agenda today. later this week we could see some action from senator reid announcing plans for legislation to respond to the recent supreme court hobby lobby ruling that the government cannot require private employers with religious objections to provide contraceptive coverage. the presiding officer: the senate will come to order. the chaplain dr. barry black will lead the senate in prayer. the chaplain: let us pray.

eternal father, in a turbulent world filled with wars and rumors of wars, be merciful to us and bless us. may your ways be known to our senators and may they seek your guidance. carry them in your strong arms, enabling them to accomplish with your might what they can't do with their strength alone. o god, summon your might and display your power in these challenging days of earth's history. use us to speak of your majesty power, and strength to those held captive by fear. we pray in your great name.

amen. the presiding officer: please join me in reciting the pledge of allegiance to the flag. i pledge allegiance to the flag of the united states of america and to the republic for which it stands, one nation under god, indivisible, with liberty and justice for all. the presiding officer: the clerk will read a communication to the senate. the clerk: washington d.c, july 14, 2014. to the senate: under the provisions of rule 1, paragraph 3, of the standing rules of the senate, i hereby appoint the honorable christopher s. murphy, a senator from the state of connecticut, to perform the duties of the chair. signed: patrick j. leahy, president pro tempore. mr. reid: mr. president? the presiding officer: the majority leader. mr. reid: i move to proceed to calendar number 459, s. 2578, protect women's health from

corporate interference act. the presiding officer: the clerk will report. the clerk: motion to proceed to calendar number 459, a bill to ensure that employers cannot interfere in their employees birth control and other health care decisions. mr. reid: mr. president, following my remarks and those of the republican leader, if any, there will be a period of morning business until 6:00 this evening with senators permitted to speak for up to ten minutes each. there will be no roll call votes during today's session of the senate. mr. president, the reason for that is last week we were able to get a few things done. we were able to do some things around here like we used to do. i know my republican colleagues lament how things used to be. well, i was there. i know how things used to be. and one of the things we used to do is we would work out pieces of legislation, as we did, on terrorism insurance.

we have a number of people who worked hard on that. chairman johnson, senator schumer, he worked with ranking member crapo, and they came up with a way forward on an important piece of legislation. there will be some amendments, but we'll finish this legislation this week. very important. important to our country, important to our economy, important to the construction industry. so i was very happy to see that done. so there are no votes tonight. and that's the reason for that. there will be no roll call votes during today's session, as i mentioned. the next roll call will be tomorrow at noon on two cloture nominations on members of the federal energy and regulatory commission. mr. president, the republicans

have made a decision on a lawsuit against president obama. it is difficult to understand how they have become so desperate that now they're talking about our issue of the day is not minimum wage. our issue of the day is not that women and men get the same amount of money for doing the same work. the issue of the day is not the crippling debt that's staggering this country. that is student loan debt and extended unemployment benefits; that's nothing they're focused on. and i could go through a long list of things that's important to the middle class that they simply are ignoring. so what are they doing to solve the problems of this country? suing the president. now, mr. president, listen to what they're suing him about. they have been broadcasting for weeks their intention to sue the president, but they just didn't know why. that's what they said. not me. now after misstep after misstep

after misstep, they know now why they're suing the president. they want to litigate obamacare. now, the presiding officer has done a remarkably good job of calling out republican senators when they come to the floor and make these ridiculously false statements. and i appreciate that, and i think everybody in this country, if they don't, they should appreciate what the senator from, the junior senator from connecticut has done. house republicans have identified president obama's delayed enforcement of the employer care act as a frivolous piece of the lawsuit. this provision which protects companies with 50 or more full-time employees ensures employers pay their fair share if their employees receive health subsidies. mr. president, listen to this.

the irony, of course, is that this specific provision which is in the bill that became law came about as a result of republicans wanting to put it in the bill. senators grassley, senator enzi and former senator snowe, this was something they worked on with baucus and other members to come up with this bill. they placed it in the bill. it became law. even more absurd is the fact the republican congress has long targeted the specific provisions of comprehensive immigration -- i'm sorry -- comprehensive health reform. in fact, mr. president, just after president obama announced the delay of the employer provision, house republicans voted on legislation to do the exact same thing, delaying the so-called mandate. so they're suing the president of the united states because he did what they wanted him to do,

delay the mandate. every word i spoke, i wrote down in my own handwriting, mr. president. that's what they wanted to do. they wanted him to do this, and he did it. and they sued him for doing what they wanted him to do. they could have applauded him. house republicans are trying something worthy of daytime television, the people's court, and one of those channels you don't watch very much, one of the court channels. but this is one you'd have to be desperate to watch something or they wouldn't put it on a channel. it hasn't made any common sense. so to sum it up, republicans create an employer obligation provision in the employer care act. the affordable care act becomes law. republicans vilify the provision they themselves offered. republicans demand the employer provision in obamacare be

delayed. president obama agrees to delay the employer provision. and house republicans sue president obama for delaying the employer provision. is this weird? is this weird? i can answer my own question. yes, it is weird. this is the behavior we've come to expect from a republican party that is determined to do one thing: undermine this president. no matter the issue. even one they ask him to do, they oppose him on it. they sue him this time. we have seen sofn here in the senate. it's not just the house. last week the republicans filibustered a bill that there were 26 republican cosponsors. that's a new one. more than half of the republican

senators put their name on a bill and then turned around and voted against it. and with this provision in the health care law, house republicans are ignoring the fact that they gave president george w. bush a pass for doing the exact same thing, delaying a specific provision of a congressionally passed health care law. then president bush through executive order waived medicare part-d pents for enrollment -- penalties for enrollment after the deadline. did he this by executive order. house republican leadership in the house didn't consider suing president bush for his administration of the health care law, so they chose now to do this. why? because it's obama. while republicans accuse president obama of executive overreach, they neglect the fact that he issued far few executive orders than any president in the last few years.

george w. bush yiewrd 291 -- issued 291. president clinton issued 364. president reagan is the record holder, 381. obama is not close to their records. he's 109 behind bush. he's 182 behind clinton. he's 199 behind reagan. what is the president's tally to date? as i've indicated, behind them all. eight-year president, he issued only 182. republicans' disdain for president obama and health care reform has preented them from presenting -- prevented them from presenting the obvious. obamacare is proving more and more successful every day. it seems like every week, sometimes every other day there is some new study or a survey showing how good obamacare is, how it's helping american families.

mr. president, the commonwealth fund, the uninsured rate for people 19 to 64 declined from 20% in july to september 2013 to 15% in april, to an estimated 9.5 million fewer adults being uninsured. that's big-time stuff. young men and women drove a large part of the decline. the uninsured rate for 19 to 33-year olds declined from 23% to 18%. remember when everybody said young people will run from this, they're not running from this. they're running to it. an estimated 5.7 million fewer young adults are uninsured. mr. president, that is so important, because of the high cost of health care previously, young people, many of them wouldn't do it. 5.7 million more wouldn't sign up for any kind of health

insurance. and what happens? young people don't realize, they get real sick also. they get into accidents also. bad things happen to young people as do middle-aged and older people. and younger people, mr. president, are signing up for obamacare. by june, 60% of adults with new coverage through the marketplaces are medicaid reported that they visit a doctor, hospital or filled a prescription. 62% said they could not have accessed or afforded this care previously. mr. president, that is stunning. it's no wonder -- it's no wonder we have fewer and fewer republicans coming down here giving these speeches about how bad obamacare is. gallop survey, in the united states uninsured rate sinks to 13.4% in the second quarter.

this deals with millions of people, mr. president. that insured -- the uninsured rate in the united states fell 2.2%. when you have, mr. president, 300 million people, 2.2% is a lot of people. the previous low point was 14.4% in the third quarter of 2008. so it's well below that. the rand corporation, changes in health care insurance enrollment since 2013, overall we estimate 9.3 million more people had health insurance coverage in march 2014, lowering the uninsured rate from 20.5% to 15.8%. stunningly important numbers. so the evidence, not the shrill statements made from my colleagues over here about bemoaning the fact of how terrible things are, all the

evidence indicates that the affordable care act is helping millions of americans. you can say anything you want, mr. president. facts are nasty things. they are nasty to the point that they are factual. don't believe all these crazy statements when there is no basis for it. it's helping this obamacare, democrats, republicans, independents. it's helping residents of red states, blue states, purple states. how about kentucky, the state of kentucky? the home state of our republican leader. well over 400,000 kentuckians have signed up for coverage through the affordable care act. that's not a state with a population of illinois or new york, california or texas. it's a partially populated

state, mr. president. 400,000 kentuckians have signed up for coverage. and even republicans love it. the commonwealth fund that i referred to found that 74% of newly insured republicans are happy with their obamacare health coverage. but instead of embracing the good that obama has done -- i should say obamacare has done and working with democrats to address any necessary fixes, republicans would rather file a foolish and meritless lawsuit. is there anyone that believes this lawsuit is -- has some basis? it's a sham. an effort to apiece the tea one yale law professor was questioned, here's what he said. i see this every day now. being covered as if it's real, as if it's somehow not a joke. it's a joke.

another law professor from harvard said -- and i quote -- "the lawsuit will almost certainly fail and should fail for lack of any congressional standing." just imagine how many lawsuits there would be if house republicans could sue the president every time they disagreed with him about something or some future police department president but there is no reasoning with the radical republicans in the house or the tea party driven members of of e united states senate. house members would rather waste dollars than accept the fact that their constituents are benefiting from health care reform. mr. president, this is a phony trial that will come up. it's a show trial. it's what republicans want. if that's what they want, they should talk to judge judy. i think she would throw this case out in half a secondñ -- s. i think judge judy would agree.

it's an expensive and wasteful. it's wasting taxpayers' hard-earned money on something that is without any merit. enough is enough. the fight over obamacare should be long since ended. the law is here to stay. more importantly, newly insured americans, all who have signed up, not only those who are newly insured but those who signed that up had insurance before want the law to stay just where it is. mr. president, will you announce the business for the remainder of the afternoon? the presiding officer: under the previous order, the leadership time is reserved. under the previous order, the senate will be in a period of morning business until 6:00 p.m. with senators permitted to speak therein for up to ten minutes each. the presiding officer: for ten minutes each. mr. reid: i would note the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

mr. barrasso: mr. president? the presiding officer: the senator from wyoming. mr. barrasso: thank you, mr. president. i ask unanimous consent the quorum call be vitiated. the presiding officer: without objection. mr. barrasso: mr. president, i rise today to discuss the nomination of norman bay. president obama has nominated mr. bay to be the commissioner or a commissioner of the federal energy regulatory commission, called ferc. the president had announced that if mr. bay is confirmed, that his plan is to elevate mr. bay

to the position of chairman of ferc. for the last few months, there have been much discussion about whether the president should have nominated mr. bay to be chairman. i think there is very good reason for us to ask whether the president really should have nominated mr. bay at all. in my view, mr. bay is not qualified to be a commissioner, let alone to be chairman of ferc. mr. bay has only five years working in the energy sector. a total of five years. this is less time than the keystone x.l. pipeline has been pending with the obama administration. during the nomination hearing, i specifically asked mr. bay about his lack of experience. in response, he cited his summer internship at the department of energy research facility during college. a summer internship during college. with all due respect, this man does not have the background, the qualifications and certainly experience to take on this

important role. now, the president has nominated mr. bay to replace the ferc's current chairman. her name is cheryl la fleur. in contrast to mr. bay who the president has nominated to replace ms. lafleur, ms. lafleur has over 25 years of experience in the energy sector. that includes four years as the commissioner of ferc and seven months as the chairman of ferc. now, i don't often agree with ms. lafleur's policies but you cannot deny that she is qualified to serve. mr. bay's lack of experience is not the only reason that i oppose his nomination. there are a number of outstanding factual disputes about mr. bay's tenure as the ferc's enforcement director. for example there are serious allegations that the enforcement staff during the time mr. bay has been in charge has violated

basic principles of due process. these allegations include the withholding of ex pull -- ex pull paratri evidence. in may the energy law journal accomplished an article by william sherman, the former general counsel of ferc and two other attorneys familiar with the situation and they write there is a widespread view that the ferc enforcement process has become lopsided and unfair. they said that one need only to observe the fact that enforcement staff denies in case after case the existence of ex pull 35 tri or exonerating materials. only to produce a subset of those materials too late in the

process to be of use in raising defenses. the authors explain that one of the fundamental principles of due process is that the government is not permitted to hide information from the accused that may aid in his or her defense. they say ferc enforcement staff routinely fails, routinely fails to produce the exculpatory documents. routinely fails to produce the documents. during mr. bay's nominating hearing i asked about these allegations. at first, he denied that the allegations were true, but then he stated that he was -- quote -- "not aware of any 123457bs in which -- instance in which enforcement staff had failed to produce the materials." so i asked him to clarify his remarks. i asked him whether the algaitionz were true or not. he pled ignorance. with all due respect, his

answer is inexcusable. this is his staff doing his work under his direction. he should know whether or not they withheld the evidence from defendants. now, there shall not only questions about his commitment to could you other dew process, there are also questions about the president's nominee on whether someone else at ferc suggested that and enforcement action be settled in return for approval of a merger. so there are questions about whether an enforcement action should be settled in return for approving a merger. the ranking member of the energy committee asked all about this during the nomination hearing. the ranking member of the committee asked mr. bay about the connection between the enforcement settlement with constellation energy and ferc's approval of constellation's

merger with ex elon. they settled the day before, one day before it approved a merger between constellation and exelon. in fact the enforcement settlement which mr. bay himself signed specifically mentions the merger between these two. the ranking member of the energy committee asked mr. bay whether he is concerned about the appearance of a quid pro quo between the settlement agreement one day, the merger approval the next. he admitted he would be concerned, the ranking member then asked if he or others at ferc suggested to constellation that it should settle the enforcement action in order to get its merger approved. in response, he said, well, to the best of his recollection, he didn't make such a suggestion. and that he did not know what others at ferc, including his

own staff, may have suggested. with all due respect to mr. bay, his answer is at best hard to believe. at the time ferc's enforcement settlement with constellation was the largest enforcement settlement in the history of the agency, completely. so they make this settlement, it is the largest enforcement settlement in the agency's history, and the next day, they allow a merger which has created one of the nation's largest utilities. are we really to believe that mr. bay doesn't remember what he or others at ferc said to constellation? can we really believe that? i believe the energy committee or some other independent entity should get answers to these and other questions surrounding mr. bay's record before we decide this senate, to confirm him and promote him.

