and it provides authorization for such sums as may be necessary to carry out this title. . to carry out this title. that's a brief description of the amendment. i ask unanimous consent that both mikulski and dodd be accepted. >> is there objection? >> okay. >> okay. all those n favor say aye. >> those agreements are agreed to? >> yes, they are. >> i understand the first amendment, senator jack reed -- >> senator, let me apologize, we need 12 members to adopt amendments and eight in order to have a discussion. we have to wait until some show up. >> we'll lay the votes aside. >> we can't do a unanimous consent unless we have eight. >> we need 12.

>> i got it. i've been to those kind of meetings. perhaps we could proceed to the discussion on senator reed's. >> thank you, mr. chairman and senator mikulski, i would offer an amendment to section 218, this is on behalf of myself and the senator for their cooperation and thoughtfulness and asked the consent that senator hatch be offered as a co-sponsor. >> no objection. >> this is the amendment that goes to the drug fact box which is shown by researchers to give consumers significantly better information, more understandable information recently fdas risk communication unanimously recommends that the f democrada standards to this reregard.

it would apply to promotional advertising and it would not be on the bottle itself, but it would be the promotional advertising and the magazines, circulars, et cetera. this has been, again, agreed to with the ranking member. we do not intend actually to displace the decision of the fda, we're telling them to study this for a year, if this propose it go forward, they have a year to pro mul gate the rule. i think it is entirely consistent. >> senator -- >> i thank the senator for working on this and i don't think that the current presentation of drug labeling is technical rkts i think senator reed is on to something with the

study and the study proposed, i'm pleased they were able to work out the solution and i'm pleased we've been able to reach agreement on the provision. i co-sponsored it and i want to thank senator reed and senator hatch for working on the issue and coming up with a solution. >> any further comment on this amendment. we're missing the necessary votes we'll have to lay this amendment aside until the requisite number of voters show up. any additional amendments you want to propose? >> there were amendments to be suggested by senator greg when improving data collection, which i know we would also -- that we could proceed on. >> mr. chairman, if you would indulge me, there are two amendments we worked out, senator mikulski then one we

didn't work out. >> you had a greg amendment nine, related to shared decision-making and you had greg amendment 10 related to data collection. >> those are both agreed to. >> i would agree. then when we get a quorum, we can do a unanimous consent. >> i would offer the greg amendment 35. >> greg amendment 35. >> can we hand that out so we don't -- >> as one more members show up we'll consider these discussed. >> what title is this? what section? >> it goes to title 2, generally, title 3 and title 4 generally. it's the gao review of the

activities of those titles. >> we now have -- is it right do we have 10 or 12 here? >> six, seven, eight, nine, ten. i'm sorry, still missing people. >> i can talk about it if you don't mind. >> go ahead. >> mr. chairman, as we all know and the president has made the point and totally appropriate, one of efforts has to be to reduce the costs of health care. rate of growth in costs over the years. we're facing -- >> we're facing a unsustainable situation in our federal budget, which has driven in large part by the cost of health care. we know that we have approximately $38 trillion on funded liability in the

medicaremenmedicare accounts. and 12 trillion in the medicaid amounts. we know headed towards 20% gdp. and that these numbers are simply not sustainable for our government or our nation. that's one of core elements of health care reform has been not only to get everybody covered, which people on our side are totally committed to and give people quality health care which we're equally committed to, in the process develop proposals which reduce the cost of health care. bend the curve has become the term of art in the cost curve. the president called for bending the curve, i congratulate him for that commitment. senator dodd has talked about that on a number of occasions, senator casey and hagen talked about it about what the effect of a really good wellness

program would be. i know there's consensus around the table that we should attempt to do that. senator conrad has been the leader on the issue of debt in this government and the fact in a his term debt is the threat is the watch word for us. at least he's got the point down. was advised by cdo and myself in a letter, that the rising cost of health care will cause federal spending to grow, putting the federal budget on an unsustainable path. it is on an unsustainable path -- >> we have 12 members presents. i think the amendment that senator mikulski and enzi, i ask unanimous consent they be adopt.

