vote:

the presiding officer: does any senator wish to vote or change his vote? if not the yeas are 91. the nays are 4. the bill is passed. mr. hatch: mr. president? the presiding officer: the senator from utah. mr. president, as you may have heard, today marks the 50th anniversary of medicare and medicaid s. while the last half century we've seen a pretty robust debate about the merits of these programs, today there is no question that they provide significant and vital elements to our nation's safety net. this week many are celebrating the lives that have been saved and improved by medicare and

medicaid. over the last 50 years. and while this is appropriate i hope that we will also take the time to look at how these programs will function over the next 50 years. let's start with medicare. medicare is quite simply a massive program designed to provide care to our nation's seniors. currently it covers more than 50 million beneficiaries roughly one-sixth of the current u.s. population and processes more than a billion claims a year. last week the medicare board of trustees issued its report four 2015 which once again detailed the fiscal challenges facing the medicare program. for example in 2014 alone we spent roughly $613 billion on medicare expenditures. that is roughly 14% of the federal budget and 3.5% of our gross domestic product for a single health care program. and in coming years these

numbers are only going to go up as more baby boomers retire and become medicare beneficiaries. over the next ten years the trustees project that the number of medicare beneficiaries will expand by 30%. we'll spend roughly $7 trillion on the program as it expands and by the end of that ten-year period we will be spending more on medicaid than on our entire national defense. # over the next 25 years spending on the program as a percentage of g.d.p. will grow by 0 60% and by 2040, about one out of every d 5$5 by the government will go towards medicare. using the centers for medicare and medicaid services most realistic projections -- remember these are the agencies of government -- medicare part-a

by itself faces long-term unfunded liabilities of nearly $8 trillion. the story is even worse with medicare part-b and part-d which do not have a dedicated revenue stream. $24.8 trillion is estimated in additional taxes that will need to be collected over the next 75 years to pay for medicare part-b and part-d services. when you look at the entire medicare program over the next 75 years once again using c.m.s.'s most accurate projections, you're looking at $37 trillion of spending in excess of dedicated revenues. those numbers are astronomical mr. president. they are really too large to even comprehend. so rather than talk about the numbers in broad terms let's talk about what they mean for seniors and beneficiaries.

as i mentioned medicare part-a, which includes the hospital insurance or h.i. program has a dedicated funding stream. it is paid for by a 2.9% payroll tax split between employers and workers. and under obamacare that rate wnts upwent up by an additional 0.9% for single-tax filers and $250,000 for married couples. part-a ran a deficit meaning expenditures for the program exceeded income from the tax every year between 2008 and 2014. last year that deficit reached $8.1 billion just in one year. because of the economic recovery and the increased tax rates part-a is projected to generate surpluses between 2015 and 2023. however, after that, deficits

are projected to return and by 2030 the part-a trust fund will efficientlily be bankrupt and the medicare program will be unable to pay full benefits to seniors. let me say that again. in 15 years medicare part-a will be bankrupt. all of this, of course, assumes that current law remains unchanged and congress is unable to reform the program. i don't think i'd be going too far out on a limb to suggest that real estate forms to medicare -- reforms to medicare are absolutely necessary if we're going to preserve the program for future generations. furthermore, i don't think it would be outlandish to suggest that congress should begin working on such reforms immediately to avoid future cliff standoffscliffs standoffs and the usually political brinkmansship. the medicare trustees they have selves said in last week's report that -- quote -- "medicare still faces the

substantial financial shortfall that will need to be addressed with further legislation. such legislation should be enacted sooner rather than later to minimize the impact on beneficiaries, providers and taxpayers" -- unquote. now, these are not the words of fiscal hawks in the republican congress mr. president. the medicare board of trustees is comprised of six members four of whom are high-ranking officials in the obama administration including jam lew, perez sylvia burwell and carolyn culver. all of these officials signed on to a report recommending further -- quote -- "-- -- quote -- "further legislation" to reform medicare and suggesting that it happened -- quote -- "sooner rather than later." unquote. let's keep in mind that we're only talking about medicare here. i haven't said anything yet

about medicaid, our other health care entitlement program which also faces enormous fiscal challenges. currently medicaid covers more than 70 million patients, and that number is growing thanks to expansions and maked under the so-called -- mandated under the so-called. more than a dozen states have chosen to expand their medicaid programs and he rollments have cornelled. this has a number of people worried about added a costs and additional strains on state budgets particularly when the federal share of the expanded program is sent to scale -- set to scale back in two years. already without the expansion under obamacare medicaid took up nearly one-quarter of all state budgets. that's right nearly one out of every $4 spent on the state level goes to medicaid and that number is going to get much higher.

in recent years combined federal and state medicaid spending has come in around d 450 billion a year. by 2020, that number is projected to expand to around $$800 billion a year or more. with all of this expansion the increased fiscal burden and instability, we're not seeing improvements in care provided by the program. put sumly medicaid is probably the worst health insurance in the country and the president's health care law did nothing to improve the quality of care provided by the program. fewer and fewer doctors accept medicaid because it pays them so little. and the program's reimbursement formulas for prescription drugs limit beneficiaries access to autumnanumber of important medications. we're going to be spending more and more on medicaid in the coming years and as a result

expanding our debts and deficits. without providing better care for beneficiaries. between medicare and medicaid, we'll spend more than $12 trillion over the next decade with precious few improvements to show for it. former c.b.o. director doug elmendorf referred to these two programs as -- quote -- "our fundamental fiscal challenge." and if you look at the numbers and the dramatic expansion projected in the coming years he was right. and, keep in mind, we still have social security which faces nearly $11 billion in unfunded liabilities over the long-term as well as the exhaustion of one of its trust funds the disability trust fund, by the end of next year and complete exhaustion by 2034. these three major entitlement programs present unique challenges that have to be

addressed in order to preserve them. and our nation's safety net for future generations. combine to swallow up our government and take our economy down with it. once again these aren't doomsday scenarios mr. president. no one disputes the fact that lasting and real reforms our entitlement programs present real threats to our fiscal well-being. the disputes typically arise when we begin talking about the specifics of reform. some would just assume use it as a political weapon to scare current and future beneficiaries into believing that the other side wants to take their benefits away. others support the idea of entitlement reform in principle but are too afraid to sign on to any specific proposals out of fear that it will be used against them in the next election cycle.