i now that some senate democrats are nervous about voting for mr. bay and i believe rightfully so. these senate democrats have said they will vote for mr. bay only because they believe that a deal was cut or a so-called deal was cut with president obama specifically they say the president will allow ms. lafleur to continue serving as chairman for nine months after her confirmation, the president hasn't put it in writing, hasn't really told all of the members that and even if the president had this is no way for the senate to be able tony force it. the truth is, this is a gimmick and it's a gimmick invented specifically by senate democrats so they can once again avoid standing up to president obama and the senate majority leader. let's be clear what president obama is asking the senate to do. the president is asking the senate to demote cheryl lafleur lafleur, demote her from being chairman. she's a highly qualified woman,

a democrat with over 25 years of experience in energy, four years of experience as commissioner of the ferc, in order to promote an unqualified man. why should the senate do this? the senate majority leader pit it this way in "the wall street journal." he said i don't want her -- he said i don't want her as chair. he said she has done some stuff to do away with some of wellinghoff's stuff. the majority leader of the united states senate. i don't want her, he said, as chair. in short, the president and the majority leader want a rubber stamp. by all indications they will get that with mr. bay. when on may 20 during his qimpletion hearing mr. bay admitted he wasn't even following e.p.a. regulations and

their impact to electricity reliability in this country. two weeks later on june 4 in response to written questions he stated the e.p.a.'s regulations are -- quote -- "manageable. he's he's an exceptionally quick studly or he doesn't take electric reliability seriously. ferc is an independent agency. it needs a highly qualified leader. a leader whose record is beyond reproach, a leader who will resist political interference from the white house and the majority leader and mr. bay is not that individual. for these reasons i'm voting against mr. bay and urge all members to do the same. thank you, mr. president. i yield the floor and suggest the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

quorum call:

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a senator: mr. president? the presiding officer: the senator from new hampshire. ms. ayotte: mr. president, i rise today -- the presiding officer: the senate is in a quorum call. ms. ayotte: thank you. i ask the quorum call be rescinded. the presiding officer: without objection. ms. ayotte: thank you, mr. president. mr. president, i rise today to pay tribute to a wonderful man, steven savage, the chief of the plastow police department who passed away friday after a three-year battle with cancer. we are deeply saddened by the loss of chief savage, a plofd member of the plastow, new

hampshire, community who dedicated his life to serving his fellow citizens. for steve, family came first. he was a devoted father, husband and brother. we hold his wife kristen and their sons billy and michael in our hearts, and we will keep them in our players. we share in their grief and we will be there to support and comfort them during the difficult weeks ahead. from a young age, steve was called to serve and he answered that call. after graduating from stevens high school in clairemont, new hampshire, in 1965, he enlisted in the air force and served our country in vietnam. he attained the rank of sergeant and earned several commendations for his military service. steve was a very patriotic person. after returning from vietnam, steve went on to earn a degree in criminal justice from

northeastern university. he joined the newport, new hampshire, police department in 1969. that was the beginning of an exceptional career in law enforcement that would span more than 40 years, including positions at the drug enforcement administration and the baltimore, maryland, police department. after coming home to his beloved state of new hampshire, in 1977, steve was named chief of police in haverhill, new hampshire. he served as police chief there until 1988. when he was appointed police chief in plaistow, new hampshire. steve served as police chief in plaistow for 28 years. he was the longest serving police chief in that community. in plaistow, steve was a friend to all and he was a constant presence at the local ball field where he coached baseball, he volunteered his time with the friends of plaistow recreation.

in addition to all of his responsibilities as police chief, steve was a highly respected leader in our law enforcement community. he served as president of new hampshire's police chief association where i had the privilege of working with him when he served as attorney general. he served as president of the rockingham county police chiefs association. he was a member of several other state and regional law enforcement organizations. steve was a great leader, and he was so well respected by all members of law enforcement throughout new hampshire. his talent, dedication and expertise helped set a gold standard of excellence for new hampshire law enforcement. in a fitting tribute just a few weeks ago, the plaistow police department named its tact cal -- tactical training center in steve's honor, ensuring his legacy will not be forgotten by the people of plaistow or the

people of new hampshire. he touched so many lives during his distinguished career, and one of them was mine. i had the privilege of getting to know steve and kristen and his family when i served as attorney general for the state of new hampshire. steve was such a kind, compassionate, devoted person, and he was a man with a big heart. he had a vibrant personality that would light up a room and a great sense of humor that never faded, despite his diagnosis. i was so proud to call steve savage my friend. i feel fortunate to have known him, and i will treasure our friendship together, and there is so much that i admired about steve savage. he worked tirelessly to keep his community safe, and when he was diagnosed with cancer three years ago, he didn't let up. he just kept trying, spending every moment he could with his family while also continuing to

lead the police department and taking part in community activities that he enjoyed. in fact, in may, he served as grand marshal for plaistow's memorial day parade. steve and his family and particularly his wife kristen faced his illness with such inspiring courage. as you know, cancer hits so many people. they found a way to turn what was a tragedy in their family to good to help others. the savage family and the pollard school worked together to organize the run for the savages, a 5-k run benefiting the dana farber cancer center and the jimmy fund. even in sickness, steve wanted to help hers others who are fighting the disease, a profound reflection of his generous and caring spirit, and i know that the run for the savages will continue, and i will certainly be running in it again, but it's

really a reflection of how much the savage family has given back to the community and what an inspiration steve's life can be for others who are facing the horrible disease of cancer. steve was determined to live life to the fullest, and he did so right up until the very end. our state lost a truly great public servant with the passing of steve savage. new hampshire law enforcement lost a brother. so many of us lost a great friend. the savage family has lost a loving dad, and our hearts ache for kristin, billy, michael, we will continue to keep them in our prayers and stand with them during this difficult time. they're an amazing family. steve went beyond the call of duty in everything that he did. as a father, as a police chief, as a friend, and because of steve's, new hampshire is a better place.

i feel honored to have known him. his legacy will live on through all those lives that he touched. we will forever honor his memory, and we will continue to be there to support kristin and billy and michael and we're just thankful that someone like steve savage came to serve our state and has been a friend to so many of us. thank you, mr. president. i would ask that the time in the quorum call be charged equally with both sides of the aisle and i would note the absence of a quorum. the presiding officer: without objection. the clerk will call the roll. quorum call:

quorum call:

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mr. nelson: madam president? the presiding officer: the senator from florida. mr. nelson: i ask consent that the quorum call be lifted. the presiding officer: without objection. mr. nelson: madam president, i

have a unanimous consent request for a committee to meet during today's session. it has the approval of the majority and minority leaders. i ask unanimous consent that this request be agreed to, that this request be printed in the record. the presiding officer: without objection. mr. nelson: madam president, i ask unanimous consent that i be able to display in the course of my speech some small vials of liquid that will demonstrate what i am talking about today. the presiding officer: without objection. mr. nelson: madam president, let me show you these innocent-looking small bottles with an eye dropper of three types of liquid. this is liquid nicotine.

the eye droppers are used to put into the cartridges for electronic cigarettes, otherwise known as e-cigarettes. there are some versions that look just the size of the cigarette that already have the liquid nicotine contained in it, but there are many, many flavors that are otherwise contained in these kind of dispensers. so when our commerce committee had a hearing on e-cigarettes, i asked the question: were these childproof? and the answer is no. i asked the question, if these are not childproof, is the

concentration of nicotine in these, is it sufficient that could harm a child? and the answer was yes. as a matter of fact, there are varying degrees of concentration of liquid nicotine in these vials, but some of them are as concentrated as 540 milligrams of liquid nicotine. if a small child got into these, which are not childproof, and ingested it, that child would either be deathly ill or dead. if that child gets into it and it spills on the child's skin, it will be absorbed through the

skin, and likewise, according to the concentration of the nicotine, the child will be very, very ill. so obviously, when we had the commerce committee hearing on e-cigarettes, i asked the question, once they said these are not childproof, do you have any objection -- i'm asking this of the e-cigarette industry that was represented there at the witness panel. do you have any objection? and they said no. so last thursday a bunch of us senators filed a bill that will require the consumer product safety commission to start the rule and adopt a rule that will cause these to be sold in childproof containers.

now, this is a no-brainer. this is common sense. and why it hasn't been addressed before, it defies common sense, because of the danger to children. already in this year -- 2014 -- between january and the end of may, there were almost 2,000 calls for liquid nicotine poisoning into the poison centers around the country. just in that five-month period. so we already have a recorded incident a year or so ago of one child having been killed as a result of this. well, this ought to be not only

a no-brainer, it ought to fly through this congress in getting the cpfc to get on with administratively regulating this. now, what's another reason? well, look what this one is called with a picture. this is banana. this one is naked peach. this one is juicy juice. madam president, appealing to kids? how about banana split or cotton candy or kool-aid or skittles or

sweet tart or gummy bear or froot loops or hawaiian punch? that's what's going on. there happens to be a point of government that is supposed to try to protect the public from danger. this is obviously something that ought to be done. now, there is a larger question, and that is the question of e-cigarettes. that's not the subject of this legislation. with all due haste, the cpfc -- and why the cpfc instead of the food and drug administration? because the consumer product safety commission is invested with the authority to create container packaging and safety packaging. so if tylenol is childproof in

its packaging, if drano is, if any other obvious item that you want childproofed is, then we best have this done and done fast. and the consumer product safety commission is the way to do it. and i hope by the attention that this has gotten in the hearing two or three weeks ago, plus the fact of a bunch of senators now coming together and filing this legislation, the cpsc isn't going to waite around until we pass it, but get on with the problem. now, there is a larger question, this on an additional but related issue, and that is the advisability of e-cigarettes and the way that they are being

marketed. as a matter of fact, e-cigarettes, there's some packaging, it looks just like a white cigarette. and guess what's happening? it is now -- this is like we've seen this movie before. this is a rerun of what went on 20 years ago when finally because of tobacco products, the advertising on television and radio was banned by law because it was geared at getting young people hooked on tobacco. and so there were very attractive young models that were shown smoking cigarettes,

wonderfully beautiful background in the television, and the beautiful music on radio. and indeed, there were advertisements with cartoons aimed at what? it came out in all of the tobacco wars that these were aimed at young people getting them hooked on tobacco so that they would be life long tobacco smokers, and it would be tough to kick the habit. and so a couple of decades ago we went through that fight, and we banned the television and radio advertising of tobacco. well, guess what's happening now. beautiful and handsome models with the e-cigarette, cartoons

aimed at young people with e-cigarettes. and so another question that this senate should consider is banning the advertising that is obviously directed at young people to try to get them hooked on this nicotine product so that it's so hard for them to get off of the nicotine addiction over the course of time. now, i can tell you that the commerce committee is going to stay on this. and the first thing that we can do is give a little sweet talk to the cpsc to get moving on the regulatory process of a rule to require the childproof packaging

of this liquid nicotine. and the next thing down the road is to stop the advertising that's being directed directly at young people on the whole issue of electronic cigarettes. madam president, i yield the floor and i would suggest the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

mr. nelson: madam president? the presiding officer: the senator from florida. mr. nelson: i ask consent the quorum call be lifted. the presiding officer: without objection. mr. nelson: madam president, i'm just busting out with ideas

that i want to discuss with the senate. and since we don't have any other senators standing in line, i want to share where i have been today and what is of urgency for the environmental community, and particularly the environmental protection agency here in the federal government to consider. madam president, we have been spending hundreds of billions of dollars to restore the florida everglades. this is a natural resource that is unique in all of the world, and its environmental effects are felt far beyond florida, the united states; but indeed for the entire planet. it is a source of water that starts southwest of orlando in a

little creek called shingle creek and flows south through the kissimmee chain of lakes into the kissimmee river into lake okeechobee, the big lake in southern florida, and then from that, the water flows further to the south in what is termed the river of grass, the florida everglades. from there, it -- it moves very slowly through all of that grass, and it eventually ends out on the southern tip of the peninsula in florida bay by the florida keys or to the southwest of florida coming out through what is an area known as the shark river into the gulf of mexico. it is a unique natural resource.

i once had senator barbara boxer, the chairman of the environment committee, come down there. you travel in the everglades in an air boat since there is little depth of the water and of course it's all watered grass. you skim across the top of the water in an air boat, propelled by a big airplane propeller, and as we took senator boxer across this river of grass, suddenly she saw in the midst of what looked like a meadow in front of the air boat, a deer, a doe and

her fawn going through the meadow, only this time they were obviously not on a meadow, they were in water and they were splashing the water as they leapt away from the air boat. it's this unique environmental, ecological treasure that so many endangered species are there, and it's a discussion for another day about how invasive species are upsetting the ecological balance such as the imported burmese python, which can get up to 20-feet long and indeed one 1'88" was caught six months ago. they are at the top of the food

chain. they attack alligators and the fur-bearing animals in the everglades have diminished in population because they are just being consumed by these beasts that have this ravenous appetite. but that's a subject for another day. because of the hundreds of billions of dollars that we have spent to restore it, restoring to correct a mistake of mankind over the course of the last century when after the huge hurricane in the 1920's that drowned 2,000 people in the lake oak okeechobee area, the whole idea was flood control. when it floods, get the water off the land. send it to tidewater. the atlantic in the east, the gulf of mexico in the west. but that messed around with

mother nature. and as a result, the whole character of the everglades started to dry up. and as a result, fortunately with a lot of forward-thinking people, and i am just merely a steward who has come along at the right time at the right place to continue this effort, the corps of engineers, the e.p.a., so many of the agencies of government, cabinet secretaries such as ken salazar to the department of interior, the department of agriculture secretary, i mean it goes on and on and on. and the effort as a 50-50 partnership in funding this restoration effort has been partnered by the state of florida and the u.s. government. and it continues.

alas, there is now oil drilling in the everglades. the subject of today's meeting in fort myers, florida, was to gather a very courageous county commission from collier county, their chairman, and representatives of the community to come in to educate me on the aspects of the drilling and of the recent brouhaha between the state environmental agency and the texas wildcatter, the dan az hughes company over they started fracking without the proper permits and without revealing what was the mechanism and what was the material that they were

using to frack. now, of course, most people have heard of fracking, but we hear of it in terms of north dakota or oklahoma or texas, pennsylvania, but florida is not built on that kind of substrate that they are going in and breaking up that rock in the fracking to release oil and natural gas which has now made us such a tremendous producer of both of those domestically here in the u.s. no, florida is on a different type of substrate. it is built on a honeycomb of limestone that supports the surface by it being filled with freshwater. it's not these hard, solid rocks

where the fracking for oil and gas is being done and with the high jets with chemicals breaking up that rock to release the natural gas. no, this is porous limestone, formed years ago, millions of years ago by the critters, the shelled critters that ultimately it fossilized. and it is this honeycomb supporting -- being supported by water, freshwater that is the sub structure of the state of florida. and so we don't have any idea what this fracking is going to do, not only to the quality of the water but also to the very support structure for the state and now lo and behold there are

attempts for permits to drill in the 250,000-anti-crime big cypress federal preserve which is adjacent to and is part of the everglades but is adjacent to the everglades national park. and therefore, it's time for the e.p.a. of the federal government to get involved. it's time to question whether their authority in law as to what is after this kind of drilling is done to inject all of that stuff that's left over back down into this substrate of freshwater. what is that going to do under the clean water act?

what is it that could contaminate the source of drinking water? what is it going to do to the structure that upholds the surface of the state of florida and very importantly since it is co-located right next to everglades ?ark and since it is a part of the area generally known as the everglades, what is it going to do to the flora and fauna, in other words all of those delicate ecosystem balance of the critters and the plants. what is it going to do in the very area that we're spending hundreds of billions of dollars of state taxpayer and federal taxpayer money to restore?

