sham mr. president? the presiding officer: the senator from georgia. mr. chambliss: i ask unanimous consent that the quorum call be dispensed with and i be allowed to speak for up to ten minutes. the presiding officer: without objection. mr. chambliss: mr. president, i ask further unanimous consent that my defense fellow, major bobby j. cox being be allowed floor privileges for the remainder of the week. the presiding officer: without objection. mr. chambliss: i rise today to address the dire national security situation and the responsibility of this body to pass a national defense authorization bill this yearme . congress has passed this legislation for each of the last 51 years -- always with broad bipartisan support. this year should be no different. our servicemen and women are

deployed around the globe in defense of our nation. to put them in harm's way, to further the american principles of freedom and democracy. yet we have failed to provide these men and women and our senior military leaders the fiscal certainty and legal authorities they need to complete their vital missions. instead, we have a senate majority intent on fundamentally altering the way the senate conducts business by pushing through bills without a full and open process. this is not the way the senate was designed to function. this year's national defense authorization act was reported out of the senate armed services committee on june 20 of this year. since that time, it has been delayed time and again by the senate majority leader as our defense leaders struggled to implement our national security strategy. general democrat see recently trans-- general dempsey recently transmitted to leadership an itemized list of 26 authorities

that will expire at the end of this year or shortly thereafter. we're not talking about legislating ancillary programs or nonessential programs. we're talking about military special pay and bonuses for deployed service members, funds to transition security responsibilities to our afghan partners, and critical counterinsurgency programs in the middle east, as well as funding for our intelligence community. while i support the underlying bill, i am deeply disappointed with the process that got us to this point and, thus, why i did not vote to invoke cloture. frankly, i had several amendments i would like to have added to this bill addressing such issues as a technical correction giving reservists and national guardsmen proper credit towards retirement time -- retirement for time spent deployed and an important land transfer of camp merrill in

georgia between the army and the u.s. forest service. i've seen many changes during my years in the senate but among those is a disturbing trend regarding the ndaa. we seem to be operating on the premise of fewer, faster and later. by "fewer," i mean fewer amendments. all senators deserve the opportunity to amend this important piece of legislation. the 20-year average is 140 amendments per year. last year we were only able to pass 106 amendments. this year we debated one. as we have seen time and time again, the majority uses the amendment tree to shut down debate and move the bill quicker through the senate. my colleagues and i have filed over 500 amendments to this year's ndaa. through hard work, bipartisan support, the two armed services

committee staffs have strived to accommodate the concerns of the senate. but even so, there are pressing issues that require full and deliberative debate in the senate. these include military sexual assault, counterterrorism and detention policy, and sanctions against those regimes that would do america harm, including iran. by "faster," i mean the bill spends less time on the senate floor. the 20-year average is over nine days, with a maximum of 19 days for the fiscal year 2008 bill. the one day we spent on this bill in november is insufficient time to debate the critical security issues confronting our nation. the senate majority has gone to great lengths to keep the bill off the floor. when they could no longer avoid it, they have compressed the time line for consideration or recommitted it to the armed services committee.

this is unprecedented and it is totally unacceptable. by "later," i mean a lack of urgency to take up the bill after committee action. looking back over the last 40 years, the senate has gone from passing the ndaa consistently before august to later and later in the year. last year it was december. this year we are running up against the end of the year. i'm deeply disappointed at the recent turn of events in the senate. under the guise of streamlining the legislative process, the senate majority has effectively blocked critical legislative priorities, such as the national defense authorization act. i urge my senate colleagues from both sides of the aisle to work together to discharge the fundamental duties our constituents, service members and veterans demand of us. we should dispose of the fewer, faster and later mentality and

return congress to regular order. mr. president, leadership matters. no one knows this better than our men and women in uniform. the constitution of the united states tasks us with providing for the common defense. i fear we have failed in our constitutional obligation and this failure is a failure of leadership, plain and simple. with that being said, mr. president, i want to pay particular compliment to chairman levin as well as to ranking member inhofe for their leadership which has not -- has not failed the country nor has it failed this body. they got together and produced a bill that came out of our committee in due course after full and open debate on many critical issues with the understanding that we would have the opportunity on the floor of the senate to file amendments, debate those amendments and have