this dynamic has resulted in a long-standing stalemate where the possibility of real reform has for years now -- for years now seemed remote. however, recently we've seen signs that it may in fact be possible to overcome this stalemate. earlier this year congress passed the medicare access and chip reauthorization act of 2015 a bipartisan bill that, among other things, repealed and replaced the medicare sustainable growth rate, or s.g.r. formula. now repealing s.g.r. was in and of itself a significant improvement to the medicare program, but there are other medicare reforms in the law as well. these include a limitation on so-called medigap first-dollar coverage and more robust means of testing for medicare part-b and part-d. these aren't fundamental medicare reforms and they won't move the program from its

massive projection projected deficits into future solvency. but keep in mind, mr. president that for years the idea of bipartisan medicare reforms seemed like a pipe dream. right with passage of the s.g.r. bill, we were able to take a meaningful first step towards this all-important goal. of course, a first step is only a first step, if it precedes additional steps. and that's what we need now. mr. president, congress must take additional steps to improve these programs and preserve them for our children and grandchildren. as the chairman of the committee with jurisdiction over these programs, i have been actively engainled in the effort -- engaged in the effort to reform our entitlement programs. in 2014 when i was still the ranking member, i put forward five separate proposals to reform medicare and medicaid. all of them were serious commonsense ideas that had received bipartisan support in

the recent past. i shared these ideas at every opportunity. i put out documents and fact sheets and faff fact sheets and gave numerous speeches on the floor. i even directly passed them along to president obama. two of those ideas were at least partially included in the legislation we've passed to repeal s.g.r. the other three ideas as far as i'm concerned with still on the table. i've also teamed up with leaders in the house to call on the disability community and other stakeholders to help us come up with ideas to address the intendedimpending exhaustion of the trust fund, and i've introduced legislation to improve the integrity of the disability snrurns program. in other words mr. president i stand ready and willing to work with any of my colleagues from either party or from either chamber to address the coming entitlement crisis before it is too late.

i've put my own ideas on the table, but i don't think the debate should be limited to my ideas. i invite all myself colleagues to come -- i invite all of my colleagues to come together so we can work together to find solutions to these massive problems. i know that when i think about these problems, my thoughts turn to my 23 grandchildren and 16 great-grandchildren. who will suffer from any promises we fail to keep, who will pay the price of any mistakes we fail to correct -- and everybody else's grandchildren and great-grandchildren. on this landmark anniversary of the medicare program i urge my colleagues to also consider future generations of americans and the costs and burdens that we are passing on to them if we fail in this endeavor. with that, mr. president, i suggest the absence of a quorum. the presiding officer: the clerk will call the roll.

quorum call:

quorum call:

quorum call:

sulaymaniyahmr. sullivan: mr. president? the presiding officer: the senator from alaska. mr. sullivan: i ask unanimous consent to vitiate the quorum call. the presiding officer: without objection. mr. sullivan: i rise to speak about the iran nuclear agreement, and i wanted to begin by saying, there seems to be, as we debate this as we as we hold hearings a growing sense of frustration as we do what is really our sacred duty here in the united states senate to review this agreement to debate this agreement and ultimately

to vote on this agreement whether it is something that's going it keep our country secure our undermine the national security of the united states and our allies. and this frustration stems from a number of sources but let me just name a few. first, as i think many democrats and republicans feel that there's been a dismissive attitude from the administration with regard to this agreement a dismissive attitude actually toward the american people on whether the united states congress should weigh in on this agreement, should represent their constituents on something that's this important to the national security of the united states of america. and i mention this because if you look at the last several

months every step of the way the administration has tried to cut out the role of the congress. initially they said, executive agreement -- congress, you're going to have no role, no role. well, i don't think our constituents like that. certainly the united states senate sincesenate didn't like that. so we started reviewing the review act. the president said he was going to veto that. again, dismissive of this body and the american people. fortunately, this body had a very strong veto-proof majority, so we're debating it, but not because they wanted us to debate it; because we're representing our constituents who know how important this is. the agreement is taken to the united nations before we weigh in on it at all. members of the united nations citizens from other countries

voting on this agreement before we had the opportunity. again, bipartisan -- democrats republicans. mr. president, secretary kerry don't do that. that's an affront to the american people. but they did it. so we're debating it, and that's important. but that attitude of dismissiveness of this body and the people we represent is frustrating. mr. president, there's a second reason there is a frustration in the senate and it stems from the fact that we -- we're not sure that we're getting the straight scoop. we're not sure that we're getting all the documents. the law now requires every document related to this agreement to come before this body and yet we find out two weeks ago that there's a very important agreement the

agreement between the iaea and iran on implementation of this agreement. how did we find out about that? one of my colleagues, senator cotton got on a plane went to iaea headquarters in vienna. he found that out. again, frustration. we're not having all the documents, as required by law to be able to review. and, third mr. president in terms of frustration, there is a sense that as we are doing our duty here, as we are digging into this agreement as we are reading it, as we are reaching out to experts as we are trying to understand it, as we are questioning administration witnesses at hearings, as we're doing our required and sacred due diligence we're told time