now, this is a very legitimate question. the collier family years ago were very generous. they gave fee simple to the u.s. government what is today big cypress preserve. they retained the mineral rights. that was clearly their right to do so, and it was very generous for them to donate that property. we have a national park range ranger manager that manages that preserve. now we have got to look at what are the serious consequences to trying to convert those mineral rights that were reserved into

drilling. the most immediate thing is that instead of seismic testing, another kind of vibration testing is expected to be done with thousands of tests in the big cypress preserve. it's called thumping. a vehicle comes in and apparently drops things onto the surface to create something instead of seismic testing where an explosion is let off to send vibrations down, and these try triangulated, since they are doing thousands of these, would determine if there is oil there. thus, another question that arises is what is the

environmental effect? we definitely have a reason for the e.p.a. as an independent agency, for the department of the interior which has the jurisdiction over things like u.s. fish and wildlife, the u.s. park service to get involved in this process and make some determinations, and if the answer is that there is not sufficient authority in law, then to address it so that we can address it here as a matter of legislating law. madam president, i want to make the senate aware of this particular threat, potential threat to the florida everglades. i yield the floor and i would suggest the absence of a quorum. the presiding officer: the clerk will call the roll.

quorum call:

quorum call:

the presiding officer: the senator from iowa. mr. grassley: i ask that the calling of the quorum be suspended. the presiding officer: without

objection. mr. grassley: i want to ask my colleagues as well as myself to think about how many times that we have made pessimistic sounding statements about america's future. i want to remind my colleagues and myself about what i see as excessive pessimism about our great country, because as public figures often what we say maybe has consequences. sometimes positive, sometimes negative. our attitudes matter, and the policy shaped by those attitudes can have an enormous impact for better or for worse on the lives of americans. president ronald reagan often expressed that america's best days are yet to come. 25 years later, i still believe

in reagan's optimism for america. in fact, president reagan even ended his final letter to the american people -- quote -- "i know that for america, there will always be a bright dawn ahead" -- end of quote. his agenda reflected that optimism, and his policies worked towards a freer, more prosperous america. but it seems such optimism about america's future might be out of fashion these days. instead of searching for silver linings, many pundits and politicians see nothing but clouds. for instance, after decades of hearing about how we're about to run out of fossil fuels, making energy in the future much more expensive and scarce, improved

technologies have unleashed enormous reserved of natural gas. this increase in supply has driven down cost and caused electrical generation to switch from coal to natural gas. that in turn has led to substantial reductions in u.s. greenhouse gas emissions. now, that seems to me to be similar to -- a silver lining. now, there's clouds on the horizon. however, rather than to celebrate the fact that the free market is achieving one of their long-held goals, many environmentalists want to ban the technology that led to shale gas revolution based on unscientific claims of potential groundwater contamination. now, it seems like it would be

a terrible shame to let all of that planning for scarcity of energy to go to waste. so i guess we'd better not take advantage of this nation's resources. on another matter, we hear a lot of hand wringing about the decline in manufacturing jobs. but this is partly due to advances in manufacturing process which seems to require fewer, more skilled and therefore higher-paying jobs. the growth in american advanced manufacturing will require job training to fill those higher skilled, higher paying jobs, and, of course, we have a community colleges throughout our country that are rising to that challenge. now, this is an opportunity to do in-source jobs that might otherwise be done overseas. that's good news for the

american economic competitiveness and from the standpoint of wanting higher-paying jobs for americans. that seems to be a silver lining. now the clouds. the decliners are so heavily invested in the story of the decline of american manufacturing that it's easier to bemoamn the lack of economically inefficient low-skilled jobs which are the hallmark of not of america but of underdeveloped countries. on another matter, the bursting of the economic bubble has forced americans to spend less and as a result, to save more. spend less, save more seems to me to be good news. now, a cloud's forming because we have economic pundits calling

that save less, spend more a lack of consumer confidence. you could look at it as a reality check in the face of unsustainable credit card debt financing spending, or is it our natural goalt goal to get people back to saving less in the future and spending more today? live for today and forget about tomorrow. now, you'd think so, based upon what you hear in the news shows. america's entrepreneurs still produce a disproportionate share of the world's innovations. still we're cautioned by people who always see clouds hanging over america that america's not graduating enough people with science and technology degrees, and the best and brightest in developing countries may soon decide to stay at home to build

their companies instead of coming to america. doom sayers have existed throughout our history. it seems to be a sign of sophistication and intellectual refinement to predict the inevitable decline of your own society. using 20/20 hindsight, the eventual decline of all the civilizations somehow seems to be inevitable. so isn't it long cal, then, to think our great nation will decline as well? perhaps the so-called great recession is a sign that america's best days are, in fact, already behind us. many people in the media and government seem so caught up in this narrative that they cannot see any other possibility but

our decline. this fever is starting to spread to the general public as polls show a record number of americans who think that the next generation will be less well off than this generation. as a result, there's a tremendous amount of energy being devoted to figuring out how to manage america's decline. this is kind of a historical determinism and pessimism that is very alien to the american character. the rise of america as the most prosperous nation on earth was hardly inevitable 200 years ago. we owe our current level of prosperity to the entrepreneurial spirit and hard work of our forefathers, and yes, to their inbounded optimism in the future of this

great country. an excessive focus, then, on managing decline risks becoming a self-fulfilling prophecy. for instance there is a lot of concern about the decline of the middle class. but instead of talking about how to unharness the entrepreneurial spirit that made america an economic superpower and grew the great american middle class that we know, all the ideas from our friends across the aisle seem to focus on expanding dependency on government and more government programs. what -- while a succession of new e.p.a. regulations rain down on businesses causing them to pull back from expanding and hiring more people, the democrats' solution is to keep

people on the unemployment benefits for a long, long time. expensive health care reform mandates threaten to force small businesses to reduce employment, reduce the hours of employment, and maybe not even to hire more than 49 people because when you get to 50, there's other requirements of the health care reform that kick in. so what's the answer? many people here in this body would mandate that small business pay a much higher minimum wage. minimum wage jobs ought to be seen as a stepping stone for low-skilled workers to begin climbing the economic ladder. however, when the economic engine stalls, the ladder of opportunity becomes harder to climb and it that more and more people get stuck trying to make

ends meet with low-wage jobs and no opportunity to get ahead. and it seems that people are concerned about tackling this problem by putting more people on food stamps. so you get back to the american dream. the american dream is about an opportunity to work hard and earn your own success in life. proposals to expand the welfare state to the middle class assume that the american dream is somehow dead and the best we can hope for is anemic economic growth with high levels of government dependency. that is a defeatist attitude that reflects distinct lack of faith in our great country, america. this is the old european model, what the -- which the experience of greece showed to

be unsustainable. in fact, the poster child for an expansive european welfare state, sweden, has taken a new route to cut taxes and reform entitlement programs. a lesson that we ought to be looking at in america. but who would ever think that we would look to sweden as an example to teach us how to lower taxes and reform entitlement programs? if we keep planning for decline, we will get it. but if we recover our faith in america's potential and redirect our energy towards removing barriers to economic growth opportunity, america's best days are still ahead of us, and that leads me to repeat what ronald reagan said 25 years ago in that letter to the american people, that america's best days are still ahead of us.

i want to speak to my colleagues on another issue as well, and that is something that has come out of our judiciary committee a long time ago, and is still on the calendar but probably will be brought to the senate floor a few weeks ago, some were calling for the majority leader to bring up the so-called smarter sentencing act to the senate floor for a vote. so i come to the floor today to express my strong opposition to this bill and argue against taking up the senate's time to consider it. in the past, pointed out that this bill would put at risk our hard-won national drop in crime. it would also reduce penalties for importing and distributing heroin, a drug that is currently

devastating our communities with an epidemic of addiction and a rising number of deaths from overdoses. in part, for these reasons, many law enforcement professionals have come out against this legislation. the national association of assistant u.s. attorneys, federal law enforcement officers association, and a long list of former high-level officials in republican and democratic administrations alike are all opposed to it. indeed, page a-12 of this morning's "new york times" contains an article entitled -- quote -- "second thoughts on lighter sentences for drug smugglers" -- end of quote. according to "the new york times," the sentencing changes that the administration has already pushed for are -- quote

-- "raising questions of whether the pendulum has swung too far. some prosecutors say that couriers have little to no incentive to cooperate anymore. border patrol officials grumble that they're working to catch smugglers only to have them face little punishment, and judges, once denounced the harsh sentencing guidelines, are now having second thoughts" -- end of quote of "the new york times" article. today i point out another perhaps less understood effect of the bill. it puts our national security at increased risk. according to the drug enforcement administration, terrorists are increasingly funneling illegal drugs into america, raising large sums of money to fund their activities while simultaneously harming our

communities. undoubtedly, the obama administration's unwillingness to control our borders we have seen recently contributes to the problem. derrick multz, of the drug enforcement operation, called this a "two or one deal" for terrorists. "poison gets distributed in the west and they make millions in the process." according to a d.e.a. spokesperson, "most people talk about the drug issues as a health issue, a parenting issue, an addiction issue. but the truth is, it's really a national security issue." end of quote. in 2006, congress took specific action to address the issue when it reauthorized the patriot act. congress also made it a separate

crime to manufacture and distribute illegal drugs to benefit terrorists or terrorist organizations. the law is codified in title 21, section 960-a of the u.s. code. it's often called the narco-terrorism law. just as importantly, congress created mandatory minimum sentences applicable to narco-terrorism. those sentences are set at -- quote -- "not less than twice the minimum punishment" -- end of quote -- applicable to the underlying drug-trafficking offenses which are codified in title 21, section 841. however, the smarter sentencing act would drastically cut the mandatory minimum sentences that apply to these underlying drug-trafficking offenses.

what this means is that by slashing in half the mandatory minimum sentences for the local drug dealer down the block, the smarter sentencing act also slashes in half the mandatory minimum sentences for members of the taliban, al qaeda, hezbollah who deal drugs to fund their acts of terrorism. so, for example, terrorists who currently face a mandatory minimum sentence of 20 years imprisonment for narco-terrorism would instead face only ten years, if the smarter sentencing act were to become law. but cutting the mandatory minimum sentences for trafficking drugs to fund terrorism, the smarter sentencing act weakens a very important tool that can be used to gain the cooperation of narco-terrorists facing prosecution.

this cooperation leads to more arrests, more drug seizures, more terrorists off the streets, and more intelligence that could help prevent further attacks. indeed, law enforcement authorities have been supportive of the mandatory minimum sentences that apply to narco-terrorism statute for this very reason. i'll give you an example. the assistant administrator for intelligence at the drug enforcement administration testified before congress that -- quote -- "the robust sentencing provisions in these statutes provide incentives for defendants to cooperate with investigators, promoting success in investigations." end of quote. the last thing that we should do is weaken the leverage that law enforcement currently has to win terrorist defendant defendants'

cooperation. twheats smarter sentencing -- that's what the smarter sentencing act would do. indeed, in opposing the bill, federal prosecutors wrote that -- quote -- "mandatory minimums help gain the cooperation of defendants in lower-level roles in criminal organizations to pursue higher-level targets." end of quote. the same principle is true and even more important when our national kiewrt inational secur. these threats to our safety and security aren't theoretical. they're very real. and the narco-terrorism law isn't -- isn't just a statute on the books; it's a tool that actively -- is actively used by prosecutors to protect our nation. for example, in 2008, kahn mohammed, a member of the taliban, was convicted under narco-terrorism laws of

distributing heroin and opium to finance attacks against american troops in afghanistan. chillingly, mohammed was just as concerned with killing american civilians with drugs as he was with financing rocket attacks against our troops. the opium he agreed to sell was to be processed into heroin and imported into the united states. as a result, mohammed was caught on tape explaining tha explainie -- "good, may god turn all the infidels into dead corpses." "may god eliminate them right now and we will eliminate them, too, whether it is by opium or by shooting. this is our common goal." end of quote. similarly, the narco-terrorism law was used to provide afghan

heroin king hashi mochco in 2012. he was also trafficking heroin to america and funneled the proceeds to the taliban. the evidence at trial showed that in 2006, his drug-trafficking organization produced almost 20% of the world's opium, and like mohammed, he targeted americans. he reportedly encouraged afghan farmers to -- quote -- "grow opium so that we can make heroin to kill the infidels." end of quote. perhaps it's little wonder that, according to the drug enforcement administration, heroin overdoses resulting in the death in the united states increased 45% between 2006 and 2010. it should go then without saying

that these aren't individuals whose mandatory minimum sentences should be cut in half. but the authors of the smarter sentencing act apparently think otherwise, because that's what the bill says. or maybe they don't understand what they're doing. either way, the american people should be extremely concerned about this bill that unbelievably was reported out of the judiciary committee. now, some may assume that the department of justice has other tools to go after defendants like these, but the only other charges that mohammed and bachco faced were for unlawful importing these illegal drugs into the united states. and, unbelievably, the smarter sentencing act cuts the mandatory minimum sentences for that crime in half as well.

in addition to these two cases, the department of justice has brought prosecutions against other narco-terrorists. many of these individuals were linked to hezbollah, one of the most notorious terrorist organizations in the world. in at least one instance, associates of al qaeda were also brought to justice for their role in drug-trafficking schemes. in many of these cases, the narco-terrorism law and the ban on importing illegal drugs played a vital role in their prosecution. we shouldn't be weakening these laws at this critical time by cutting the penalties associated with the -- with those acts of crime. of course, if possible, i'd rather these terrorists be treated as enemy combatants and not be subject to civilian

criminal justice system at all. but on those occasions when they are prosecuted in our criminal justice system, i want authorities to have the strongest tools available to address the threat that these criminals pose. according to the united states attorney for the southern district of new york who has brought many of these cases -- quote -- "there is a growing nexus between drug trafficking and terrorism, a nexus that's increasingly imposing a clear and present danger to our national security. combating this lethal threat requires a bold and proactive approach." end of quote. cutting the mandatory minimum sentences for narco-terrorists is moving in precisely the opposite direction of what the u.s. attorney for the southern district of new york just said. -- or i just quoted. trafficking in illegal drugs has

long been understood to be a way that these terrorist organizations raise funds. but it's now equally clear that this activity also is a way for them to target our fellow citizens directly. in effect, then, drug traffic something a way of waging war against the united states. it is a way to terrorize our communities with poison without firing a shot. it is a way to threaten the lives of americans just as surely as using a bomb, a gun, or a hijacked plane. terrorists are wielding another tool in their efforts to destroy and defeat our country. this isn't the moment to weaken one of the tools that we have to actually stop them. this is no time to let down our defenses. it's no time for the senate to

take up the misnamed smarter sentencing act. i yield the floor and suggest the absence of a quorum. the presiding officer: the clerk will call the roll. you quorum call:

quorum call:

mr. reid: mr. president? the presiding officer: the majority leader. mr. reid: is the senate in a quorum call? the presiding officer: yes. mr. reid: i ask unanimous consent that it be terminated. the presiding officer: without objection. mr. reid: i now move to proceed to executive session to consider calendar number 850. the presiding officer: the question is on the motion to proceed. all those in favor say aye. all opposed no. the ayes appear to have it. the ayes do have it. the motion is agreed to. the clerk will report the nomination. the clerk: nomination, ronnie l. white of missouri to be united states district judge for the eastern district of missouri. mr. reid: i ask unanimous consent the reading of the names -- no, not there yet. i send a cloture motion to the desk, mr. president. the presiding officer: the clerk will report the cloture motion. the clerk: cloture motion. 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 debate on the