up oup-or-down votes. chairman levin has been more than accommodating throughout that process before and after this bill came out of the armed services committee. likewise, senator inhofe has been more than accommodating to make sure that members on this side of the aisle had free and open access to the debate process. they have provided the kind of leadership that we expect. unfortunately, the majority leader has made a decision to cram this down the throats of the senate and that simply from a national security standpoint is not the way this body is designed to work or should work. mr. president, i'll support the passage of this bill because i think the end product, amazingly enough, has turned out to be a pretty good product. could it have been better? you bet. could the process have been better? without question. i just wish we had had the opportunity to debate the serious issues that are on the minds of a number of members of

the senate when it comes to national security and that we had had the opportunity to present amendments that would have made this strong bill even stronger and to provide our men and women in uniform and the leadership at the pentagon with the tools they need to ensure that we remain the world's strongest military power and that we're able not only to defend america and americans but to provide for freedom and democracy around the world. mr. president, i would yield the floor and suggest the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

mr. whitehouse: mr. president, may i ask unanimous consent that the pending quorum call be suspended. the presiding officer: without objection. mr. whitehouse: thank you. mr. president, i'd like to engage perhaps for the next 20 or so minutes with senator cantwell who is arriving shortly. i will begin with some remarks and then if i can have unanimous consent for us to engage in a colloquy. the presiding officer: without objection. mr. whitehouse: thank you very much. i am here today to talk about the health care problem in the country because the fixation of this body on the health care web

site, as -- has i think taken our eye off the fact we have a very, very significant and fundamental health care problem. this graph represents how much we spend on health care as a country. it begins back here in 1960. i was 5 years old in 1960, so this is a lifetime, one lifetime 50-some years. $27.4 billion. that's what we spent on health care, $27.4 billion. now here we are, this is up to 2011. $2.7 trillion. this is what we spent on health care. it's 100 times as much. in 50 years, 100 times as much.

now, granted, there are more americans, but not 100 times as many. this has been an explosive cost growth curve. and when we were trying to pass the health care bill, that's what we were looking at for costs, and it is a big competitive problem for our country. this is a really interesting graph, and i wish every time anybody talked about health care, they would take one minute and look at this graph, and i'll explain briefly what it is. this column right here, our up axis, measures life expectancy in years country by country. 65-85, where do countries fall in terms of their average life expectancy for their population,

for their citizens. this along the bottom is the cost, the health spending per capita, per person in that country. so if you measure it all out, what you see is a great raft of countries all through here -- japan, great britain, netter land, switzerland, norway, italy, greece. there is a whole large group of countries right here, and all of them have life expectancy 80 or older, all of them, and they all spend between $6,000 and $2,000 per person on their country's health care. essentially, the entire modernized civilized world is in that zone. from here to here to here to

here. guess where we are. the united states of america. boom. here. we are below them all in life expectancy. we are trailing the pack of modern industrialized nations in our life expectancy. do you know who we're competing with? chile and the czech republic. but japan, greece, great britain, france, germany, luxembourg all manage with their health care system to achieve longer life spans for their people. and we're doing it at a cost of about $8,500 per person per year. to give you a comparison, here are switzerland and norway. they are the two most expensive other countries in the world per

capita on health care spending, and they are at about $5,700 per year. if we could just bring our per-capita health care spending in this country down to the most expensive countries in the world, if we could just compete head to head with the most exen exen -- expensive countries in the world, we would save more than a trillion dollars a year. so this is an interesting graph because it shows basically all the modern industrialized nations here and it shows us here as a way outlier, and it's a big deal for us to be an outlier here because it means we blow about a trillion dollars a year in wasteful and unnecessary health care that could be building infrastructure, that could be solving problems, that could be reducing the deficit, that could be doing other things. instead, we have spent it on a

health care system that doesn't produce good health care results, at least not measured by life expectancy, which is a pretty good proxy. so there is a huge cost, a trillion dollar a year cost to our society in being that bad of an outlier, and the cost is also measured in lost lives and lost years of life because we're averaging 77 years, and these countries are averaging 82 years of life. so we have a real problem on our hands, and obsessing about a web site is a complete distraction from getting after this problem. five years off every human's life in this country and a trillion dollars a year, that's worth paying attention to. now, the health care changes that we brought are actually making a difference. here are some interesting graphs. each one is a projection done by the nonpartisan congressional