and again that the plain language of the agreement doesn't appear to mean what it means. and this is frustrating. and this is particularly true with regard to sanctions. so let me give you a few examples. first, we had a closed briefing. almost every member of the senate came to that briefing a couple weeks ago and there was a big question. was there a grandfather provision with regard to sanctions? meaning, if you are a company and you rush to iran right now and cut some deals and sanctions are later imposed the mere fact that you jumped in early, are you grandfathered away from these sanctions? well a lot of people had questions. secretary of state looked at 100 members of the united states senate and said, there is no grandfather clause in this agreement. there's no grandfather clause in

this agreement. mr. president, this is paragraph 37 of the agreement. and i am just going to quote it. because it certainly sounds like a grandfather clause to me. "in such event that sanctions are reimposed these provisions" -- in this paragraph -- "would not apply with retroactive effect to contracts signed between any party and iran or iranian individuals and entities prior to the date of application application." that's when the agreement starts to be implemented. so that sounds like a

grandfather clause. now maybe there's elements here, maybe there's special circumstances that make it not a grandfather clause, but the secretary of state was in front of all of us saying, there's no grandfather clause. it's hard to square that with the plain language of this agreement. let me give you another example mr. president. the much-touted "snapback" provision in the agreement. secretary le wmplet, lew the secretary of the treasury, has talked about how we have a strong snapback provision. these are terms that he has been using in testimony. in many ways i think members of this body, democrats and republicans, see the effectiveness of this entire deal might hinge on this so-called "snapback" provision.

but the more i read about our sanctions and how they work in this agreement the more questions i have. because, mr. president to me the snapback provision seems to be an i illusion. it actually seems to be aimed back at the united states. i don't think we should be calling it a snapback provision. maybe it should be called the boomerang provision because it is aimed at us. let me talk a little bit more in detail about it. -- about this. first the term snapback is not in the agreement. it is a good term. it is catchy. sounds good. it's actually a term used in trade negotiations. when a party violates a trade agreement, trade agreements will have snapback provisions where we raise tariffs on goods immediately. that is a snapback.

but that's not what's going on here. that's not what's going to happen here. the practical reality of sanctions, particularly economic sanctions, is that there's no snap when you put them in. it's a slog. let me give you an example. in my experience, mr. president i worked with many people at the beginning of our efforts in the bush administration in 2006, 2007 2008 to start economically isolating iran. what does that mean? well what we did we leveraged the power of the united states economy in close coordination with the congress of the united states and we went to countries and companies that were big investors in iran -- say in the oil and gas sector -- and we

told them that they needed to start divesting out of the largest sponsor of terrorism in the world or the congress of the united states might look to sanction their company or limit their access to the american market. we were leveraging the authority of the congress and the power of our economy to get countries -- yes, many of whom were our allies: norway, germany france, japan -- to divest and economically isolate iran. mr. president, that took months. that took years. it was a slog. there was no snap. so what do we see today? european companies -- it's in the paper every day european

c.e.o.'s -- i believe senior administration officials in germany, government officials are already in tehran already. companies looking to set up shop looking to invest billions as they did before. they're there now. this deal isn't even done yet and they're there. they can't wait, licking their clock to reinvest in one of the -- not one of the biggest the biggest terrorist regime in the world. to kill more americans than probably any country in the world in the last 30 years. of course this is disappointing but this history is a reminder to all of us that the sanctions regime that secretary kerry talks about that we certainly did have iran surrounded in terms of sanctions that was

110% american-led sanctions regime. democrats, republicans this congress the bush administration and yes a lot of credit to the obama administration on this economic isolation of iran. which is what brought them to the table to begin with. so if we reimpose sanctions there certainly won't be a snap when it happens. it will be slow. it will be a slog again trying to convince reluctant europeans, russians, chinese to pull out of the market once again. but finally mr. president i just want to say one other thing and it goes again back to the plain language of the agreement. we're -- the snapback provision, the so-called snapback provision seems aimed

at us, the boomer rang provision. i've posed a hypothetical to secretary kerry, secretary lew in a closed session to try to get specifics on what would happen in certain situations. so i gave them this hypothetical. let's assume sanctions are lifted in the next six to nine months. these are called annex two sanctions. it is a huge list of sanctions. the most powerful sanctions that our country has placed on iran, all of them, financial oil market. they're going to be lifted six to nine months. let's assume that happens. as we're already seeing european companies other countries, certainly chinese, russian japanese are going to be rushing into this market. investing billions once again.

assume the iranian economy is going to start humming with all this new investment, the lifting of sanctions a senior iranian official said they're looking for $120 billion of new investment by 2020. and they're likely going to get a lot of it. and they're abiding by the deal. no violations of any of the nuclear aspects of this deal. and then what i think is very likely, sometime in the next three, four, five, six seven years iran commits a major act of terrorism. let's say they kill more american troops. let's say they blow up a consulate, an embassy somewhere. they are the world's largest state sponsor of terrorism and it doesn't look like they want to do anything but continue to do that. that's a very likely scenario. when that happens this body

reapplies sanctions. it looks at annex two some of our most powerful sanctions we are very upset bipartisan, we reapply sanctions, the president, whoever that is signs it, because that president he or she is very upset and we reimpose serious annex two sanctions. now, what happens then? well i think what's going to happen very likely at that point is iran is going to look at this agreement and they're going to cite either paragraph 26 or paragraph 37. let me read you both of those. again, this is the plain language of the statute.

paragraph 37. iran has stated that if sanctions are reinstated in whole or in part, iran will treat that as grounds to cease performing its commitments under the entire agreement. another provision. iran has stated that it will treat the reintroduction or re reimposition of the sanctions specified in annex 2 as grounds to cease performing its commitments under the agreement. that's in the agreement. see you see mr. president if we reimpose sanctions as part of the snapback, iran can look at this agreement and say i'm done

done i'm walking. i can legally leave this agreement. they can legally leave this agreement with a humming economy, on the verge of a breakout of a nuclear weapon, still being the largest state sponsor of terrorism and they can say hey i complied with the agreement. the united states reimposed sanctions, i told them what i was going to do, and they do it. so again the bottom line, if we use the so-called snapback provision, it certainly appears from the language of this agreement that the deal is done. so i've asked secretary kerry and secretary lew twice now how is that an improper reading of the agreement?