nomination of ronnie l. white of missouri to be united states district judge for the eastern district of missouri signed by 17 senators as follows. mr. reid: i ask unanimous consent the reading of the names not be necessary. the presiding officer: without objection. mr. reid: i ask consent the mandatory quorum under rule 22 be waived. the presiding officer: without objection. mr. reid: you move to proceed to legislative session. the presiding officer: the question is on the motion. all those in favor say aye. opposed, no. the ayes appear to have it. the ayes do have it. the motion is agreed to. mr. reid: is the motion to proceed to 2578 pending? i have a cloture motion. the clerk: cloture motion, 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 motion to proceed to calendar number 459, s. 2578 arcs bill to ensure that

employers cannot interfere in the employees birth control and other health care decisions, signed by 17 senators as follows. mr. reid: mr. president, i ask unanimous consent the reading of the names be waived. the presiding officer: without objection. mr. reid: i ask unanimous consent the mandatory quorum under rule 22 be waived. the presiding officer: without objection. mrs. murray: mr. president? the presiding officer: the senator from washington. mrs. murray: mr. president, last month we saw five male justices give their blessing to c.e.o.'s and corporations across america to go ahead and deny legally required health care coverage for their employees. when that news broke, i was outraged, and i know i was one of millions of people across the country who were shocked and angry. mr. president, these women are looking to us. they are demanding a change. and today as women across

america took to social media for a digital day of action, their message was delivered loud and clear when they echoed my personal health care choices are not my boss' business. period. and it wasn't just women who were speaking out on social media today. in fact, we heard from several men who understood that if bosses can deny birth control, they can deny vaccines or h.i.v. treatments or any other basic health care service for their employees or their dependents. i heard from conrad in my home state of washington on twitter today who said he really doesn't want his boss knowing what medications he's on, diabetes or heart medications. conrad said -- and i quote -- "it's simply not my boss' business." mr. president, i also heard from my constituents when i was home this weekend. on friday, i spoke directly with business owners and others who were hearing the same thing. women are tired of being targeted and are looking to congress to right this wrong by

the supreme court. one such woman was a woman named morgan beach. morgan joined me friday at odd fellows cafe. it is a small seattle business whose owners stood up and spoke out about their disgust as employers by this ruling. morgan is one of the 58% of women who use contraception for reasons other than to prevent pregnancy. and as she spoke out about how the supreme court decision would impact women like her, morgan said -- and i quote -- "the terrifying power this ruling gives to a small minority to make sweeping personal decisions is frightening. the simple fact is birth control is not my boss' business." end quote. morgan's right. it is not her boss' business. mr. president, we're going to be talking about this urgent issue at more length tomorrow morning, but i wanted to come down this evening and share what i heard from back home this weekend and throughout today, because we have legislation that is now

slated for a vote later this week, and we're going to be talking about this today, tomorrow, and through that time. and i hope that all of our colleagues are listening, because it is time for congress to get to work. women and member are watching. i'm delighted today to be joined by my colleague, the senator from colorado who is my partner in presenting this legislation. mr. udall: mr. president? the presiding officer: the senator from colorado. mr. udall: mr. president, i rise to speak about a proposal that senator patty murray and i introduced to restore women's power based on information best for her and her family not according to to a employer's belief. the act, not your boss' business act, aims to counterbe act the far-reaching conferences of the u.s. supreme court's hobby lobby decision. that decision allows closely held corporations to now deny their employees coverage for

contraceptives through their employees' health insurance plans. as senator murray did in her home state of washington, i also traveled around my home state of colorado and several days ago i stood shoulder to shoulder with women's health experts including an ob-gyn in denver who told me that physicians might now have to consider how an employer's religious beliefs might fit into their diagnosis before they make a medical recommendation. that ought to be based solely on their patient's well-being. it's unacceptable. women should never have to ask their bosses for a permission slip to access common forms of birth control or other critical health services. today as senator murray alluded to, champions in women's health are taking a stand on social media to illustrate why the senate should come together this week to pass the not your boss' business act. this outpouring of support from

all over the country shows how important it is that we keep private health care decisions in employees' hands and out of the corporate boardrooms. as part of today's digital day of action across the country, my staff and i put together a buzz feed post to dispel some misconceptions about the hobby lobby decision and highlight why we need to pass the not your boss' business act. go to buzzbead.com/markudall and share my post to help push back about some of the myths. despite what some people say, mr. president, this decision a bad deal and it will undermine women's access to contraception across the country. but more and more americans are joining us to speak out because of how backwards this hobby lobby decision really is. and i'm proud to have groups from across the centennial states such as the colorado organization for latino opportunity and reproductive rights, naral pro-choice colorado, planned apparenthood of the rocky mountains and

colorado's religious division for reproductive choice come out in support of our bill. i believe the supreme court was wrong in its misguided hobby lobby decision which is already adversely affecting american women and families. but, mr. president, we have a chance to fix this, and i stand here today to call on my colleagues from both sides of the aisle to join me, join senator murray and america's workers who agree that women's health is not your boss' business. mr. president, i yield the floor. mrs. murray: i suggest the absence of a quorum. the presiding officer: the clerk will call the roll. quorum call:

quorum call:

the presiding officer: the senator from hawaii. ms. hirono: i ask unanimous consent that the quorum call be vitiated. the presiding officer: without objection. ms. hirono: mr. president, i ask unanimous consent that kina mcdonald in senator leahy's office be granted floor privileges for tuesday, july 11, 2014. the presiding officer: without objection. ms. hundred: i understand there are two bills at the desk and i ask for their first reading en bloc. the presiding officer: the clerk will read the titles of the bills for the first time en bloc. the clerk: s. 2599, a bill to stoop exploitation through trafficking. h.r. 4718, an act to amend the internal revenue code of 1986 to modify and make permanent bonus depreciations.

ms. hirono: i now ask for a second reading en bloc and i object to my own request en bloc. the presiding officer: objection having been heard, the bills will receive their second reading on the next legislative day. ms. hirono: i ask unanimous consent that when the senate completes its business today it adjourn until 10:00 a.m. on tuesday, july 15, 2014, that following the prayer and pledge, the morning business be deemed expired, the journal of proceedings be approved to date, and the time for the two leaders be reserved for their use later in the day. that following any leader remarks, the senate be in a period of morning business until 12:00 noon with senators permitted to speak therein for up to 10 minutes each, the time equally divided and controlled between the two leaders or their designees and the majority controlling the first half and the republicans controlling the

final half. that following morning business, the senate proceed to executive session as provided for under the previous order. further, that following the cloture vote on the lafleur nomination, the senate recess until 2:15 p.m. to allow for the weekly caucus meetings. finally, if cloture is invoked on either of the nominations, the time until 3:00 p.m. be equally divided and controlled equally divided and controlled between the two leaders or their designees and at 3:00 p.m. the senate proceed to vote on confirmation of the nominations as provided for under the previous order. the presiding officer: without objection. ms. hirono: at 12:00 noon tomorrow, there will be two votes on the burr and flai nominations. and if cloture is invoked, votes on confirmation of the nominations at 3:00 p.m. if there is no further business to come before the senate, i ask that it adjourn under the previous order.

the presiding officer: the senate stands adjourned until senate stands adjourned until

emad does is for a quiet real quick. good morning everyone and welcome. so many of you getting up on a saturday morning brought a hope you enjoyed last night entertainment and enjoying your national experience. we are loving having you all here. i want to call to order the meaning of the health and human services committee and let me begin by saying we have a few administrative items to take care of. the briefing, the governor should have received briefing and e.g. of days. seated next to me as their legislative director for health and human services for nga and she will be available after this session anybody either on the panel in the group or anyone else needs further details of what we are talking about. a reminder that the proceedings of this committee are open to the press and meeting attendees i would ask you to silence your cell phones and other electronic devices. today's discussion will focus on

two key issues that i know every governor spent a lot of time thinking about them working on. first given given demographic changes rising cost of health care and a range of other factors, how can we expect u.s. health system to evolve over the next decade? for all of us unwilling to make the safe bet that health care costs are a major factor in our budgets, a major part of our jobs. second ban would be having governors harness these forces to improve the health care in their states also while reducing the financial burden for state governments, for employers and their families. whatever changes may be on the horizon we can be certain that governors will be dealing with them because again a lot of what we do has to do with dealing with health care. in tennessee we recently launched a statewide initiative to better reward patient-centered high-value care. over the next five years at

tennessee health care innovation initiative close shift the majority of health care spending both public and private away from fee-for-service to three outcome based payment strategi strategies. the first is an episode they strategy that aligns financial incentives to promote successful outcomes for a discrete event such as a joint replacement or pregnancy. the second strategy focuses on primary care transformations that encourages prevention, coordination of care across -- and involves the position and management of total cost of care for their patients. the third incorporates other value based payment approaches that will award quality care for long-term services and support providers as well. with these efforts of wrote the tennessee will be at the forefront of a national trend that's expected to gain momentum in the coming years. many governors are implementing or considering similar statewide multi-payer initiatives to help move from fee-for-service to assist in their own words value over volume. the federal government supporting many be separately this state innovative --

innovation models initiative. tennessee received a model design award in the first round and in the second round will compete for model testing were to support implementation of our state plan. despite other federal efforts to support innovation successful statewide transformational requiring air of collaboration between states and their federal partners. this enhanced state and federal partnership is a key for states to continue moving the needle to more efficient care and better health status. to this end of the last meeting in february governors approved a series of recommendations developed by the nga health care sustainability task force. governor kit sauber of oregon and i have the privilege of leading.task force on a number key issues. those include streamlining the federal process for reviewing innovation proposals creating a path to permanent seat for successful state programs and allowing states to share and federal savings resulting from

the efforts. achieving these and other goals outlined in the task force report will give states the flexibility and the resources they need to transform their health care systems and respond to future challenges and opportunities we will be discussing today. i would like to turn to the vice chair of our committee governor shumlin for any remarks that he may have. >> thank you fellow governors and panelists. i have to say i don't want to get myself in trouble here but i have to say this has been the most successful summer nga meeting that i have ever been to and i think the governors agree. last night's entertainment show was just one example of how you get things right so thank you for everything you are doing governor haslam and for the nga and all of us. [applause] is going to make it tough for any of us to host future summer meetings. you will just shut them down going forward. listen i want to thank you all

for being here. governor haslam is doing extraordinary work in tennessee. this is an area in health care where we all agree that we have got to get costs under control in today's discussion is critically important to the work that governors are doing around this table and around the country leaving our state. when it comes to health care we are all working to stop skyrocketing costs and better -- hammering job creation and little middle-class working families and education roads and bridges public safety and job creation. i know in vermont as an example in this map is no different than other states today in vermont we spend 20 cents on every dollar on health care on average and if we were to see health care costs rise just for the next 10 years at the same rate they did for the last 10 years that number would double.

i often say to vermonters raise your hand if you think that's your prescription for job growth or economic prosperity for a great future for all this. health care costs as words. containing costs as governor haslam just noted. his body alignment among stakeholders that outcomes-based payments moving from quantity to quality is the wave of the future and we governors are prepared for potential challenges that lay ahead from a rapid aging population is the governor just mentioned to increase consolidation of our health care industries that we are seeing in all of our states. there are many trends that are duplications were health care transformation in our states. in vermont we are focused on containing costs by covering health care providers and payers with funding from the state innovation models grant which has been a huge help to us. we are one of the states that got a single grant so just for a second imagine a health care system were health care

providers everyone in the system our doctors, nurses and hospitals and on the ancillary services are driven to keep you as healthy as you possibly can as a team and i don't have to use as many expensive health care services to achieve those goals. second imagine a system where providers have the health care records at their fingerprints and an i.t. system that can't be beat with american innovation and they are there when they need them in third where providers work with people outside of the health care system to make sure you have the support you need to stay healthy went to him move back into your committee sent homes such as good housing, good nutrition at the preventative care i often say eating good vermont grown food and not smoking and exercise in all the things we know we should be doing. [laughter] >> it's got to be vermont. that's important i know.

innovation project supports three kinds of work. the first is change provider payments. change provider payments that we pay for outcomes of care not volumes of care. that's going to be a major transformation in our system and when we award providers and patients for achieving that for doing the right thing. second we are completing buildout of health care information systems that i just mentioned that link their providers together in third designing a statewide system for highly targeted coordinate services to keep folks getting better. so how do we achieve, what have we achieved so far in vermont in our innovation project? we have created shared savings programs for providers. the obvious question is how do you achieve this model? how do you move the model to one that goes forward. shared programs are the first step away from volume-based payments for health care providers towards value-based --

we have wants one program for medicaid and one for private insurers. vermont is the first day to launch that kind of program on a statewide all-payer basis so everybody is in and we have for health care providers are hospital exempt everyone around the table trying to figure how to get this right. we have also invested grant funds in health care information technology such as i mentioned continued buildout of that interface between health care providers in the states health care information exchange system is critically important. that includes establishing connections between hundreds of health care sites across the state. we all face that challenge is governors. funny building an electronic gateway that will root health care data for quality reporting care management and improvements to patient care. we have all of our major payers and providers in the state talking about collaboratively a common approach to health care improvements. .. s quality of care,

keeping people healthy. second, everyone is taking their own approach to health care improvements. that is what we need. , coordinatedl out effort across the state, and, finally, this is what we are building in vermont. so, i look forward to the presentations we will here, the comments of the other governors. i really do believe that the governors working together in a bipartisan spirit with the states as the models for innovation and change in health care is where the rubber is going to hit the road and bringing about affordable, quality health care that allows us to spend more money growing jobs and investing in infrastructure. thank you so much governor haslam, and i'm delighted to turn it back over to you. >> thank you, governor peter shumlin. we have a distinct panel.

if you could hold questions at the end of presentations. we will set aside a good chunk of time for questions and answers at the end. let me begin by introducing tom lack of it -- tom, a director of mckinsey and company who has spent 13 years working to improve the performance of the health-care system. he leads the payment sector and the state and local government practice. he also found that health care analytics, a special department within mckinsey. welcome. dreyfus, us is andrew chief executive officer for blue cross, blue shield of massachusetts. prior to becoming ceo, he spearheaded the alternative quality contract, one of the largest commercial payment reforms in the country. he also recently led the

massachusetts foundation and massachusetts hospital foundation. he led numerous positions in massachusetts state government. also, found out his son is an aspiring singer/songwriter, so you're in the right place. finally, bill rutherford of the hospital corporation of america, one of tennessee's in the nation's leading provider of health care services. they are based here in nashville. servedhis tenure, he has to hisriety of roles current role as chief financial officer and executive vice president. in 2005 he took a brief hiatus to start his own training and education company, and then served as chief executive officer of the behavioral service provider psychiatric solutions. , mr. tom latkovic,

i would ask you to leadoff. >> thank you. i'm with mckinsey and company, a consulting firm better known for our work in the private sector, but we also do quite a bit of work with governors and states across education, economic development, technology, etc., and we are working with a number of states on health care, payment innovation, performance improvement, technology, etc. today, perspectives will be from our research is a firm in my personal experience working in the public and private sector. i should also clarify where not a political organization. , and weretty much nerds come at things from an operational, technical standpoint, but not from a political one, so none of my comments will reference any policies or pieces of legislation, including the affordable care act. i would like to take a step back and make a case for the kind of initiatives going on in tennessee and vermont.