budget office of what health care costs are going to look like in the future. and what you see is a progression. they did this graph in august of 2010. that's what august-10 there means. this was where they projected health care spending would go when they projected in august of 2010. for this period from 2014 onward to the next decade. a year later, they went back and they projected again, and look, they projected actually the costs would be lower, and then they came back in august of 12 and they did another projection, and their projection showed that these anticipated costs went down again, went down again. every year, lower and lower. and here's the big one. in may of this year, the congressional budget office went back and redid its projections

for medicare and medicaid spending from 2014-2023, and look how far below what they had projected one year ago, two years ago and three years ago the current projection is. that's a saving of about $1.2 trillion in that decade. now, that's a long way from a trillion dollars a year that we could be saving if we just got back to where we were on this graph if we just got back from here to where switzerland and norway, the most expensive countries in the world are, that's a trillion dollars a year. this is $1.2 trillion over ten years, but it's still a big change and it's still moving in the right direction, so we shouldn't be too quick to condemn obamacare when that kind of saving is already being projected. and the last slide that i'll show before i go to senator cantwell, who has been good enough to join us, is this one.

why might it be that those costs went down so far in may of 2013? why might it be that that graph of projected costs keeps going down and down and down? it's because of changes in what's going on out in the health care system, and this is one good example. this shows the hospital readmission rate from january of 2011 until august, 2013. this is how often somebody was discharged from the hospital and went home and then within 30 days had to come back and be readd mitted. now, -- readmitted. now, that could be for a completely new reason, potentially, but usually it's because the discharge planning wasn't done well enough, and there was a bad handoff between the hospital and the primary care physician or the nursing home, and what we found is that you can make that transition

much better for patients, and when you do, guess what? they don't get sent back to the hospital. and when they don't get sent back to the hospital, you save money. now, that's just one way that the kind of huge $1.2 trillion over ten-year savings that c.b.o. has already projected could be taking place, but this is clearly a part of it. it's improving the quality of care so people aren't going back into the hospital, aren't going to the emergency room, and you avoid that cost at all by having handled the patient better, by having given them better treatment and better care. and if you look at it, it's really pretty astounding. in 2007, right through here until the end of 2011, it was a pretty steady readmission rate, and then when we change the signal to the hospitals to cut their payment for readmissions, boom, down it fell, and that

represents a very significant savings in the system and in the personal lives of those people and their families, not having to go back to the hospital. that's a pretty big plus, too. so it was senator cantwell's idea that we should come down today and talk a little bit about the delivery system reform side of the health care discussion, and i got started a little bit before she could get here, but my wonderful colleague now has arrived, so let me yield the floor to her, and i will yield it by putting this back up because i wanted to leave this here for whenever the camera swings my way. i want people to see this graph. it is inexcusable that all of these competitor industrialized nations of ours should be able to deliver universal, high-quality health care for what would be a trillion dollar

a year savings if we could simply match them and they produce a longer life expectancy for their people and we're stuck competing for life expectancy with chile and the czech republic. i mean, come on, we can do a lot better than that, and that should be the ball that we have our eye on rather than obsessing about the obamacare web site. so i yield the floor. the presiding officer: the senator from washington. ms. cantwell: mr. president, i come to the floor to join my colleague from rhode island, and i want to applaud him for his diligence in making sure that this debate happened today and to his leadership on this issue. it might sound kind of wonky to say that there are a group of senators who have a caucus called the delivery system reform caucus, but we wear that banner with pride because we know that there are savings in our health care delivery system, and we want to make sure that they are delivered for the american people. so while some want to talk about

cutting people off of service or raising certain ages, we're focused on the fact that there are hundreds of billions of dollars of savings in the delivery system and that it is our job to improve upon them. i'd like to say to my office team, there is a reason why ma bell doesn't exist anymore. i have so many young people that some don't remember ma bell. but the issue is that the delivery system for telecommunication systems change and look at what it released -- a lot of great technology. yes, change, but ways to drive down cost and deliver better access. that's what we're taig talking about here with the health care s my colleague has had a group for more than a year that has been talking about these delivery systems and we're going to try to have a dialogue with with our colleagues about why it is so important. we've taken a small step, a very, very important step, led by our senior senator from