secretary lew, secretary of the treasury he's trying to argue we're reading that language wrong. he says annex 2 sanctions the big american sanctions that are really what's kept iran down and what's brought them to the table, they can be reimposed if they're reimposed for nonnuclear violations, like terrorism. well, when i read this agreement it seems to be a bit of a stretch. certainly there's a lot of ambiguity. but it's also clear that the iranians clearly won't agree with that reading. they don't agree with that reading. mr. president, this was filed and i ask unanimous consent to submit it for the record. the presiding officer: without objection. mr. sullivan: this is the iranian record dated 20 july, 2015 to the united nations security council. and it's their interpretation of

the agreement. you want to know what the iranians say about the reimposition of so-called snapback sanctions? here's what they say. quote -- "it is clearly spelled out in the agreement that both the european union and the united states will refrain from reintroducing or reimposing the sanctions -- now they're talking about annex 2 sanctions -- in restrictive measures lifted under the agreement. it is understood that reintroduction or reimposition, including through extension of the sanctions and restrictive measures will constitute significant nonperformance which would relieve iran from its commitments in whole or in part of this agreement.

my colleague senator ayotte from new hampshire yesterday asked secretary kerry and secretary lew about this provision. they didn't give a clear answer. because there is no clear answer. right now there's huge disagreement between the united states and iran and the language in the agreement on whether what the snapback -- so-called snapback provisions will work or will undermine our national security interests. which is what i believe they will do. so i've asked the administration to quit using that term. it's not in the agreement the language makes clear that it's going to take years -- there's no snap -- and that if we ever use it, that's it for the agreement. and they've not given the

members of this body a straightforward answer on that issue. so mr. president, we need to keep asking these kind of questions. we need to keep doing our due diligence but we need clarity. the american people need clarity, not spin. on critical issues such as the side aiaea agreement which nobody seems to have read and we certainly haven't seen, the grandfather claws which certainly looks like a grandfather clause which now we're told by secretary kerry is not a grandfather clause and perhaps most positively this so-called snapback provision which i believe is illusory and is aimed at us, not at the pariah state that we're all concerned about and that's iran. mr. president, i yield the floor.

the presiding officer: the senator from maine. ms. collins: mr. president, i ask unanimous consent that the senator from delaware, senator coons, and i be permitted to proceed as if in morning business. the presiding officer: without objection. ms. collins: mr. president i send a bill to the desk on behalf of myself and senator coons and ask that it be appropriately referred. the presiding officer: the bill will be received and appropriately referred. ms. collins: thank you mr. president. mr. president, today i'm very pleased to be joined by my colleague from delaware, senator chris coons in introducing the reach every mother and child act of 2015. the purpose of our bill is to improve the health and

well-being of women and children in developing countries. mr. president, every day approximately 800 women will die from preventable causes related to pregnancy and child birth. in addition, more than 17,000 children under the age of 5 will die each day of treatable conditions such as prematurity pneumonia and diarrhea, with malnutrition being the underlying cause in nearly half those deaths. while progress has been made in improving the health of mothers and their children, it is a tragedy that so many preventable deaths still occur especially

given that there are many effective and established lifesaving maternal and child health protocols and policies. these lifesaving interventions include clean birthing practices, vaccines, nutritional supplements hand washing with soap, and other basic needs that remain illusive for far too many women and children in developing countries. our legislation would strengthen the american government commitment to ending preventable deaths of mothers newborns, and young children in the developing world. there are simple proven and cost-effective interventions we know will work if we can reach

the mothers and children who need them to survive. our bill will also allow us to leverage greater investments from other parties especially the private sector, partner governments, private foundations, and multinational organizations. according to usaid a concentrated effort could end preventable maternal and child deaths worldwide by the year 2035. however, u.s. leadership and support of the international community are critical to meeting this goal. the u.s. agency for international development usaid, has set an ambitious interim goal of preventing the deaths of 15 million children

and 600,000 women in the next five years to ensure steadfast progress toward that ultimate goal. due in part to american leadership and generosity many lives have already been saved. since 1990, the annual number of deaths of children under the age of 5 has been cut in half. nevertheless mr. president far too many mothers newborns and young children under the age of 5 still succumb to disease and malnutrition that could easily be prevented. the deployment of intervention that is have been proven to be successful must be accelerated. our bill would require the administration to develop a

ten-year strategy to achieve the goal of preventing these deaths by the year 2035. our bill would charge usaid with meeting that goal. one provision of our bill would establish a maternal and child survival coordinator at usaid who would focus on implementing the ten-year strategy and verifying that the most effective interventions are scaled up in target countries. our bill would also establish an interagency working group to assist the coordinator in promoting greater collaboration among all the federal agencies involved in this effort. to promote transparency and greater accountability, our bill requires that detailed reporting be published on the foreign assistance dashboard where it

can be assessed by the public, congress and nongovernmental organizations to track the implementation of the strategy and the progress being made. finally, the united states cannot and should not take on the goal of eradicating these preventable deaths alone. our bill recognizes this reality and requires the administration to develop a financing framework which would allow the use of u.s. government dollars to leverage additional commitments from the private sector, nonprofit organizations partner countries and multinational organizations. as other investments grow, the need for u.s. government assistance would decline. mr. president, at a time that we must make very difficult