>> so ordered. >> that's a good start, mr. chairman. >> we've gotten five done. we're debating now senator gregg's amendment, number 35. >> right. >> so this amendment addresses that issue of spending. because as we know, this bill has been scored only a sixth of the bill has been scored because the cdo didn't have a full score, a score that increase spending by $1.3 trillion with an offset of $300 billion in new taxes. the net being $1 trillion. and when you throw in the potential for the medicaid score on this bill and the potential for the government title depending on how it evolved in the bill, you could end up a bill easily headed towards a $2 trillion price tag unfunded.

which the would go on our debt and aggravate tremendously the situation. unfortunately, the bill does not include a lot of nainitiatives that have been suggested. cdo has given us a number of knows, bundling payments to hospitals, there are preventative and wellness programs in this, the suggestions are not included. increasing the cost sharing per patient. and then the president's own proposals in controlling costs are also not in here that he sent up just last week which represented $300 billion in potential savings. so what i'm suggesting in this amendment is that before we go ahead with initiatives which are represented as being cost savers when actually -- some of them are being scored as expenditures, we should actually have an independent umpire take a look at these proposals and say, are they cost savers. the purposes of title 2, 3 and

4. are to contain costs using new initiatives in the area of prevention and quality, specifically and workforce. so if that is the purpose of these titles, then why not hold these titles accountable to that purpose, which is to contain cost. all this bill does is very simple, says the gao will review proposals and before it can move forward, we have to have a determination that it will actually save money. save money. that we will end up instead of adding a new extension to the item health care business of government, that we will actually do what we claim we'll do, which is reduce the cost of health care over the years. if it's a loser in the first two years but nets out as a money saver over the ten-year window,

then it goes forward. if it doesn't, we have to go back and look at it again and see in the language should be used. a simple amendment, score them for us, as to whether they are going to save money. if they don't save money they shouldn't go forward until they do net money over the period of ten years. >> senator wwnow i'm going to oppose it. i always admired his frugalty he brought to the table and brought things to our attention that we had to pay attention to. but i find his recommendation -- his amendment to be most peculiar and i will tell you why. first of all, there's no doubt, we have to acknowledge the cost of health care and the cost of writing a new prescription for health care. this would only add one more

layer to evaluating what cost is. i think the sequences are number one, i have never heard of gao doing a perspective analysis of anything. they've always done a retroanalysis, usually to give us a sense of cost or better and more efficient management reforms. so gao can't do this because they would know what it is we're doing other than what is actually in title 2. i don't know how they would evaluate it other than giving us scrubbing information that is already in the public domain. so i view this amendment as simply throwing sand in the gears. we do have ongoing conversations with the congressional budget office on the cost of both this

title and the cost of the bill. oddly, that's the appropriate place where those conversations should be going on and i believe the committee established a feedbackroup now between us and the gao in terms of the cost of whatever title. however, let's talk about cost and what prevention and quality is. there are many things in here when you score the cost -- my father used to say, basrb, sometimes you have to spend money to make money. we have to save money to spend money. i didn't sit here while i was getting a manicure and wrote up five ideas on how to achieve quality. we had extensive hearings in terms of public experts in the

area, number two the consensus in that area about what needed to be achieved, number three, estimated costs that it would be based on real life experiences. like the north carolina approach on medical homes. the management, the patient safety implementation, the checklist that was developed that saved michigan $200. we went and held extensive haegz and went to the public domain on the consensus of ideas to improve quality and got estimates about what it would be. we put a lot of stock into these agencies, gao and cbo and i have a lot of respect for say you wanted to go over the cost of your gasoline expenditure that your family -- and your family checkbook. and you went out and brought it -- you bought a hybrid.