dark water things i want to share with you. one, i think we have a unique time and opportunity to fundamentally change the trajectory of the health-care system in this country, and that is exciting. years of the critical but the change will be difficult. second other states may not. third, i would argue that governors action and inaction would be consequential in the private sector and the public sector. there is a huge opportunity for what >> innovation and to be on thecess man they will need to be shifted agenda, capability, and governance.

so, to start with, and i am a consultant, so i came with two charts, although two is pretty good. i will not belabor the point, strengths, its many there is an enormous and well-documented opportunity to improve our health care system. there are a number of studies, including some done by mckinsey, that would suggest that hundreds of billions of dollars -- we spent hundreds of billions of dollars when we need to for the outcomes that we get. medicaid,ue across and across the public sector. documentinga paper how intelligent changes in our payment system could literally lead to saving $1 trillion over the next decade. in the face of that opportunity, which there is strong consensus for, we are experiencing a number of real discontinuities or massive forces affecting the system -- some of them were mentioned. increasing prevalence of current disease, it proliferation of technology and data, growing provider specialization,

increasing role for consumers, and across all this, inaffordability crisis with -- an across all this, affordability crisis. effectively, i believe these forces present a huge opportunity to capture the opportunity in front of us, however if ignored or addressed and effectively, it could make things worse. so, the challenge is harnessing these forces is quite difficult. there are a great deal of stakeholders in the health care system. it is externally fragmented. that brings me to my second perspective, which is we anticipate greater separation between states with high-performing health systems and those with less performing of their systems. innovation that is needed will ultimately play out at a local level. it will depend on the actions and behaviors of literally thousands of physicians, hospitals, mental health professionals, managed-care company, employers, consumers, etc.

some will make changes more effectively than others. allow me to be more specific. i will highlight a few areas where i think there is a lot of consensus, not exactly on how to do this, what the elements of success include. one of those factors on a success that is that there is nothing competition among sticklebacks there is productive -- there is a doubt the competition -- there is part of the competition. productivee cap, competition is limited because few purchasers understand performance in ways that matter. on a success path, health-care providers will be rewarded for delivering better outcomes at lower cost. a failure path will largely continue to pay providers for activity. the last example, on a success path, most consumers would have adequate insurance and savings, agnostic of the approach that we used to get there. the good news is that the state

were communities that did on and aay on this success path had real opportunity to experience moderate health cost increases, more in line with inflation, --luding medicare program or program. in other words, being on the success path has a really long return on investment both for states directly in terms of their budget and medicaid, and in a broader, societal sent. -- sense. much of the change will occur in the private sector, so why will government and state actions be consequential? the largest party state influence regulation and infrastructure, which has a profound effect on how the private sector operates, but safety is not just a referee in health care. it is an actor. there is a kilo-way linkage between the actions of state takes -- two-way linkage between the actions a state takes three

medicaid expansion is in large part a function of the performance of the entire delivery system in a state. it is difficult for a medicaid system to improve from a cost standpoint without the delivery system in that state fundamentally improving its performance. that includes physicians, nursing homes, mental health professionals, etc. it is incredibly difficult, if not impossible for those providers to change and improve the performance only for medicaid enrollees, thus medicaid enrollees and private sector enrollees are inextricably linked together from a performance standpoint. in that way, the two interact. let's assume you want to be on the success path. that sounds a lot better. let's assume you buy the argument that states could make a positive difference in private sector programs and in accelerating private sector innovation. what can you do? a few suggestions here at a high , i wouldthe first is argue to start to measure success on what you influence as

governors and state, not what you directly control, and from the perspective of citizens and employers. for example, the employer premiums go up or down, did people get healthier or not, how many bankruptcies were there in your state? onond, shift focus a bit enabling private sector innovation where most agree what is required but need help getting over the hump, especially given how fragmented the system is. one of those areas is performance transparency, which is fundamental for productive competition. another is changing fee for service to outcomes-based payment and that includes episode-based payment and a number of different models. most health care stakeholders agree that is the right direction to travel, but it is really difficult to get done without a critical mass of both payers and providers agreeing on a way to do it, which is why the efforts in tennessee and vermont are so terrific.

another area of consensus, both human capital and technology. lastly, there is an opportunity efficiency at optimal levels of insurance and savings. the other thing to consider in the way of doing that is to consider the influence of the state on health care beyond regulations specifically, both as a convener of the private sector and other stakeholders, as well as a purchaser and medicaid. the question there is both in medicaid and in providing benefits for employers in the state, are the programs designed in managing a way to put you on the success path, a way that is neutral to it, or in a way that actually causes it to be more difficult? . the last thing i would say is along with shifting focus and the way you influence things, affecting this change will require identifying your governance model with more integration across various agencies that affect health care and its programs. another way to say that is who is accountable within each state, in your states, for overall health care inflation?

not the medicare budget, but overall health care inflation -- is there such a person? partneryou will need to to get stronger capabilities from a private sector standpoint, it is all of people that understand the models, health-care technology, and large-scale change, which i think is a different skill set than running administrative programs. the last thing i will say in a few seconds here is a couple of practical things -- who is on point, name somebody. invest a little bit of time learning what is going on here at there is -- going on. there has been more inactivity in a long time -- then there has been a long time. use that to build a action plan. last thing, a number of states are innovating -- dissipating in the innovation model, it --

participating in the innovation model, and a number are not. i believe that could be a strong catalyst. thank you. >> thank you. very helpful. mr. andrew dreyfus, we will let you bat second. >> thank you very much. the most important point that i want to make to you was actually made by governor haslam and governor shulman when they spoke because you have governors from different that are geographically, ideologically, and in terms of their health care markets. they both focus on the same solution, to change the fee for service system to an outcome-based, value-based system as central to the solution for both improving care and promoting affordability, and i will tell you a very short story about how massachusetts over the past five years has done just that, and what some of the results have been. before i do so, you might step back and say is the experience

in massachusetts really relevant to our state? after all, are you a deep blue rule, one-party progressive use of social and other issues, and the health care market centered on large, academic medical centers? what i will tell you is we are much more diverse ideologically, politically, and in terms of markets than you might think, so there are some surprises in our story. from the diverse views within our state, we actually have forged the kind of consensus that the governors spoke about, and in doing so we have tackled some of the thorniest problems in health care, and we have done it right balance in these issues that we just heard about -- the role of government versus the role of the market -- how do you balance those two, constantly recalibrate those two forces, and how do we make sure the market and continue to innovate? so, let me tell you about what we have done in that respect.

i think you probably mostly know the story of the progress we made on health care coverage. we passed our version of the aca , signed by governor romney, back in 2006, implemented in 2007, so what the nation is expanding in 2014 we experienced dramaticand you see a reduction in the number of uninsured in the state. there are no uninsured children in massachusetts today, in a very small number of uninsured adults, but we had a second problem, it cost problem. some people say on the coverage issue you started from a stronger point. we started from a weaker point because we are the locus of the most expensive health care, not just in the country, but perhaps the world, so we had a lot of work to do on cost. our plan, blue cross/blue shield of massachusetts, we step back back in 2007 and said how do we tackle the cost problem, and the answer come as the governor said, was to fundamentally

change the way we pay physicians, hospitals, and health care givers that moves us away from the volume-based, activity-based system towards one that rewards polity and outcomes. we did it. we designed our own system. it is not the solution. it is a solution, but it has proved to be surprisingly popular and surprisingly productive. so, we started with what you might think of as a pilot or demonstration project in 2009. we had about 1500 physicians covering about 300,000 of our members in massachusetts who agree to accept, rather than fee for service payment, global payment for each of the blue cross members that each of those combineds cared for with very significant quality incentives, not just a point or two of a four performance, but up to 10% on top of what we paid them they could earn if they

performed well on a set of agreed on quality incentives. no blackbox. these are transparent incentives that are nationally recognized. these are voluntary contracts, but we rapidly were successful. very quickly, almost 90% of the physicians in massachusetts, now accept this form of payment. it covers about 700,000 of our members, making it the largest, or one of the largest payment reforms initiatives in the country. at one point, our own government, governor patrick asked me, andrew, how can we move this faster, and i said to him with all due respect, it will not the elected officials or health plan executives who are going to persuade physicians to change something they have been doing for 75 years. it will be other physicians who say i can take better care of my patients under the system, and that is what they started saying. this is not only the largest, but the most carefully evaluated payment reform initiative in the

country. from day one, a team of independent researchers, health economists, and physicians at harvard medical school were hired to evaluate it, and they published in "the new england and other medicine, academic publications the results that showed us approaching what we all think of as the holy grail of american health care -- better care at lower costs. we have the first two years of years threers 2 -- and four should be published this fall. i will not be able to talk about them because they are not published, but i will just tell you that i am happy about them. what else did we do -- not only did we ask physicians and hospitals to change what they did, but we had to change. governor schaumann talked about how part of the solution is having data at the fingertips of the practices, so we put that data at their fingertips. i do not expect you to look at this.

usage of samples of the dashboards we get to physicians -- these are just samples of the dashboards we get to positions -- some was as a blessing did you know your patient was admitted to the emergency room last night? many did not know unless they are on a system. a lot of it was did you know how your diabetic patients are faring relative to other diabetic patients in similar practices across the state -- here are ideas on how you can get at her. what happened when the physician started looking at this is they started changing the way they provide care to the patients. one of the leaders has talked to me about getting liberated from the tyranny of the office visit. we have constructed our office system for 100 years around the office visit, and obviously, many times it is very important, but most health-care takes place between visit. so, what are we doing between visits? the practices started hiring social workers, it embedding them in the practice --

inventing them in the practice. -- embedding them into practice. they have pharmacist looking in medicus -- medicine cabinets. they start communicating with patients online through telemedicine and a variety of different efforts. they like practicing better. as a consequence, we now have close to half of the physicians in massachusetts except in this form of haman, not just from us, but you need all payer solution -- not just from us -- this form of payment, not just from us, but you need all payer solutions. this works in urban practices, practices that serve low income patients, practices in the suburbs, practices affiliate with large, academic medical centers. but, i said is not just the private sector. it is also government. in 2006 we passed our health care reform while, but every

year, every two years after that, we passed and our governor signed a cost-containment law. each law started to ratchet up the pressure until 2012 will we passed a law governor patrick sign that actually says state health spending in massachusetts shall not grow any faster than the overall state economy, and you probably know we have been growing at a bill that rate. it is not government that will enforce that law. it is the private sector. that is the balance between innovation and government involvement. finally, repeating some of what you heard -- what can states do much mike i-79 university of virginia's millet -- i served on the university of virginia miller center's panel that looked at these issues and i encourage you to look at those results, to meaning a broad-based conversation within

your state on cost, quality and value. promoting experimentation we are hearing about in tennessee and vermont. investing in wellness. i know governor haslam you have a wellness institute you establish and have worked hard on. obviously, governor shumlin has done so much on the chronic care issue. we know 5% of our patients are driving half of our spending, almost all people with chronic illness. then, understanding technology and the key role he could play. again, from what appears to be a single, deep blue state, we have had an adverse -- a diverse experience of market innovation dallas with government involvement -- balanced with government involvement resulting in a dramatic drop in health care expenses and supported by the physician and health care leaders in massachusetts. thank you very much. >> thank you. bill. >> to i.

i am bill rutherford -- thank you. i am bill rutherford, chief financial officer of hca and it is my pleasure to be here this morning. i will a tasty -- i would like to take a -- few minutes with you. is theht know hca largest nongovernmental health care provider in the united states. over 35,000twork of nonaffiliated efficient, and we operate in 42 markets across 20 states. system, across the hca we will see 7 million emergency room visits, have 1.7 million inpatient admissions. 80% of our hospitals have been recognized as top performers, and historically, about 8% to 10% of the patients we care for have had no health insurance. we think that gives us a fairly

unique perspective on the health-care landscape. we see more health care than just about anyone across a range of diverse marketplaces. i wanted to share with you some observations. clearly, what is dominating the discussion in our industry is health reform, efforts to help people gain access to care, and delivery system reform improvements that we have earned about this morning. those efforts are clearly continuing to unfold, but we are encouraged with early signs that we are seeing with the impact of that across many of our markets. when we reviewed our first quarter results, we have about five states across the hca footprint that elected to expand medicaid, and in those states we saw a 30% in uninsured activity as those individuals gained access to -- 30% decline in uninsured activity as those in the visuals gained access. about one-third of the patients

are newly insured. momentum is clearly gaining on those efforts to help people gain access to care, and we think those are positive developments. i would like to share with you three key observations based on our experience across the marketplace. the first i will share is hca, and provide the systems that we see are investing heavily to create what i will refer to anti-value, innovative delivery -- high-value, innovative and they areem, important prerequisites for preparing for changes in the evolution of care and reimbursement methodologies. obviously, continuing to advance key quality it -- and a focus on innovation in what is historically a fragmented delivery place between hospitals, physicians, and ambulatory settings. we are investing heavily in technology. electronic health records and other integrated that forms that

will allow data to transition to the continuum is one -- easily. cost ofd focus on the health care either through consolidating of administrative services, reducing variation, sharing best practices, and a host of other efforts, and most poorly continuing to focus on improving the patient experience -- and most importantly, continuing to focus on improving the patient experience. all of these are in an effort to bring together a hospital effort, a physician network, and ambulatory network tied together with technology in an effort to improve health value, outcomes over cost while improving the patient experience. i believe these are three key ingredients for success in prerequisites as changes in the health care system occur. the second observation i would like to share with you is the payment reform and value-based purchasing is garnering,

probably, a lot of attention. we see the models and limited to the slowly across many of our markets and in various forms. there are clearly models being introduced by governmental entities and commercial entities. we have new pay-for-performance entities in many payer relationships that largely theide incentives for achievement of certain quality or otherobjective -- objective measures that we heard about in massachusetts. we think it is really a prerequisite necessary for providers to continue to strengthen their delivery system capability through integrating, technology, focusing on cost, and improving the patient experience. they are all important success factors that will survive and be important under an array of different payment mechanisms that might be in the marketplace. lastly, the third observation i will share with you, as you may know, there are still many

regulatory hurdles that likely will slow the pace of the evolution integration in the marketplace. we know there are many regulations that govern the relationships between hospitals and affiliated physicians. as we search for ways to provide incentives and the line key objectives, often times -- and the line key objectives, often times you have to set of administrative and public structures that require time in order for evolution to see in the marketplace. we also know there is a lot of administrative costs in health care system. is ourantage of hca scale, that we are able to leverage our scale, if you need to work on reducing those costs and many of those are redundant between pairs of providers -- continuing to search out how to -- payers and providers. continuing to search out how to reduce cost we believe is an important component. it is an exciting time -- health reform, efforts to help people gain access to care will be

important development to no marketplace, and we are encouraged with early signs we -- development to our marketplace, and we are concerned -- encouraged with early signs. bringing hospitals and physicians together to invest heavily in technology to be able to transport data and information that will help reduce the cost structure. payment reform is occurring, unfolding at a moderate pace across the country. we think that will continue to accelerate and it will be an important component for delivery system reform improvement. there are still initiative and revelatory activities that are real and operational that we have to deal with as we think about evolving the marketplace that will facilitate our move to the next generation of health care. so, it is my pleasure to be with you this morning i look for to questions or the discussion points. thank you, governor. >> thank you, bill, tom, and andrew. i will open it up for questions, but let me ask the first one.