decisions regarding federal priorities and our budget, this is an important and responsible provision that ultimately will reduce the reliance on u.s. government contributions. improving the health and well-being of mothers and children around the world has far-reaching social and economic benefits as well. an independent group of economists and global health experts from around the world known as the lancet commission, has indicated that the return on investment in global health initiatives is very high. in fact, for every dollar that you invest, there is a return of $9 to $20 in growing the gross domestic product of the country

receiving the investment. other global health initiatives such as the successful president's emergency plan for aids relief or pepfar which was started by president george bush demonstrates that results-driven interventions can turn the tide for global health challenges like maternal and child survival. taking lessons learned from past initiatives our bill would provide the focus and the tools necessary to accelerate progress toward ending preventable maternal and child deaths. i urge my colleagues to take a close look at the bill we're introducing today and to join senator coons and me in

supporting this bill to save the lives of mothers and children around the world. thank you mr. president. a senator: mr. president? the presiding officer: the senator from delaware. mr. coons: mr. president i join my colleague from maine on the floor this afternoon to talk together about what it is we can do to save the lives of newborn children and their mothers in some of the poorest communities around our globe. i'd like to start by thanking senator collins for her impressive leadership and for the energy that she has brought to this work. i share her belief that our bipartisan bill called the reach every mother and child act or just the reach act will go a long way towards eliminating preventable maternal and child deaths and will do so in an impressively targeted and cost-effective way. mr. president, the preventable death of newborns, their mothers and children under 5 is a genuine tragedy that remains a widespread reality in far too many places around our world

today. as senator collins has just said 17,000 children a day lose their lives to preventable diseases like pneumonia diarrhea and malaria. illnesses we know how to not just treat but prevent and three million children will lose their lives due to malnutrition worldwide this year. nearly three million newborns die every year, one million of whom don't live to their second day. and 300,000 women don't get to experience the joy of raising their child as either pregnancy or giving birth takes their lives. i doubt it would come as any surprise to those in this chamber today that it's the families that are living in the poorest communities in the developing world that are most at risk, so what brings senator collins and me to the floor today is the fact that there are things we can do to prevent these deaths from ever happening and to do so in a cost-effective and transparent way. mr. president, since i first entered office, i have been confronted here with challenges

both at home and around the world that demand our action but where real solutions remain out of the reach of this senate or our government. this is not one of those issues. some doubt that we can make a lasting and meaningful impact on the poorest of the poor in the developing world but the fact is we have made real progress. it was time spent in east africa 30 years ago that first really changed my life and engaged me passionately in these issues, and what's striking is how much progress we have actually made. over the past 25 years, we have cut in half the number of children and mothers who die -- the number of children under 5 and mothers who die in illnesses associated with childbirth. mortality rates are now declining faster than ever, and while we do face real and seemingly intractable challenges across the international development landscape our progress on this issue remains a

real telling sign of what's possible when we pull together and apply thoughtful interventions. just last year, the administration took an important next step in laying out a new strategy with ambitious goals saving the lives of 15 million children and 600,000 women by the end of this decade. think about the scope and reach of the change that would mean for families and for communities in some of the poorest places on this planet. these goals are based in the lessons we've learned about what really works. providing neonatal care to expecting mothers works. vaccinating young children works. providing access to clean water so that children don't die from diarrhea works. providing h.i.v. positive mothers with antiviral drugs works. why i am -- while i am -- why i am hopeful about finding competitive remedies to these problems is because many of

these solutions are things we take for granted on things that work here in our own country. in the u.s. what would be a fairly routine complication of childbirth would in many communities in the developing world be a life or death situation. for example let me talk for a moment about something called a resuscitation bag a simple piece of plastic that costs just a few dollars. most american parents have either seen one used or ready to be used in the delivery room. we know that in an american hospital -- or really it should be the hospital of any developed country, when a nurse needs a resuscitation bag for a newborn who is struggling to breathe it's right there and waiting. but in the poorest communities where newborns are losing their lives at astounding rates the significant factor is the simple absence of these bags to save the lives of newborns. when a nurse if there even is a nurse reaches for one there's none to be found. and yet these simple devices that cost just a few dollars can save literally hundreds or thousands of lives. so what our bipartisan reach act

does is recognize that many of the steps we can take are very much within our grasp and our bill would take these solutions a step further by reforming them and scaling them up so they have a larger, longer term impact. our bill would increase coordination to better implement u.s. strategies with the goal of ending preventable maternal newborn and child deaths within 20 years. it would build new partnerships with the private sector and improve coordination across agencies and insist on real targets and transparent and measurable progress. it also would as senator collins referenced, allow u.s. government dollars to be leveraged. and i love it when we leverage our resources. with the private sector, with multilateral donors, and with our partner countries in the developing world. critically it would focus on the most effective interventions and in the poorest most vulnerable communities and put in place targets that can be effectively tracked. mr. president, these communities in the poorest parts of our

planet face many challenges, but when it comes to saving the lives of mothers and their young children, we know exactly what it will take to make a meaningful difference, and today together we're offering a strong path forward. so i want to close by urging my colleagues to follow the real leadership of senator collins and to join both of us in ensuring that american ingenuity and leadership can continue to save lives and to offer communities around our world a brighter future. thank you. ms. collins: mr. president? the presiding officer: the senator from maine. ms. collins: mr. president i just want to thank the senator from delaware for his very eloquent statement. i know how passionate he is about helping people, particularly in africa. he has extraordinary expertise about that region of the world about that continent, has been

there many, many times and i really look forward to working with him to make this bill a law. it is something that is bipartisan. it should bring together people across party lines and i hope we will be able to get it signed into law this year. thank you mr. president. mr. wyden: mr. president? the presiding officer: the senator from oregon. mr. wyden: mr. president 50 years ago today president lyndon johnson signed into law the social security act amendments that created medicare and medicaid.