under the method, that would be counted as a cost. we are counting it as a savings. that is kind of what we're doing here. we're looking at is how we can achieve savings by improving quality, by improving health outcomes, and at the same time, we make expenditures in the long run. improving. i oppose the gao study because it is -- they've never done anything like this before. i believe we should stick with cbo, even where we question these methodology, we have both an organization that advises congress and we have a feed back group where we can be discussing this. i urge that we defeat the gregg amendment. >> mr. chairman if i might briefly respond. >> senator gregg. >> first off, i don't think it's throwing sand in the gears to

find out how much the programs will cost. whether they are going to be savers or expenditures. i have no dog in the fight on behalf of gao, i'm willing to modify the amendment and would ask to modify the amendment to wherever it says gao, we'll insert, end or cbo. i would say that we -- what we do need, however is an umpire, a fair ash ter of whether or not we're getting what we claim we're asking for. this bill is already scored as being a trillion dollar add onto the deficit, the debt, we haven't seen the entire bill. when we finish scoring the entire bill, should we get the language, i'm sure it will be close to close to a $2 trillion in spending. so to spend more to get savings, which was may well have been good advice from your father, i

don't think is applying when you're talking trillions of dollars. i think a better metaphor would be the one out of vietnam, where we had to destroy the village to save it. when you put this much debt on the back of america for purposes of improving the health care system and getting savings, you'll never catch your tail. the debt will overwem you. i believe that we should have a gate keeping that says, okay, this program yes, it's projected -- you're saying it's going to save you money, yes, it will. another program, you say it will save money over the long term. no, it won't. take one example in the workforce section of this bill, there's -- >> wait a minute. we're entitled -- you can do that when you get to workforce. >> i'm taking this as an example. there is a lot of talk about adding a lot more personnel, the dartmouth studies which are the rule of the road around here in

the area of quality developing saves, says when you add a lot more personnel, you increase costs. there ought to be an evaluation, we can do the same in the quality area. a lot of issues on the quality side. i don't think that we should go forward on a wish and prayer and anecdotal events. we ought to have an independent evaluation whether the things will save money. honestly if they don't save money, we're in deep trouble. we're running up trillions of dollars of debt. and the debt as senator conrad says it the threat. i just would ask we support this amendment obviously. >> if i can, just to express a point on that. whether it's the gao or the cbo or -- these are not policy making bodies and we are. we can debate about whether or not an investment in some aspect

of quality is a good decision or not a good decision. i would be reluctant to set the precedent of giving an outside organization to have the ability to cancel the program because they've conclude that's it might have a cost associated with it. that's really our function as a body here as well as a finance committee to make those determinations. it's been a general conclusion over the last number of months as we've had a number of hearings and working groups that we clearly are going to bend the curve down, it is going to be in the area of prevention and quality, not quantity as has dominated the health care, how much people are in a doctor's office, in a hospital that determine the sick care system. we're all interested in keeping people out of those offices, out of those hospitals, true prevention and improvement of quality. we rank 37th in the world in terms of quality of health care

according to organizations that evaluate these kinds of issues. title 2 of our bill includes the following, includes research and provisions of research and provide patient with medication management and reduce hospital readmissions, facilitate shared decision-making and conduct health outcomes, researches, integrate patient study training in clinical education and improve the health of women. stream line transactions, those are ideas that have been submitted to us and these are areas that could vastly improve quality. there will be some cost associated with it. if the criteria is exclusively, whether they decide then to strike them from the bill. we basically relegated ourself to nothing more than the

proposals of the bill and to determine whether or not they include it or not. that in my experience is never something we've done before, given the outside organization the ability to preclude something. we need to assess. i would like to know what costs are, that a legitimate inquiry and essential inquiry. to defer the power to terminate goes way beyond what anyone would want to set as a precedent. >> i don't think his amendment deals with terminating. it preincludes i am plimtation which means we don't get to start it. we're not stopping a program already in effect, it's allowing us to set the policy. but we're not the accountants and the ones that put together the numbers and that's why he's putting cbo in it as well. they are the one that's can tell us what -- kind of what the numbers are -- >> but they have.