washington, senator murray, on the budget. but there is a so much more we can do if we will include these delivery system reforms. so i want to thank senator whitehouse, the senator from rhode island, for his leadership on this. i want to talk about just one area today, the area of long-term care services. i authorized a provision in the affordable care act called the balance incentive payment program. while that sounds in and of itself like a wonky title, balancing in my view payment program, this program is real think to promote home and community-based care over nursing home care. so it's -- if you ask any senior, they'll say, of course they'd like to receive health care services in their home or community. no, they don't want to go to a nursing home. but the discussion has been limited on how much cheaper it is and how much better the care could be for delivery in the home as opposed to nursing home caimplecare. according to a survey by aarp,

over 90% of seniors age 50 or older disieshe desired to remair home as long as possible. and we know that home-care is 70% cheaper than nursing home care. for us in washington state, we thought about this long ago, and we decided that we were going to implement a system to reform our state and put more community-based care in our state and hold medicaid patients away from nursing home care. so we did that and we successfully made that transition. so this chart shows you what i was just referring to, that home-based care can be as little as $1,200 a person versus that same person getting care in an institutional facility is $6,000. so we made the transition in washington state to be predominantly a home and

community-based care state. we did that with our own state dollars, our own program, and it was a transition that took place over many, many years. we're kind of the antithesis of what the federal system is. it is still more weighted 0en a state-by state basis toward nursing home care. that means people are going into nursing home care and we're footing the bill for more expensive care at $6,000 per person when we could have services in the community that would allow them to stay in their home and get more efficient care. so in 2009, the long-term care budget overall for medicaid accounted for 32% of the medicaid expenditures. so of $360 billion a year. so you can see that this is an area that is a very expensive area for us at the federal level, and if we could do anything to help change those numbers, we would be delivering an improvement to the system. so when we first made this

transition from 1995 to 2008, the state of washington saved $243 million from this investment. but, more importantly even than just the money, an article in "the spokesman review" -- a spokane story called "dying to live at home," a family of nancy and paul dunham, a couple of more than 60 years, said they wanted to age at home. because of the medicaid funding for in-home services, they were able to stay in -- mr. dunham was able to stay in his home until the age of 83. so i'm sure many of my colleagues know people who are getting on in years who prefer to stay at home. but the balancing incentive program which was in the affordable care act was the first federal effort that we had that tried to assist states to move away from nursing home care

and move affords community-based care. so we put some incentives in the pravment here arprogram. here are the states so far that have taken the federal government in the affordable care act up on this program -- new hampshire, iowa, georgia, texas, indiana, connecticut, arkansas, new york, new jersey, louisiana, ohio, maine, illinois. so a diverse group of states, i might add. so some states probably, you know, where people -- governors said they didn't want to support the affordable care act but yet are taking advantage of this provision. some states that probably are forerunners of delivery system reform and have done lots of delivery system reform and want to do more. so it is a minimum of states, and i think a -- so it is a mix of states and i think a lost great examples of those -- and a lot of great examples of those states and when we can do to

transition away from traditional care to home-based care. it supports including structural changes that help streamline the system. conflict-free case management, standardization of assessment, single-entry systems so that it's not confusing, so that the system is very streamlined, and states have until september of 2015 to increase their long-term care services in the community and support expenditures of these noninstitutional-based care facilities. so we're very excited that it has had a robust uptake by these states, and i am encouraged that there has been so much interest shown in changing the political orientation, if you will, of states to how do you deal with long-term care? we know that everybody is living

longer and as baby boomers retire, it will be a bubble to our health care delivery system. but this is an excellent idea -- or way for us to deliver better care. so what does it do? as i said in the first chart, $1,250 versus $650 i,,000 in nug home care. reducing costs is a key focus for us. these medicaid recipients are people who maybe start on medicare but because of the extreme cost of health care at the end of life end up spending down -- end up being a federal responsibility. if we can reduce those costs by driving more community-based cairks it is care, it is a win-. the second thing it did is it helps improve quality. if people can stay at home and get access to the delivery system by these new requirements of making sure it is

case-managed and single point of entry, and standardization of the home-care system, it helps us be efficient about what the quality of care that is being delivered. and, again, when you have a community-based setting either in the home or care delivered through the home, there's lots of ways for us to have checks and balances on the system. now, i've talked to many people who are in the nursing home industry, and they will say, we like the idea that we're only going to take the sickest patients much we like the idea we're only going to serve people who really need to be there, as opposed to some people who may not be ready for those facilities but end up there anyway just because there aren't the community things to support it. and -- so besides reducing costs and improving quality, we save money. so, mr. president, that's why we're here today, to talk about these important ideas that save money. so this is a simple one, but it's already in place.