our countries slammed the door to the days when far too many older people languished in poverty without the financial security that comes from affordable high-quality health care. it was a day when sick, older people were warehoused on poor farms and in alms houses. just picture that. on the edge of town, we had older people literally without a shred of dignity in what came to be known as alms houses. but lyndon johnson and others said that had to change, and five decades ago it did. today more than 100 million americans have access to high-quality health care, thanks to medicare and medicaid, and you can measure the remarkable

success of these programs in so many ways, but in my judgment, mr. president, one of the most important and most appealing aspects about medicare and medicaid is their ability to grow their ability to change, their ability to evolve to meet the needs of our country and the reality is medicare in 2015 is going to be very different than medicare in 1965. medicare in 1965 was about something like a broken ankle. if it was a serious break you would be in the hospital, part a. if it was not a particularly serious break you would go to the doctor. that was part b. but that was medicare circa

1965. today, medicare is about chronic illness. it's about cancer. it's about diabetes. it's about stroke. it's about heart disease. you put alzheimer's in, that's more -- well more than 90% of the medicare program. so it is a very different medicare program today than it was in 1965 and one of the aspects of medicare and medicaid that i find so appealing is they've shown a certain ability, a sense of creativity to always evolve with the times. and so what i'd like to do today is take a few minutes to describe how i think medicare and medicaid are going to change in the next 50 years because i think there are some remarkable developments ahead. i see my wonderful colleague

from the senate finance committee here and she's been very involved in a number of these changes that have been so exciting in medicare and medicaid. and what i'm going to do this afternoon, mr. president is just take a few minutes to talk about four or five trends that i think are going to really be led by these two programs that have done so much, so much for seniors and vulnerable people in our country. the first mr. president is i believe medicare and medicaid are going to lead a revolution in caring for vulnerable people at home. our health care programs are going to give seniors more of what they want, which is to secure treatment at home where they're more comfortable. and i think people are going to

be amazed to see that seniors will get more of what they want which is treatment at home in michigan and oregon and nebraska and we now have hard information, mr. president that it will be less expensive for older people to get what they want. in the affordable care act i was able to you a lower a provision with our colleague the distinguished senator from massachusetts, senator markey, the independence at home program. and this program is already showing that it can save more than $3,000 on average for every patient who takes part. so picture that. this is not an example of reducing the medicare guarantee, these guaranteed secure benefits that older people in every part of america

rely on. this is about protecting the medicare guarantee mr. president, and colleagues, and doing it in a way that keeps seniors happier and costs less money. that is a pretty good package by anybody's calculation. in my home state of oregon, the medicare program also has a smart policy that tracks this focus on caring for the vulnerable at home. in effect, what oregon medicaid has done is allow health care providers to offer services that go beyond what many might consider the textbook deaf in eggs of -- definition of a medical service. it's all about keeping people healthier at home and out of the emergency room. so instead of waiting to treat broken ankles or wrists, perhaps in a hospital emergency

room after a senior falls again and again and again what we are now doing in the oregon medicare program is saying that the staff of this program will visit the senior's home and perhaps replace the broken floorboards or dangerous drugs -- dangerous rugs that are causing the seniors to slip again and again and go to the hospital emergency room. so think about that. you could help a little bit at home by replacing a dangerous rug, or you could have somebody slip and fall again and again and go to the hospital emergency room. now, again replacing that dangerous rug wouldn't probably meet the clinical definition of a medical service as it was always determined, sort of years past. but now we're seeing that it's

part, again, of having older people in a position to be at home where they're more comfortable for less money. the second significant development where i think medicare and medicaid are going to lead is on pharmaceuticals. mr. president, and colleagues, i think the pricing of prescription drugs in the future is going to be connected in some fashion to the value of treatment. we have seen remarkable, remarkable changes in pharmaceuticals. the reality is in the last ten -- the reality is we're seeing real cures for illnesses where there was really a death sentence perhaps a decade ago. but the sticker prices on some of these pharmaceuticals are just astronomical and for so

many working-class families and seniors of modest means they look at these prices and they say this just defies common sense, and they seem to get more expensive over time. and sometimes there's a six-figure, you know, price tag. and the reality is medicare and medicaid weren't set up for these kind of costs. the experts at the congressional budget office are starting to ring the alarm bell particularly on medicare part d. addressing this issue is going to take a lot of vigorous debate here in the congress but it can't be ducked any longer. and senator grassley and i have been working for about a year now in looking into one of the hepatitis c drugs which has had

enormous ramifications for health programs medicare and medicaid and others, and we are continuing our work. third, in addition to pharmaceuticals and home care, i think medicare is going to lead the revolution for open access to health care data. senator grassley and i here again, have put a lot of sweat equity into the issue of data transparency and medicare. and it paid off in 2014, when the obama administration to its credit opened a massive waive of information. a massive wave of information starting with doctors and "the wall street journal" reported this extensively the next step is turning open data into valuable tools and getting them into patients' hands.

health care data packaged the right way ought to help seniors and others choose doctors and nursing homes ought to figure out where doctors and nursing homes excel and so exactly what you get for your dollar with various treatments or doctors. fourth, i believe medicare is going to lead the debate on improving end i have life care -- end-of-life care. with respect to end-of-life chair point to patients having more choices and a better quality of life. and in my view, we ought to make sure that patients are in the driver's seat. and in this regard i was very pleased that the obama administration announced just a few days ago a real breakthrough

in terms of end-of-life care. we've certainly had that debate in the affordable care act where we heard about seniors not being given the opportunity to choose life and to choose cures and they were going to in effect be receiving what amounted to death sentences. and in the affordable care act i was able to get included a provision that made it clear that that's not what this debate would all be about. and now for the first time, for the first time, mr. president it would be possible for an individual who is receiving hospice care to also have the option for curative care. in other words, they would not have to sacrifice one for the other.