i think we all see the reality of health care costs are driven by folks dealing with chronic disease or end-of-life, and as we talked about patent reform and moving away from fee for service, how does the fact that, you know, the cost -- somebody here might know -- what is the cost of those two? members is chronic, and they account for health -- half of the spending. so, if you have chronic illness and end-of-life, you're talking about a big chunk of what health care is costing us. given that, as we talk about payment reform and fee for service, given those realities, how does fee for service impact the world? >> let me start on the chronic illness side. almost the first thing that physician practices do when their given a different set of

incentives if they focus on the patients with chronic illness because those are the patients that they see the most, are hospitalized most regularly, and most of the time those hospitalizations could be prevented if the patient chronic conditions could be managed more effectively. i sat with a practice in california that has eliminated and missions for patients with congestive heart failure because they are monitoring the patients in the home with electronic scales tied to the physicians offices, making sure the medication interactions are working appropriately, having a lot more home-based care. this is common to end-of-life care and chronic illness -- trying to move the care out of the hospital and with all due reverence to the hospital were presented on the panel, i am sure he would agree that we only want the patients in the hospital who must be there. most patients with chronic illness, they can avoid hospitalization, and if they are

hospitalized, to prevent them from being readmitted to the hospital. so, there is a huge opportunity there. many patients with chronic illness also have a psychiatric or mental health diagnosis, and managing those much better, we know patients with chronic illness will consume more services. so, getting the clinical team focused, and i say clinical team because health care is moving from an individual sport to a team sport, and as a team sport, nurse practitioners, pharmacists, social workers, care managers are making a difference. variety ofad a chronic illnesses and she would often call her physician up and she just had a question about a symptom and he would take him to the office, i will take a look. she did not need to be seen. mrs. dreyfuss, let's change of medication, and that would have helped a lot. it would've saved a lot of money. it is a great opportunity and a

great question. >> epic is a great question from my view, dealing -- i think it is a great question from my view. i think there are some prerequisites. you have to bring the system of care together because as you mentioned, it requires a lot of different settings -- your primary care physicians, outpatient settings, specialists, post-acute, and a lot of other activities. so, the first effort is to be able to collaborate what in many communities today is still a fragmented delivery system. so, investments in technology to be able to transport data across those different continuums and provider settings is a very important prerequisite to occur. creating structures that allow flow of information and other information to flow so that we can better manage those patients for the right condition. >> other questions from the governor? i could keep going. >> my question is for mr. tom

latkovic. you mention in your presentation you call one of the essential first steps toward moving toward quality of care payment based on outcomes versus services performed was a transparent, fact-based measure. could you give some examples of some fact-based data systems that the public could see? >> sure. sure. it is a great question, and i think -- there are two things i mentioned. one is simply there are some overall health care statistics in a state like premiums or health status, things like that, that are useful to track, but in terms of what will help actual providers make better decisions were compete on value, or help consumers trying to make a decision about which health care to, the trick is most of the data provided is

selected the way the system is structured. as ill described, in any episode -- as bill described, let's say in an episode where you have to get your hip replaced, there could be a dozen providers you interact with over that episode of care, and today, the data released, it if it does exist, you might get a glimpse of those 10 providers. what you do not get a glimpse of is any sense of physically the surgeon doing the surgery or the hospital -- how does the performance look in terms of the entire episode of care? that would be a slightly different way to show transparency. another example would be, as andrew described in their model, if you have a primary care physician or primary care team that is -- that historically were just see you in terms of office visits, as a consumer you almost have no way to know which

of those teams or individual clinicians would do a better job in helping you manage your chronic conditions or a worse job. at asked, you might get a little bit of information as them -- on ms providers. the real trick with performance is not just the data, but framing it in a way that is actually usable for consumers, employers, etc.. that, andfollow up on pick up on what andrew said, is moving from an individual sport to a team sport, so you're moving from playing a small what you are up that that, with the ball is he to you, where you are playing soccer or basketball, we record meeting with the team -- how ready is our entire provider community to play what looks like a fairly different game? are different states of evolution. in some cases there is a generational divide, and some older physicians that are used

to practicing the way they practice, and maybe one decade or less to retirement say i want to keep practicing that way. younger physicians and older physicians that have come to see it better.ike they see they can spend more. the chronic patients -- you cannot have a 10-minute visit with a patient that is on eight to nine the medications and has multiple conditions -- cancer and depression, serious arthritis and asthma -- you cannot manage those patients in 10 minutes. once they see they can be limited -- liberated from the 10-minute office visit, they like it better. they see the value of the practitioners. this has been going on in edx for 20h -- in pediatrics years that needs to happen more often in adult medicine. governor shumlin talked about having the data at fingertips.

some practices are wired. some are not. it is important that we have some world practices that are not -- rural practices that are not yet wired that are performing previously in our new payment model -- fabulously in our new payment model. >> my observation, i agree with andrew -- i think it is very different in very -- in different communities across the country. there are certain places that are both culturally, from infrastructure standpoint, and from, you know, a formal sense, the way providers aggregate to each other or relate to each other is very different community by committee, and that is part of the reason why we all agree there is no single solution that will work everywhere. it will require differences in local markets. ahead.rnor herbert, go >> well, thank you. i appreciate that the watercooler topic of the day in most states is of care, and

bill, you said it is an exciting time in health care. i guess that is the understatement of the day, because i think it has become and has been very divisive. it is a complex issue, and we appreciate the fact that you are coming here to shed some light on the issue for all of us. utah thatm a state in is generally considered a healthy state, one of the healthiest in america. been rated as the lowest cost for health care in america with about the fifth rated asked quality -- the quality. so, we are doing very well. we are below the national average and those that do not have average -- access to health those couldlf of have helped her, but chose not

to, for whatever reason. care, but chose not to, for whatever reason. mandate,we have this the concern is will go from a good system to the average. cost and lower quality will say this is good, we are moving to the average. in massachusetts, you are grateful you are slowing the rate of growth in the highest cost health care in america, or the world, and we do not want to be that high. so, my question for all of you is a simple, basic philosophy. one, i think we all share the same goals, although i did we do not define the goals very well. is the goal for health care reform in the future to be dues the cost of health care? -- to reduce the cost of health care? is it to improve the access of health care? is it to have better quality of health care? maybe it is all of the above, or

additional things. where we disagree and the divisiveness is how do we get there -- what is the effect of process to get there? as we look at the history of america and our tradition of the free market system, free market competition, individual choice in making those decisions coupled with individual , some arelity concerned that we are moving away from that. >> yeah. >> so, why, if we think historically that free market competition, individual choice and opportunity has given us the best products, the best service, for the most people at the lowest cost, why do we seem to be moving away from that that is a philosophical question and i'm anxious to hear you. governor, it is a question of

the nation right now. couple of thoughts. first, you are right about all the comparative information. is so the reasons utah successful is because they have systems such as the intermountain system, which was one of the early adopters of these practices we are talking about, and one of the first exchanges in the nation that was a private market oriented exchange. when the aca was passed, it anticipated a uniform national set of standards and activities that the nation would adopt. as a result of the supreme court decision and actions by individual governors, we are going to end up with five or six flavors or variations of how the aca is going to play out in various states. that may be a really positive thing. it allows for different models for different states that have

different markets, different sense of what that balance is between five innovation and government involvement, different political cultures, and different delivery systems. think that state experimentation variety will take us very far and governors can take the lead in that. that is why i said initially the statements that our cochair said comic from two very different states but showing extraordinary leadership in their states -- coming from two very different states but showing extraordinary leadership in their states. the best care at the lowest possible cost. we want an efficient system. our system has a long way to go to promote the kind of efficiency you have established. know that people who have coverage get that her health.

it is not just that they have a card. the card is just a start. betteretting them to health and respecting individual choices that people want to make. let the state experimentation flower. >> governor sandoval? a lot of the focus has been on changing a providers system, moving from a fee-for-service to outcome based services that rewards quality in outcomes. we have set a goal in iowa of becoming the healthiest state in the country, which from where we began -- i guess 19th, and we are tense today. -- 10th today. the only way it works is to get take ownership of their own health, instead of looking to their health care

provider to have all the answers , to get people to make healthy choices, whether it is not using tobacco products, exercising regularly, making good choices in terms of nutrition and all of that, and then trying to align the provider reimbursement so that it also rewards and supports that. i guess i would like your reaction to that. i don't think all of these efforts work unless you get a buy-in from the patient. there are too many people historically who -- i just look to my doctor for answers, as opposed to taking ownership of my own health. we are trying to lead by example and do a lot of things and get communities involved. we have these blue zone communities, and we are setting all this focus on that. reaction fromhe

the panel to that strategy that we are in the process of implementing. fromive-year goal is to go 19th to first. we are in the beginning of the third year of this. >> i am familiar with the strategies, and my colleague john forsyte speaks highly of the commitment you have made. blue cross blue shield likes the idea of blue zones. you are right. you may have heard this before, the most expensive piece of medical technology is not a positron emission scanner, but a physician's pen because they are ordering the tests that cost so much. piece of expensive medical technology is strapped to my belt, a pedometer.

we need to engage patients at multiple levels, first in their , setting ambitious goals and getting people to participate. both cochairs talked about tobacco, diet, nutrition, exercise. the second piece is, how do we products thatce place some responsibility on the patient's to think about their own care, and how do we couple that with transparent public data that allows them to make steer orand how do we encourage patients to choose high-value types of care? that is the advantage of consumer driven products in which patients have some skin in the game, some financial responsibility. we know from the early results that when that happens, they make different choices. ask about health

risk assessments. we are trying to incentivize people to do health risk assessments so they know their own risk factors and can work on those. >> that is a big role for employers, especially large employers are embracing that. wellness at the worksite is an important setting. you have to understand your own health before you can know what actions to take, in collaboration with your physician or another caregiver. we have one program where we are paying the patient, the doctor, and giving incentives to small business owners together to promote the health -- not big, thousand person companies -- we find it is that circle, if you get all three focused and aligned around health and wellness, you will start to see actions. >> to build on that with some respects, in many

consumer incentives are ahead of incentives of the delivery system. let's say you have the consumer who is in power. they have financial incentives to take care of themselves and their health. in most parts of the country, the incentives of the providers are in some respects at odds with the consumer expense -- incentive, and there isn't an incentive for the provider to spend the time to equip the consumer with the information and the guidance that they can use to manage their own health. if someone at a hospital is being discharged, most parts of the country today -- many of them do it out of the general goodness of their hearts. they are not compensated to spend time helping that patients understand the medications. catch uped to do is with the consumer incentive program and make sure those two things are aligned. >> governor sandoval. yourally appreciate

presentations. listening to gary's comments about utah -- that is very impressive. to opt ine decision with regard to the affordable were 49th in we the country in uninsured. we are going to be adding 300,000 insured lives within a year. oft is an immense amount people that are coming into our health care system on a regular chronicany of whom have diseases about a lot of things that you talked about. bend theke we can curve with regard to utilize asian and healthier living, -- utliilization and health care living. i would like to hear your thoughts and observations with regard to those costs.

80% of these lives will be in managed care in nevada. i'm trying to do everything we can to implement those wellness programs. are putting these bans on to pass those out so people are living healthier. to pass those out so people are living healthier. i don't really know what to do. i would like to hear your thoughts. that is an easy question. i will take it. [laughter] it is incredibly difficult. it is the challenge of the western world right now, how to control health care costs. no one really understands the full answer. a couple of the ingredients -- there is reasonable consensus on, and can be a helpful start. the activities that andrew and bill described are great

starting points. some of those ingredients include -- what most people believe is there is an opportunity to reduce some of the inefficiencies in the current system, but most people also believe that to change the actual rate of growth will require more permanent changes, especially in the payment an incentive system. there are some things you can do in the near term to management programs, things like that that can reduce some of the costs in the near term. time, cost exchange over you both have to change how consumers think and behave. you need to create long-term incentives for stakeholders, health-care providers, and others to be inventing new ways to do things better over time. that is a long-term challenge that requires lots of short-term changes. if i can add a couple of thoughts.

we are trying to make some advances. picture look at the big and what has happened across all of our states in varying degrees, we are spending more than anyone else on health care in the world for less good outcomes. long than the countries who spend less than us. we have higher infant mortality than countries that spend a lot less than us. we continue to have health care costs rise at rates that are higher than our income. moneyi believe that drives america -- that is what we do best, we are the best entrepreneurial place in the world -- you have got to bring your providers around to the thought that they can do better a differentwith payment system. i fundamentally believe that is

true, and when they actually sit down and work it through, they realize that is true. in my rural state, most of my hospital administrators and providers believe that the current system is not sustainable. we are not talking about the corner grocery store going out of business. we are talking about our health-care system. i had an experience a few months ago where i go down to the southwest part of my state, the hospital administer is flipping out because the monday before the nearest hospital next to him after 160 years of business just said, we are done. it was over the line in massachusetts. wasought at first it governor patrick's problem. i realized they were having heart attacks and strokes and babies and they were getting cancer. they had nowhere to go except to my hospital.

a blueprint for health, in our small communities we are given our technology to providers so they are getting on one uniform system where they can measure and integrate delivery with each other. the i.t. piece of this is huge. as they do that, they see they can get better outcomes for less money with the patients, which we forget is what health-care providers want to do. trainedand nurses are to make people better, not to navigate a complex payment system we currently have. out --pointed this governors cannot tell their docs and providers, we are going to do this together and you are going to love it. a very deliberate and carefully designed partnership that allows us to facilitate providers figuring

out that they can do what they love to do, which is make people healthy, in a payment system where they get rewarded for less quantity and better quality, and measure those outcomes very carefully so that those who are doing the chronic care don't end up getting punished for a system pays for less quantity and more quality. it is doable. you have to have those three pieces. the i.t., the buy-in from providers, and agreed upon, so thatle outcomes you're improving quality as you spend less money. >> i have a question for mr. dreyfuss. state, 85% of the health insurance coverage is provided by blue cross blue shield of north dakota. crossn't i just tell blue

that i would like them to offer the massachusetts alternative quality care contract, and save myself years of groundwork in trying to develop something? [laughter] me in a lot of trouble. we have our great friends from blue cross blue shield tennessee here. they have their own innovations they care a lot about. >> they are texting north dakota blues right now. [laughter] off, is not that far because the entire blue system is working on a model. the model i described works great for the people who live and work in massachusetts. but we ensure a lot of companies that have people who work across the country. in north dakota, vermont, tennessee. ourave to be able to link payment model to payment models that blue cross blue shield of north dakota in tennessee and vermont have.

we are working on a national system that will not be identical to this. markets are different and we have to respect that. we will link the two together. as for governor, setting a direction and pushing your largest payer to accelerate their work around payment and delivery reform is an appropriate role. you don't have to write a lot of new regulations. you don't have to create a lot of new agencies. you can say, i will insist the private sector do it. i got some calls from my governor. we got moving. can i also respond to governor sandoval's question to? i want to make the point to preach a little patience. tens of thousands of americans turned 65 every week, and they enter the medicare system.