>> they haven't, because we're rushing head long into the bill without having the numbers and we need those numbers to make good evaluations, we need to have them after we do that if not before. that will give us better numbers to go on. there have to be some limits to what we're spending and when they exceed all programs that you mepntioned there over the ten-year period would result in savings, and that's what we're hoping for. so it seems like a logical provision to me when we don't have the cost to begin with. >> could i just enter a fact into the conversation as we listen. title 2, first of all, when cbo gave us the preliminary scoring, and we saw the trillion plus, that was uncovered. they looked at title 2 and said there was no cost to my title. so cbo has already spoken on

title 2. what they raise as a flashing light, yellow light was the coverage. so you're going ask cbo to do the same thing that they did a view of. >> but that, as senator knows, a little bit at the margins are of the implications of what they said because they said there was no direct spending in title 2. it is an authorizing events which create discretionary spending potential. because we pursue that, we should know whether or not it's going to return the savings that are represented it well. you're not going to be able to know that unless you have cbo or gao look and give us a score on whether that's going to occur. it is a bit off the mark to say they didn't score it as costing anything because it was an authorizing event. as we know authorizing events

lead to appropriations -- >> senator bingaman. i was going to comment. i think the amendment assumes that the ga omt or cbo can know more than they actually claim to be able to know. we have this letter that doug endorsed, the director wrote to senator conrad on the 16th of june a few days ago and he talks about -- says policy options that could produce budget tri savings in the long run. a number of specific reforms show great promise for reducing federal spending on health care overtime without harming people's health. then he goes on to say, however, experts do not know exactly how best to structure those reforms to achieve that goal. they will need to learn through experimentation. some of what we have in here is

going to inform our judgment about what works and what doesn't in reducing health care costs and reducing the budget deficit. for us to say until -- saying until the experts can tell us that it will, we will not proceed means we will never do the experimentation that's needed to inform the judgment of experts in these areas. i think it would be a michigsta- >> this bill is not an experiment. the health care delivery system of this country is virtually nothing experimental about the bill. it is a massive re-write. >> i disagree entirely. i think this is a significant reform of the health care system but frankly a lot of the changes that have been suggested by both democrats and republicans

have -- are very much in expectation in changes which we're not certain will occur. and i hope they do and i very much hope that we see the improvements in quality and reduction in cost that we're working for here but i think there's a lot of experimentation in this. >> i don't want to close off debate, but i would like to move along, if we can. senator mikulski. >> chairman, if senator bingaman and senator gregg, the statements we made, we're comfortable we're at the point where we will see cost savings. he anticipated there would be savings from the wellness provision, prevention proigs, what are we afraid of? if we think it will demonstrate savings, what is the harm in affirming in a. i think as senator gregg has

mentioned, this is not something that we're going to float out here for a few months or a year. we're going to be putting in place a system, systems that will be with us for perhaps decades. and i think it is important that we have some understanding as to the cost. if we believe that we've structured this in such a way that we will see the costs, why are we afraid of whether it's a gao or a cbo score? >> the reason is as you read the amendment it precludes implementation of any program. so any program. there may be programs within here, you're eliminating something that -- >> like immunization. >> they may actually reduce costs but any program with an increase in cost, which we can't know until you try them out, that's the part of this that worries me. i'm not afraid of find gs out

what things cost, the gao or some other group would have the right, power of collectively the congress, even though we thought something had value, the gao says it costs too much, it is gone. that's exceeding way beyond -- >> that's a precedent i would be uneasy about implementing. >> i would be happy to name the program that's would be subject to this requirement within titles 2, 3 and 4 and negotiate which ones with the chairman are applicable to this requirement. >> well, i don't know if we can do that this moment here. why don't we just -- if there's no further debate we'll call this question. all those in favor say aye. >> those opposed? >> no. >> the clerk will call the roll. >> senator dodd. >> no. >> no by proxy.

>> senator mikulski. >> snow. >> senator bingasman. >> no senator brown. >> no, senator casey? >> no. >> senator hagen? >> no by proxy. >> senator enzi. >> aye. >> senator gregg. >> aye. >> senator bird. >> aye by proxy. >> senator mccain. >> aye by proxy. >> senator coburn? >> aye by proxy. >> 13 nos and ten yays. >> 13-10 was