and that's very important to patients because even when patients are contemplating the prospect of hospice care, they want to know because it's almost in our gene pool as americans as nebraskans and oregonians, that maybe there's a cure. just maybe our ingenuity is going to come up with a cure and they want to have that hope. and now they're going to have it. as a result of the change, it's called concurrent care, the care choices model for the first time for the first time patients and families will be in the driver's seat and you will not have to give up the prospect of curative care in order to get hospice. and for the first time we're giving those who want treatment in a hospice some real flexibility.

next mr. president, i think medicare is going to go further to protect americans with catastrophic coverage. the reality is that millions of americans who are younger than 65 are protected against the huge expense of an accident or serious illness so this is an area where medicare having led in so many areas with the kind of creative genius that i've described that i think is going to show the way on home care and pharmaceuticals and end-of-life care and access to data -- this is an area where i think most people advocates for seniors say that medicare has gotten -- has got a little catching up to do. seniors ought to have the safety of an out-of-pocket maximum in medicare and i know this is an

area where i very much look forward to talking with my colleague from michigan about -- she's been a wonderful advocate for seniors throughout all her career in public service and i think colleagues on the finance committee of both political parties are going to say if there's catastrophic protection in the private sector it's high time we have it for seniors on medicare. i think this is an area that we'll also be talking about. i want to wrap up with one last point, mr. president. that's about medicaid. i also believe more states are going to come around and expand their medicaid programs. to nearly two decades for all 50 states to adopt medicare initially, so there's a history of this unfolding over time. when you look at the numbers you sigh that the proposition of expanding medicaid is not exactly some theoretical notion.

a new study shows there is a gulf opening up in terms of access to health care between states who have expanded medicaid and states that not have. in our country everybody should have access to medical care regardless of their zip code. but it's not only a question of what's best for the health of our people, it can often be pretty important to a state's economy. a recent study found that kentucky and their cost of covering new medicaid patients will be far outstripped by the other economic benefits of expanding the program so in my view more states are likely to do the right thing by their citizens and their economies and the gulf between those states that cover individuals on medicaid and those that do not will narrow. mr. president, i'm going to close on a little bit of a

personal note. my background is working with older people. years ago i was director of the oregon gray panthers. it was an extraordinary honor to be able to do this. those were the days when if a town had a lunch program for older people, this was considered a big deal. senator stabenow was starting her career in the michigan, you know legislature and she remembers those days. it was a big deal when a town just had a lunch program where older people could, you know, congregate. that was considered a pretty serious array of senior services because you could get a few things there where older people got lunch. so now we're looking as you've heard about the opportunities for extraordinary innovations. elizabeth holmes was here today and we had a chance to visit

with a lot of, you know, members. she's taking the whole notion of personalized medicine and personalized medicine where in effect an individual could order their own test and it costs only a few dollars and the state of arizona has already embraced it. she's talking to government officials about something that once again would empower patients and would make sense from a health quality standpoint and from the standpoint of costs. she's a young woman a very gifted woman. i believe a graduate of stanford my alma mater. and i talked yesterday to her about this, and i could just see the enthusiasm for the future of health care and what she has already been able to accomplish and what she is going to be able to do in the days ahead with this new focus on personalized

medicine and tests that empower patients to in effect make their own decisions about health care and the sums of money that are involved for the tests i'm not sure they're even going to be processed by government computers because they're too small. we're going to save too much money. so there are going to be very exciting developments ahead for medicare and medicaid. the last 50 years have been an extraordinary run for these programs. it was a personal thrill for me, mr. president, to have been involved in the early years of these programs. now they are essential to the well-being of more than 100 million americans. and as we take this special day to kind of savor how much progress has been made from that day when america had those

poorhouses alms houses for seniors, to today where medicare is leading the way on home care and disclosing data and looking at new approaches with respect to health tests like elizabeth holmes has been here to visit on you can see that medicare and medicaid in their particular genius is that they're always keeping up with the times and looking to new approaches that better meet the needs of older people and do it in an affordable fashion. and i'll just close by way of saying that i don't think there is a single area i've talked about, mr. president and i know my colleague in the chair is a member of the different political party. i don't think there's a single issue that i have brought up here in the last 15 or 20 minutes that democrats and republicans can't find common

ground on. and, in fact, chairman hatch in the finance committee to his credit has said that by the end of the year, he wants democrats and republicans on our committee to produce a bill dealing with chronic illness which as i have suggested is what the programs -- which is what medicare is all about responsible for more than 90% of the spending. so on that hopeful note that after an incredible 50-year run i think the next 50 years are going to be even better, and in the four or five areas that i have been talking about for a few minutes i don't think there is a one of them where democrats and republicans can't find common ground, and i know my colleague from michigan is waiting to speak and i'll just note as i wrap up, she has really been a leader in this field, particularly in getting democrats and republicans together. and by the way as she begins

her speech, i just want to note that many americans are going to receive better mental health care services in the years ahead, and it's largely been due to the work of my colleague bipartisan work on these issues. so i'm happy to wrap up my -- my comments and look forward to hearing from my colleague from michigan and i yield the floor. ms. stabenow: mr. president? the presiding officer: the senator from michigan. ms. stabenow: before my friend from oregon leaves, and to -- just make a couple of comments about our leader on the finance committee because sitting and listening to him about his optimism and hopefulness helps me have optimism that we can actually come together and get things done. i can't think of anybody who first of all is more creative or willing to look at all kinds of inside in order to be able to

strengthen health care, medicare medicaid, more quality cost containment. back during health reform, i was proud to join with senator wyden on what i thought was an extremely thoughtful approach around health care. i very much appreciate all that you do. and i have to say that as you -- i know you have reminded me many times coming to the senate and elected office, from the early years of the gray panthers and organizing for seniors. i come to public service and elected office, up for a big fight to save the county nursing home in ingham county, michigan. so we both came into public service fighting for health care for older americans and it's my honor to continue to serve with him and also with the senator from pennsylvania who has joined us on the floor. as well.