them come in having insurance because they work for companies, and some of them come in uninsured. it would not surprise you that the ones who come in uninsured are more expensive for the first few years because they have not been seeing a doctor. after a few years, they even out. 300 thousand newly covered people you have in nevada, some of them probably have had insurance for years. for the first year or two, they will probably be more expensive. we learned that in massachusetts. don't assume because they are more expensive for a year or two that they will be more expensive forever. if we do get the right systems in place, we can get the health care inflation down. there will be a lot of attention to premium increases in the fall in different states, to premium increases. . .on chronic illness and wellness and

prevention -- like in iowa, you will get the results you want and your health status will improve and your costs should not start to skyrocket. >> gary, do you want to add something? make an observation and editorial comments. i think everybody here recognizes -- utah did learn for massachusetts, with your exchange. we put an exchange in place which is a little bit different from yours. it fits more of our culture if it's more of our culture or our desire to get better health care so we learn from massachusetts. i heard some great things coming from vermont here. i'm very concerned about the one-size-fits-all and i think is the committee wanted the things we have to be pushing is to give states the opportunities to find their own ways with their own

demographics, their own unique challenges that they have which are all different. utah or nevada are similar since some ways and some ways in different another sewer needs are different, our challenges are different in the solutions will be different. let's make sure we give you states the opportunity because laboratories of democracy where we can learn from each other and probably gravitate towards a similar area but we will learn from our successes. we will learn from our failures that were not as successful but we will actually find that optimal place as a country and get to the place where we want to be for health care reform. >> thank you. i want to ask governor shumlin if you would make closing comments on this. >> binky mr. chairman things were great work. i think that gary just gave the best summary that we can give which is you know i think we all agree we are in a time where not much is happening in washington

d.c.. governors have been making decisions to get things done. we work together with the bipartisan spirit to do that and i want to thank the nga staff for putting this panel together. i think is scary just said we are going to be the laboratories for change in health care to improve quality reduce cost and get better outcomes and if we can use this forum and the conversation we just had here as the fuel for that transformation we are all going to win and we can get this right but i really do think it boils down to governors having the courage to work together with our partners to push where we need to, to pull where we need to enter share common discoveries where we need to to get this right because it's critical to job creation. it's critical to quality of life and we have got to find ways to reduce the costs are where all dead economically and what we are trying to achieve. thank you mr. chair and think you panelists and thank you governors.

i think this is an area where the nga can really make a difference help set up the tools to be laboratories for change. >> i think what you just heard from governor herbert. two different states to fairly different ideologies in two different approaches to aca even bet i think we hear a whole lot more agreement than there is disagreement in terms of what the key issues facing us are so i appreciate that. i want to thank our panelists. you guys were terrific and have been very helpful and practical and specific and that's sometimes hard to do on a panel so thank you very very much. [applause] >> before we break we are going to have a one and a half minute update on the center for best practices. thank you very much.

>> thanks very much. i'm the health division director at the national governors association. his conversation was a perfect segue for what we wanted to announce to all of you which is after the hard work of this committee and the health care task force earlier this year one of the request that came out of the discussion was is there a way for the standard to work to get individual states the ability to move forward with the federal government and negotiate individual authorities under medicaid around statewide transformation. so we have been working for the last few months and we want to thank the robert wood johnson foundation who has agreed to fund this project and we will be announcing in the next week or so on opportunity for three to five states to come forward to work together to negotiate with the federal government new broad authorities around statewide transformation. these are individual authorities for each state so each state for

that size and not a one-size-fits-all for that state. we are hiring leading national consultants and we'll have an expert panel that will be working with the states and the federal government. we have received confirmation from leadership at hhs that they will bring their a team to bear on this so we can have really constructive conversations. so the rfp the states will be released in the next week or so and we will give them six weeks to respond. the launch will be in october and we will work over the next year with hhs with individual states and with their experts to try to reach an agreement and concept on broad statewide authorities in medicaid and i think after it's over we will be working very hard to basically build a template for other states interested in receiving these kinds of authority so we can accelerate and move past the very laborious back-and-forth

that we see so often in these discussions so that this template build and also hhs's ability to let states jump ahead a little bit in the discussion so they can get to it faster to use these these templates and new processes. so very ambitious, very exciting and please if you guys are interested have your folks reach out to us and let's get busy. >> high-stakes, high roller. thank you. linda are we get it? i really want to thank everybody who attended our panelists and the governors. this was a great session, very helpful and thanks as always to nga for making at health -- making it happen. thanks to nga. good job, well done. [inaudible conversations]

>> certainly the iron dome system that the united states has worked with israel to set up to protect israeli citizens has been effective. i should say it's been effective in protecting so many of the civilians that are in harm's way on the israeli side of the border but is now designed to ultimately bring those rocket attacks to and that is what is really important. we need hamas to stop launching rockets that are putting israeli citizens in harm's way. now the same time the united states is also very concerned about those palestinian civilians who are in harm's way and that is why we have been urging israeli political leaders and palestinian leaders to do

everything necessary to try to safeguard the safety and well-being of civilians on both sides of the border. that is why we have decided that nobody wants to see a ground invasion because that would put even more civilians at risk. but again this is israel's decision to make. and israili political leaders certainly have the right even the responsibility, to protect their citizens and that is what they will do. >> can you clarify you said either approach could work either rewriting the 2008 law or writing a new love. it sounds like legislative action is necessary for you to be able to set these up quicker. in other words you can't do it with your executive authority. congress has to pass something. >> what i was trying to say it's the details are important. i don't want to lead to you to suggest that we don't care about the details. we do care about the details but ultimately in pursuit of this

goal which is to balance these competing equities which is to meet the basic humanitarian ways of individuals apprehended along the border and to assure that they receive the due process that they are entitled but also to enforce the laws as efficiently as possible. >> that's something you can't go with your executive authority loan. >> bear some aspects we are able to do with our executive authority. the president has given authority to deploy the resources that are part of the immigration court system that would allow us to process that'' more quickly and meet all of those goals. what we are seeking are a couple of things. resources that would allow us to increase the number of personnel to that effort but we are also seeking additional authority that can be vested with the secretary of with the secretary of homeland security so he can exercise his discretion and look for ways to more efficiently enforce the law. that is to repatriate those

individuals, who the immigration courts have decided have no legal basis for coming into the country. >> you said you have reduced the immigration -- and the courts already. you have reduced them? you said he used his authority to remove them to the border and that is reduced significantly the flow through the immigration courts. >> thank you for giving me the opportunity to clarify. that is not what i said. what those resources have done is they have helped address the problem that we are seeing. what we have seen as a spike in individuals who are attempted to come across the southwest border. that is led to a backlog in our immigration court system. by deploying additional resources to that core system we have been able to speed up that process. that backlog is still significant and remains and so that is why we are asking congress for significantly more resources to add to the bandwidth to the court system if

you will to try to make the system more efficient. >> one more question. as the president considers what kinds of unilateral actions he's going to take in the fall to ease deportations you know he is asked for these recommendations, how does this crisis affect that decision-making process? >> well i think what i would say is simply that these are two separate but not completely unrelated issues. the challenge that we are seeing in our current broken immigration system is that well its a variety of things. one is there are some including the president who believe that we would benefit from additional resources being used to secure the border. there is a historic investment to border security that is contemplated in the common sensibility to pass the senate. there limitations on how much of

that you can do with using executive authority. the open question that some have and that the president's attorneys are investigating is what exactly can you do to address some of the other problems that are caused by our broken immigration system collects many of them are dressed in the senate bill but the question is whether or not there are additional steps that you can take to level the playing field for businesses. there a lot of businesses right now who are very rigorous about observing immigration law and that creates an opening for someone's businesses to undercut them and to to bypass the system and essentially hire undocumented labor for a cheap cheaper -- for cheaper. that obviously is not playing on a level playing field and one that is not fair to business owners across the country that are trying to do the right thing. we also have this large question

that lambs about the population of undocumented undocumented immigrants that are already in this country. many of them as the president has discussed have lived here for quite some time and many of them have been raising children here and have been paying taxes. these are individuals who in many cases are largely indistinguishable from so many other americans. the question is how do you, you know how do you confront that challenge in a way that reflects our tradition as a country of immigrants but also a country that enforces the law? so these are all very difficult policy problems. the real shame of all of this is that the senate has acted in a bipartisan fashion to address many of these problems to what the president has said is let's look for ways since house republicans since house republicans have signaled that they are going to block that senate legislation, that

commonsense bipartisan policies the president has said what can we do using my executive authority to address some of these challenges? that is what these lawyers are hard at work on. i'm at the timeframe for you other than than the presents a than the presents a human to see a set of recommendations by the end of the summer and he wanted to add shortly thereafter. >> is it fair to say this crisis has made this decision-making process more politically fraught? >> it certainly has elevated the debate in a way that seems to sort of rise and fall based on other stories. i think that we have in some ways this is the largest sustained elevation of the story line in the news media at least in quite some time. so in some ways it does put republicans in the spotlight and make said harder than ever that for them to explain why they would block a commonsense proposal that would address many of the problems that are then highlighted by this challenge. but you know it's hard for me to

assess at this point whether or not this is a political impact on a possible executive action to address these problems. major? >> the israelis have accused the palestinians have acting disproportionately and in some cases engaging in war crimes. is there anything that believes his ballot about that criticism of? >> not that we have seen. >> indiana senior at messerschmidt officials describe what they brought to the table is unworkable and inadequate and would be hard to contemplate things like an extension without seeing significant progress on the issues. i didn't hear any of that in your original answer to julie. you seem to be more deferential or respectful of what their ratings are brought to the tab table. >> i don't think there's a disconnect. i think over the course of these negotiations we have seen them engage in these conversations in a serious way.

that said there are still serious gaps that remain up in the last couple of weeks we have seen the good shooters hard at work to try to resolve or purge the substantial gaps. there still remains quite a ways to go but secretary kerry has been there to assess whether or not those gaps are in fact able to be bridged. >> if it's -- how can you be serious if it's unworkable? >> it isn't sufficient to bridge the gap to our side. >> in 10 minutes we will be joining lawmakers here for the house veterans affairs committee holding a hearing on the benefits and disability claims process for veterans. this is one in a series of hearings they will be holding on veterans issues. post your comments and c-span's facebook page or c-span's facebook page or send us a tweet. just you'd be sure to use the hashtag c-span chat. a look at majority reader harry reid came to the floor to speak

about the loss of the house republicans. here are his remarks. >> the republicans have made a decision on a lawsuit against president obama. it's difficult to understand how they have become so desperate that now they are talking about our issue of the day is not minimum wage. our issue of the day is not that women and men get the same amount of money for doing the same work. the issue of the day is not the death that is staggering in the country that is student loan debt and extended unemployment benefits. now i could go through a long list of things that is important to the middle class that they simply are ignoring. what are they doing to solve the problems of this country? suing the president and this was and what they are suing him

about. they have been broadcasting for weeks their intention to sue the president but they just didn't know why. that's what they said, not me. now, after misstep after misstep after misstep they know now why they are suing the president. they want to litigate obamacare. now the presiding officer has done ever markedly good job of calling out republican senators when i come to the floor and make these ridiculously false statements and i appreciate that and i think everybody in the country and if they don't they should appreciate what the senator, the junior senator from connecticut has done. house republicans have identified present a bomb is delayed enforcement of employer obligation to the affordable care act as the centerpiece of a frivolous lawsuit. this provision which affects

companies with 50 or more full-time employees insures that employers pay their fair share if their employees receive health subsidies. mr. president the list -- listen to this. the irony of course is that this provision which is in the bill that became law came about as a result the republicans wanted to put it in the bill. senators grassley, senator and see and former senator snowe. this was something they worked on with members to come up with this bill. they have placed it in the bill. it became law. even more absurd is the fact that the republican congress has long targeted this provision of comprehensive immigration, i'm sorry conference of health reform. in fact mr. president just after president obama announced the

delay in the employer provision house republicans voted on legislation to do the exact same thing in delaying the so-called mandate. so they are suing the president of the united states because he did what they wanted him to do, delay the mandate. every word that ioke wrote down in my own handwriting mr. president. that is what they wanted to do. they wanted him to do this and he did it and they sued him for doing what they wanted him to do. they could have applauded him. house republicans are trying something worthy of daytime television of people scored on one of those channels you don't watch very much. a lot of court channels but this would be one that you have to really be desperate to watch or they couldn't -- wouldn't put it on their channel. to sum it up, republicans created an important provision

in the affordable care act. the affordable care act becomes law. republicans vilified the vision they themselves offered that obamacare be delayed. president obama too late -- agrees and the house wants to sue personnel, for delaying the provision. is this weird? is this weird? i can answer my own question. yes, it is weird. this is a behavior we have come to expect from a republican party that is determined to do one thing, undermine this president. no matter the issue. even when i ask them to do it or if they oppose him on it. they are suing him this time and we have seen this so often here in the senate. it's not just the house. last week the republicans filibustered a bill that had 26

republican co-sponsors. that's a new one. more than half of the republican senators put their namn the pill and turned around and voted against it. and with this provision in the health care law house republicans are ignoring the fact that they gave president george w. bush a pass for doing the same exact thing, law. then president bush through executive order which medicare part d penalties for seniors who enrolled after the deadline. he did this by executive order. house republican leadership in the house didn't consider suing president bush for his administration's waving of the health care law so they have chosen now to do this. why? because it's obama. while republicans accuse

president obama of executive overreach they regret the fact that he has issued far fewer executive orders than any president in the past 50 years. president clinton issued 364 executive orders. president reagan's record holder 381 executive orders. obama is not close to their records. he is 109 behind bush. he is 182 behind clinton and 199 behind reagan. what is the president tally today? as i have indicated behind the mall. eight year president. he has issued only 180 to two. the republican disdain for president obama and health care reform has prevented them from accepting obamacare proving more and more successful every day.

it seems like every week, sometimes every other day there is some survey showing how good obamacare is how it is helping american families. mr. president the commonwealth fund. the uninsured rate for people 19 to 64 declined from 20% in july to september 2013, 250% in april to an estimated 9.5 million fewer being uninsured. that's big-time stuff. young men and women drove a large part. the uninsured rate for 19 to 33 euros decline from 20% to 8%. remember when everybody said young people will run from this? they are not running from us. they are running to it. an estimated 5.7 million fewer young adults are uninsured. mr. president that is so

unpredictable. because of the high cost of health care previously young people many of them wouldn't do it. 5.7 million more have signed up for health insurance and what happens? the young people don't realize they get sick also. they get in accidents also. bad things happen to young people as they do middle-aged and older people and younger people mr. president are signing up for obamacare. by june 60% of adults with new cover to the marketplace have visited a doctor or hospital or fill the prescription. 62% said they could not have access to forget this care previously. mr. president that is stunning. it's no wonder, it's no wonder we have fewer and fewer republicans coming down here giving these speeches about the

bad obamacare is. a gallup survey, the united states uninsured rate sinks to 13.4% in the second quarter. that's millions of people mr. president. the united states fell 2.2%. when you have mr. president 300 million people, 2.2% is a lot of people. the previous low point was .4% so was well below that. the rand corporation. changes in health care insurance 2013. overall we estimate 9.3 million more people had health insurance coverage than in march 2014 from 28.5% to 15.8%. stunningly important numbers.