it's already started. there are many states take us up on this offer, but it's critical that we understand and score these costs because they can show how we can save billions of dollars in our health care delivery system. so i know my colleagues, some of them on the other side of the aisle -- well, all of them on the other side of the aisle -- tend to support the affordable care act. take a second look at what your states are doing. your states are supporting the legislation -- at least through one provision -- and i think that you -- when you check and seekers you'll see that that one provision is going to save your state money. it is going to give your citizens a better choice in their quality of care. it is going to help us reduce our federal costs and expenditures as well. that's what the delivery system is all about. mr. whitehouse: isn't the heart of this, what you said a moment ago, which is that there is an area that actually touches on a lot of health care,in, it a

big arks where yo area, where yo things at once: you can save significant money for taxpayers and insurance ratepayers, and at the same time you can improve the quality of care that people receive. so often in legislative matters it's a zero-sum game. one wins society other has to lose exactly -- one wins so the other has to lose exactly by the same amount. this is a win-win situation, so there really should be energetic efforts to pursue these win-win opportunities. ms. cantwell: i thank you. mr. president, i thank the senator from rhode island for that question. his charts just pointed to the fact, and he was articulating the fact that everybody is arguing about the web site. as somebody who has been involved in a software company that vote code, it is very unfortunate about what's hasmed but writing code and fixing that

is a straightforward task that can be achieved. it is a little less difficult than cleaning up oil in the gulf or something of a more large environmental impact. so, to me, we'll get that fixed. but, in the meantime, there's a lot of things that have to happen to need to change in our delivery system that are about saving cost, delivering better-quality care that we know are proven, successful answers to this puzzle, and we need to get more than just these states to take us up 0en this offer; we need to get c.b.o. to actually give us a score on how much money this has the potential of saving, and then we have to figure out a way to incent' incl other states to implement this as soon as possible. when you think about our senior population, this is what they want. they want to stay at home as long as possible. it's so much cheaper per medicaid beneficiary to do this.

so this is what we have to achieve. we hope that by coming out here and educating people about the various things in the affordable care act, the things in delivery system reform that are on the agenda to improve access and help save costs, we'll start taking hold and we'll get more people talking about these solutions. but this is absolutely the direction we need to go. mr. whitehouse: if i could ask the senator another question, in response to what you just said, not only is it a win-win -- being lower cost and better-quality care -- but i believe the senator said that there's actually a third win here. much there is eight win of lower costs, the win of better-quality cairks bucare,but for seniors te win of being able to maintain your independence and be able to stay at hoax it is hard to pu h. it is hard to put a price on that. but if you're able to stay at home, it is a very, very big

plus. so really it is not win-win. it is win-win-win. ms. cantwell: well, mr. president, i thank the senator from rhode island. he is correct. there are the individuals who win, the state -- in this case saves medicaid dollars -- and the federal government slaves dollars as well. but the individual, if you ask them, this is their choice, they want to stay at home. nobody says they want to go into nursing care. we appreciate the nursing home care delivery aspect of health care and they deal with some of the most complex patients, but they don't need to deal with people that don't need to be there. but we have to have a delivery system that helps support community-based care for long-term care. and i hope that -- i hope that we will get more support for these ideas and that we will help figure out a way to get a score for them as well. i think that part of the mystery in this whole issue of health

care savings is figuring out ways to take things that are -- they're not so complex in what they are doing, moving from nursing home care to community-based care, $1,200 versus $1,600. that's not the hard part of the equation. what's hard is getting c.b.o. to estimate or, if you would, guessty nate ho,guesstimate. if you take the number of seniors that are to be affected as the baby-boomer population reaches that retirement age and reaches, if you think they're going to be sparre supported pry by nursing home care -- i think our state has now made the shift, the majority of our people who are on medicaid are taken care of by long-term care services in the community -- if they're seeking those services -- versus the federal numbers are just the opposite. the majority of people seeking

those medicaid long-term care dollars at the average of federal states are more towards nursing home care. so we need to flip that. and if -- you're right. it would be a win-win-win situation for all of us. i thank the senator for his leadership one this issue. wows white house imr. whitehouss been frustrating and bedeviling to run up against the inability to project these savings in a way that would allow us to what we call in washington "score" them and get budget credit for them. but i would say that even though they have that difficulty, there are some very, very serious organizations that project the very significant savings of this kind that i've mentioned -- $the