mr. president, i do, in fact, come to recognize the 50th anniversary of the signing of medicare and medicaid into law and i view these as great american success stories and the best about us in terms of our values. i think it's important though, when we look at this to sort of -- this is thursday, we're going to do a throwback thursday moment here and look at the context in which these programs were created because it was the early 1960's. it was a time of great social upheaval. it was a time, frankly of segregation and jim crow laws and a time also when there was no safety net for older americans or americans with disabilities when it comes to the possibility of going to the doctor or getting the medical care that people needed. and if you were living in poverty, then you simply could not afford to see a doctor to be able to get medicare -- medical

care for you or your family. but with the civil rights movement our nation become more in tune to injustices in society for people of color as well as those in society who were struggling with illnesses just basic health care needs or with poverty. and in 1963, in his "i have a dream" speech, martin luther king challenged americans to live out the true meaning of the creed of our nation's declaration of independence, that all men and women are created equal and that all of us are entitled to life and liberty and the pursuit of happiness. i think that includes access to health care for ourselves and our families. our country responded to that challenge through the passage of the civil rights act and through the passage 50 years ago to legislation that created medicare and medicaid. this was a momentous event in

our nation's history and it demonstrated our willingness to take action to ensure that our nation's laws were in line with our core values as a country and it's so important that we be working together to do that again. that's what we should be doing every day. and let's remember that the -- before the creation of medicare, only half of our seniors had health insurance or could even find health insurance and that means half of them were struggling probably didn't get the medical care that they needed at all or they were going into an emergency room which, by the way is the most expensive way to be treated rather than going to your doctor and getting preventative care and so on, and we saw about half of our seniors and people with disabilities in that situation. president lyndon b. johnson was

the strong, principled leader that we needed in this moment, and 50 years ago he signed the medicare bill into law. when he did he said -- quote -- "no longer will older americans be denied the healing miracle of modern medicine." no longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years. the medicare program really is a great american success story that connects all of us together, each generation, and each generation has done its part to strengthen that, including our own and that's why it is so important that we not go backwards at this time, and this is where unfortunately we see a real difference in the senate and the house and in the

political discourse more broadly, because we have seen unfortunately a republican budget house and senate that have passed this year with almost $500 billion in medicare cuts efforts to turn the system away from a universal program into something that -- whether we call it vouchers or whether we have other names for it would take away the confidence and ability for older people and people with disabilities to know that they had health care, which is what medicare's all about. what we need to be doing instead of those things -- and we even have presidential candidates saying we should phase out medicare -- we should not be doing that. we should be working to ensure the program's health and longevity so that people are confident that as they work and pay into the system -- because by the way people are paying

into this system -- that it will be there when they retire in terms of a health care system for them. i also very much appreciate our ranking member in the finance committee talking about the new things that we need to do, and i would just mention one because when we look at medicare, one out of five dollars today is spent on alzheimer's as our ranking member knows. and so many of us are working together a bipartisan effort is going on to tackle this question. senator collins from maine and i have what's called a hope for alzheimer's act and senator collins is working also very, very hard and has in fact, increased research, which is so, so important. but we need to know that we're doing everything we can to support alzheimer's patients and their families and to find cures, and the exciting part is that we are seeing more and more

opportunities through research. i have had so many conversations with researchers in michigan and across the country. we are so close in so many areas to be able to break through if we don't go backwards on research funding as unfortunately will happen if we are not coming together and appropriately funding the budget. so there's a lot of things we need to do, save dollars increase quality and make sure that we're tackling the challenges right now of health care for older americans. and i am constantly reminded that in my state, there are nearly 1.5 million people right now that get their health care through medicare. some 40 million nationwide. let me talk for a minute now about the other hat on that legislation which was medicaid, medicaid. now, that program came in response to a crisis in health care for low-income americans and those with disabilities as

well and has been nothing less than a lifeline for people. saving lives now for 50 years. and during this last great recession that we had there were so many families struggling to pay for basic health care needs that medicaid literally was the saving grace that helped them and their families get back on their feet. medicaid is especially vital to women. nearly half of all births in our country are funded through medicaid. it gives young women access to preventative services like cancer screenings. i want to also say again and thank our ranking member and our chairman for including legislation on medicaid in a series of bipartisan bills that just passed the senate finance committee. quality for moms and babies act is about making sure we have quality standards across the country for low-income moms who are pregnant, going through prenatal care, delivery and

babies. and senator grassley from iowa is my partner in that effort. it's also critical to know that on medicaid, that actually 80% of the dollars goes to long-term care. low-income seniors. when i got involved, again as i said in the beginning in this whole process of public service in elected office, it was because of a nursing home that took medicaid and helped low-income seniors have a nursing home. in fact, 80% of medicaid goes for seniors in nursing homes and long-term air. and unfortunately as with medicare what we have seen in the budgets rather than working together to strengthen medicaid, we have seen countless attacks over and over again to cut funding, to block grant the program. over $1 trillion in the next ten years to cut medicaid.

actually passed by the republican majority in the house and the senate. that's not the direction we need to go in as we're celebrating the 50th anniversary of medicare and medicaid. and i finally have to say that we still have governors who refuse to use funding that's available to them to cover their seniors and nursing homes under medicaid or moms and babies, you know families, low-income working families. we put in the affordable care act the ability for people that are working in low-paying jobs to be able to have access to health care through medicaid and yet we still have 3.7 million americans who can't get health care not because the money is not there but because of politics. and i think that's pretty