations requires taking a closer look at whether the savings and outcome improvements actually materialize, and we have to be hardheaded and clear-eyed about whether they're working. the metrics must be applied. we need to measure success and measurements are possible. as i said at the outset, no longer a mast guesswork. there are -- no longer a matter of guesswork. there are scientific-based measurements. the success of these organizations will have more to do with how they're run than

with how they're structured. as sophisticated as many of our health care systems are the development of process goals has only recently become a consideration. the association of american medical colleges recommends, for example, use of surgical checklists through their best practices program. peer-reviewed studies have shown that the use of comprehensive checklists is associated with reductions in complications and mortality during surgery. but they are most successful when health care organizations subscribe to a culture of safety. that culture of safety and prevention is essential. some hospitals in connecticut have been rewarded through the medicare program for their commitment to improving quality through the use of process measures. bridgeport hospital, st. mary's hospital in waterbury, middlesex hospital have all seen increases

in reimbursement rates through the value-based purchasing program. again, the federal government can provide incentives and encourage and support this effort. manchester memorial hospital, hartford hospital, and rockville general hospital -- all have avoided medicare penalties by lowering their readmission rates. while payment differences for these programs represent a small portion of the overall medicare payment, hospitals should continue to be rewarded for addressing these issues. i also want to conclude by drawing attention to some of the innovative work being done in my state of connecticut around delivery reform and data collection. i've menin mentioned the importf measurements and metrics. much of the work is supported by grants that were made available through the affordable care act.

but it's really been the state itself that's decided how to use these funds. while connecticut has established a, wooing group -- g group around innovative reforms which continue towork on recommendations for reform the health care system, one of the areas of focus has been to ensure integrated clinical data exchange between health care providers. connecticut has invested in interoperable health information technology systems and developing an all-payer claims database to create comparable, transparent information that can be better used to understand utilization patterns and enhance care access. one of the most basic being a expects of refor thfor the purp- of reforming any system is you understanding where the problems why. yet we still lack the data necessary in many systems to truly understand where the unnecessary spending is taking place.

it's like diagnosis of any kind of medical condition. facts are essential. data are key. and i believe an investment in information technology and data collection activities will help inform payers and consumers about where our health care dollars are being sent, where they are being spent most effectively, where we can reduce spending that will ultimately enhance health care outcome. connecticut is taking a considered and insightful approach to obtaining and utilizing data, while considering the needs of consumers and looking toward developing stronger programs for telemedicine and provider coordination. technology is advancing. data collection can help implement technology where it does the most good. we need tangible