so the evidence, not the shrill statements made from my colleagues about how terrible things are. all of the evidence indicates the affordable care act is helping millions of americans. you can say anything you want mr. president that the facts are nasty things. they are nasty to the point that they are factual. don't believe all these crazy statements when there is no basis for them. it's helping residents in blue states red states and purple states. how about kentucky, the state of kentucky? the state of our public and later. well over 400,000 kentuckians have signed up for the

affordable care act. that's not a state with a population of illinois or new york or california or texas. it's a sparsely populated state mr. president. 400,000 kentuckians have signed up for coverage and even republicans love it. the commonwealth fund that i referred to found that 74% of newly insured republicans are happy with their obamacare health coverage. instead of embracing the good obama has done, i should say obamacare is done to address any necessary fixes republicans would rather file a foolish and meritless lawsuit. is there anyone that believes this lawsuit has some basis? it's a sham. an effort to appease the tea party radicals in the house of representatives. one yale law professor was

questioned why the lawsuit was receiving so much media attention here's what he said. i see this every day now. as if it's somehow not a joke. it's a joke. another law professor from harvard said and i quote the lawsuit will almost certainly fail and it should fail for lack of any congressional standing. just imagine how many lawsuits they would be of house republicans could sue the president every time they disagree with him about something or some future president. there is no reasoning with the radical republicans in the house or the tea party driven members in the united states senate. house republicans would rather waste taxpayer dollars that except the fact that their their constituents their very own neighbors are benefiting from health care reform. mr. president this is a phony trial that will come up. it's a short trial and it's what republicans want. i guess that's what they want

but if that's really what they want they should talk to judge judy. i think she would throw this case out in half a second. the united states congress is no place for quickly motivated litigation and i think judge judy would agree. in this expensive and wasteful waste of taxpayers hard-earned money on something that is without any merit. enough is enough. if idle for obamacare should have long since been ended. the law is here to stay and more importantly newly insured americans all of whom signed up not only those who are newly insured that those who signed up and have insurance before. they want the law to stay just the latest. >> lee joined lawmakers for the veterans affairs committee on veterans and disability claims for veterans. >> the deputy chief of staff detailing the vha 14 day scheduling a standard and arbitrary, to cut the vha needs

to be restructured and lacks transparency or accountability in its management and three, the corrosive culture has led to personal problems highlighting poor management distrust between va employees and management in the history of retaliation in employee issues. employee stated in the letter quote if vha is replaced by vba in 14 days is replaced by zero claims over 125 days and 98% accuracy these excerpts from a report applied equally to the vba end quote. to determine the scope of this statement at the end of last week the committee asked afge to inquire whether employees nationally agreed or disagreed with this sentiment and in less than two days the fast responses were received from 18 regional offices.

not one regional office employee responded in disagreement. in fact 16 agreed unequivocally. let that sink in. vba is still running guns blazing on this questionable path without a real plan, without a real change. so let's begin tonight by reminding everyone again at vba's real mission. it is quote to provide benefits and services to veterans and their families and responsive timely and compassionate manner and quote. you have seen the perverse consequences at the mix metric goals within the veterans health administration and tonight we are going to look at the targets. we will hear what is being done to push claims out the door, out the door at any cost. 125 days and 98% claims based accuracy would be a laudable goal if it were at all realistic. weeks before tonight. we begin asking vba to provide

this committee with information on the research and analysis that was conducted prior to setting the this goal as well as this information on performance standards. vba has declined to provide timely and complete responses and in fact just got an e-mail a couple of hours before this hearing. their purported responses failed to fully answer the questions that have been asked and we are going to discuss that again later. the vba's 2015 goals were outcomes directed by the then secretary of veterans affairs to make progress. they were a call to action and however well-intentioned they have now become a distraction from accomplishing progress. employees have been working for a year on a 20 hour per month mandatory overtime schedule with no end in sight. in fact we know that vba has been ruled out actually increasing the 20 hour overtime

mandate. we will hear from jail later about how 75% of the regional offices that they surveyed have agreements with the local unions that all veterans disability claims work done on this candle burning over overtime shall be exempt from any quality review. i look forward to hearing from vba on how that's being sold as a veteran friendly platform. essentially it's the equivalent of saying just make a decision and we will hope that the veteran does not appeal. chronic incidence of unchecked vindictive management within many of the regional offices to be honest expert input at vba employees has been silenced, ignored and at times punished. i am told the performance requirements on production and actors he had been westernized if you will to keep vba

employees and check. to what and? it's certainly not in the name of service to americans veterans. it is instead to create an appearance of success. just as vha attempted to do by cooking the books on schedule times in our vacations involving disease. the va office of inspector general will testify to the potential over $1.3 billion in improper payments. all claims that were two years old or older to be created within 60 days introduced a scheme called provisional ratings. this was another hard and fast deadline dictated by central office and vba promise don't worry, would you will get them done right. they won't be going out the door without service treatment records without medical exams if that's necessary.

so what was found at the regional office? guidance that read and i quote the new vba exam request will have a negative impact on our ability to meet the goal that has been mandated by her leadership" map. so vba employees were directed to move forward even if a medical exam was necessary to decide these aging claims. contained in the guidance and i ask you to look at the screen and members you should have this at your desk, i quote from an e-mail where it says i understand this may be difficult to do. it may appear to go against the values of how we do work" map. quote i want to assure you that and here it is typed in boldface, there will be no negative consequences for you. the employees as a result of

following this guidance. the only possible negative consequences are those that exist if we fail to meet our goals for this project and for for any access that keeps us from doing so end quote. va oig support issued earlier today found that regional office staff and correctly processed 83% of the provisional rating decisions that were reviewed. who was paying the price for vba's self defined success? there are roughly 280,000 veterans languishing in three, four and five years of an appellate backlog and nearly 240,000 veterans waiting on their dependency award adjustments. we then have a complicated case, the old cases which were lost and subsequently found under a

contrived and disingenuous interpretation of epa's guidance at may 20 and 2013. even more egregious vba has recently put out guidance to the regional offices that unless a veteran puts specific words on their claim form a form that doesn't provide any comment that the claim condition has existed, that the claim condition has existed quote since service and a medical exam will not be ordered and the claim will be denied. denied. robert gates former secretary of defense recently released his memoir incorporated title duty which he dedicated to the men and the women of united states armed forces. he writes about the va and his feelings as former va secretary. the secretary notes i was staggered when he said the department wasn't was in good

shape and had no problems and he continued i have been around long enough to know that one of the head of the department says the organization has no problems he is either lying or he's delusional. so i will close my remarks by speaking to vba directly. whatever when you attempt to take credit for in 2015 you will not be celebrated. it has been clear that there is not a leadership that will not cut nor statistic that they will not manipulate to lay claim to a hollow victory. what we all want to see both my republican and democratic colleagues on this committee is progress, not deception. with that i now recognize the ranking member for his opening statement. >> thank you very much mr. chairman for having this hearing this evening.

tonight we will have an opportunity to continue an important discussion we have touched upon in several of our previous oversight hearings. veterans benefits administration and their progress in reaching goals related to the claims backlog. the scandals at the veterans health administration weighing heavily on us tonight the committee wants to assess the current state of play at the vba, the agency appears to be making some progress on its goals of the lemonade claims backlogs by the end of 2015. i do however have concerns in the va oig shares the concern that the resources needed to achieve va's backlogged goals are being directed and applied disproportionately ultimately harming other veteran services. i refer in particular to nonreading workload benefits delivery at discharge

independent disability of valuation system and appeals to name a few. we have heard over and over again of the dangers and failures of a system geared towards defining success based on narrow fixed metrics. then as now -- not how good customer services deliver. that is not our veterans perceive success and why should they? what good is it for a veteran if vba process his or her rating in an unacceptable period of time that then takes years to add a dependent? from july 2010 to july 2014 the number of backlogged dependency claims cases has gone from 9367 to 192,322. this represents a nearly 2000% increase. since march of last year the number of pending appeals has

gone up 12% and continues to increase. there are personnel issues as well. we have heard reports of an unacceptable practices and challenges that many va facilities. at the baltimore va regional office that oig found as many as 9000500 documents including claims, claims related mail and other various documents contained personal identifiable information. lacks measures and practices with records to veterans personal information is simply unacceptable. again, to me this is the focus on narrow performance measures are not realistic for defining success. veterans to find a good timely care and services on their whole experience from start to finish. that is what makes sense to read it as something we today's

hearing and in the larger term as we continue on our important work to reform the va. the department of veterans affairs cannot morally claim success in delivering medicare to our veterans if the progress has come at the expense of delivering other key services to veterans in a timely manner. this work takes an increased urgency as more and more veterans are coming home from service abroad and operation iraqi freedom and operation enduring freedom. to fix the current shortcomings in the delivery of service we need all of the facts and we need honesty, frank discussions. that is what i'm hoping to get out of tonight's hearing because if we do not base our form efforts based upon what is realistically achievable and what the facts are we are saying the department of veterans affairs race and and more

importantly our veterans opt for failure down the road once again. i think we can all agree that this is not an option. so tonight mr. chairman i appreciate you calling this hearing because he gives us a chance to take a hard look at what vba needs to do to ensure that it provides the workforce with the training and tools needed to deliver timely and accurate benefits to our nation's veterans and their families and all the areas of their responsibilities. i want to thank you mr. chairman and i yield back the balance of my time. ..

>> officer of the inspector general. ms. halliday is accompanied by brent arronte director of san

diego division. and then allyson hickey and she is accompanied by dianne rubens who is the former deputy for field operation and thomas murphy and we will hear from the director of education awork' force and accountability office. i will yield to the colleagues for a brief introduction of our first witness. >> i would like to introduce ms. kristen ruell. she is a law school graduate and practicing attorney in pennsylvania. she works as a quality review

specialist at the philadelphia regional office that serves hundreds of thousands in the community and throughout the country. she is a strong supporter of veterans and have been reporting various types of data manipuilation to anyone who would listen to her. she was frustrated in 2012 that the va wasn't responsive and reached out to my office for help. i was inspired and honored to work with her to get to the bottom of this. she will tell her story of what can be described as no less than gross mismanagement at the philadelphia office. i appreciate her doing so. >> thank you very much. we appreciate you being here to

introduce the panel. i would ask the panel to raise their right hand. do you swear the testimony you are about to provide is the truth, the whole truth and nothing but the truth? thank you. you can see seated. ms. ruell, you are recognized for five minutes. >> my name is kristen ruell and i have worked for the department of veterans affairs. i work at the philadelphia regional office an authorization director. i poses a law degree. mr. chairman, community members, veterans and guest, i have been identified as a whistle blower. i started reporting glitches in the vet system, the system responsible for paying out va benefits since july of 2010. i discussed what i saw as

mismanagement at the filled office and raised issues but not limited to the improper sledding of mail, beneficiary receiving inappropriate payments, data manipulate and other various misreadings of the law. i have been targed by the the va despite the fact aig confirmed these reflections. the va's problem with a result of managers who have the power to and continue to ruin people's lives. i can speak from experience. i do not believe in manipulate the data while harming the veterans and survivors. the va listed fast letter 2010 and a simple reading established

the claims would be few and far between and to qualify for a new data claim, rather than using the date when the claim was discovered, it had to be undiscovered and put in a memo folder. upon completion of the claim, an e-mail was sent to the office and understanding the claims and why it would have an alter newer date. it was supposed to be tracked by a flash and this fast letter was a solution to solving the problem with the back log. philadelphia took the letter to mean they could change the dates of claim on every claim older than six weeks old regardless of the circumstances. when investigated, the managers pled ignorance.

a veteran should have a date of claim in 2009 but instead they used the date of claim of 2014 appearing it to be new and they have a new priorty claim it it will not show up on reports for claims pending longer than 120 days. i have been suspended because i was unable to work overtime and by management. no one else was given that severe of a punishment for such behavior. i wasn't given a job that i was qualified and i was followed around by management, i was accused of slander and lied to

many times. my name was reported to the people i turned in and my car was dented and there was coffee all over my car. i have no proof who did it but i don't put it past the workers there. i contacted numbers thinking i was doing something the department of veterans would appreciates. the management nor the central office had any interest in hearing about the problems at the agency regarding the extend. i whistle blew when i realized it could be in the millions. what i thought was happening the taxpayer and the veterans and the beginning of a horrible nightmare i have been living. i know the va covers up to gain

bonus and target anyone that steps in the way. many employees were depressed and upon seeing me stick up others began to tell me horror stories. i now spend free time representing the employees who have been treated poorly. the people that serve the country and the employees that serve them deserve more respect than the veterans affair is giving. the agency is unable to police themselves and operating out of control at the veteran's expense. the requirements placed on employe employees have required them to decide what is right and wrong. they are bullied into doing thick things they are doing. they make unattainable goals set by people that don't progress

claims. i will be available by e-mail to answer any questions i have experienced and welcome the community to meet with anyone who is interested in fixing the problem. >> thank you very much, ms. ruell. mr. robinson you are recognized. >> good afternoon chairman, ranking member and members of the community. on behalf of my comrades and employees thank you for the opportunity to discuss the evaluation of administrations goal that was established in 2009 by eric shinseki and had 125 days at a complete and 98% claims accuracy. serving veterans shouldn't be about unclaimed goals but how can we serve them better? it has been proven that setting

unrealistic and unplanned goals with long-term targets without short and immediate targets to validate effectiveness is a disaster. acting secretary gibson visited and it was refreshing to hear the top leaders say it isn't abo about matt but it is about building trust one veteran at a time. he addressed transparency, accountability, retaliation of employees. he acknowledged it was his job to create conditions for employees to be successful. he is setting the tone for changing the culture for lack of accountability and retaliation and va talking points.

in october 1995 when i arrived at the columbia vro as a work study there was a poster in the hall on the hallway that read making a difference with accountability, integrity and i was impressed and embarked on the journey to make it a reality. in february of 2013 i visited the hauls and the same paper was there but the words on paper are meaningless without corresponding. this is a service organization created to serve veterans, widows and orphans. we serve those who made the ultimate sacrifice and seen horrific acts of war and need

comfort, those who have been mentally and physically disabled and need health care. those who are homeless and need support and shelter. those thinking about suicide and need a lifeline and all of the authoritys who have honorable and faithfully served our country. this is about serving those who served and the va providing the leadership and the tools in creating an environment for employees that are conducive to providi providing accuracy and timely decisions to our customers, veterans, survivors and their families. when unrealistic goals throw out leaders to throw out common sense and analysis out of the window it is time for a reassessment and shift the focus back on our own mission. to care for those who owned the

battle and his widow and orphan. president roosevelt on the day he signed the gi bill stated the members of the armed forced have been compelled to make greater economic sacrifice and every other kind of sacrifice for the rest of us. and they are entitled to definite action to help take care of their special problems. ladies and gentlemen of this committee, i served 20 years serving this country.

we need tools to do our jobs. we need to be lifted up. not pulled down. and this is done not by anybody else but the failed leadership of our organization. it is our organization as well. >> mr. soto, you are recognized for five minutes. >> i thank the chairman, ranking member and esteemed members of the community for the opportunity to be here. my statement relates to my experience at the saint petersburg florida regional office which i will refer to at st. pete. the problems, in may opinion,