chairman, not an objection but there was enzi number six was the easy one, enzi number four was the easy one. >> why don't we then talked about enzi number four. i withdraw my unanimous consent and resubmit to murkowski number nine, a couch, number nine and had 21 as modified. i ask unanimous consent that it be adopted. they are saying that is murkowski six. i'm sorry, i can't quite read this note. i apologize. i withdraw my unanimous consent request. murkowski number six is the physician's assistants, hatch number nine, had 21 as modified. i ask unanimous consent of the three amendments be adopted. >> is their objection? without objection i thank senator enzi for the agreement. those amendments will be agreed to. >> i need to go to enzi number four and number six on administrative simplification. i am going to say to my good friend from wyoming that in consultation with the white house, because what enzi number six does is one to strike the word operations procedures in the administrative simplification. there is concern that if we implement well, first of all, senator enzi, you might e

. >> i'd like to continue the debate because i think senator enzi says i don't -- he doesn't stifle trial by jury. i think we need to talk about that and i think we need to talk about what a health court is. it sounds great like a drug court. like a mental health court, et cetera. but really, what a health court would be, it would be a new entity emerging within our legal system and health courts don't have juries. okay? they don't have juries, they're like workman's compensation courts, if you will. so you don't have a trial by jury. and then there's this whole section of voluntary which is where do you -- at what point do you choose when they're going to trial or when you're being admitted to a hospital. so we can continue that this afternoon. but i want to respect where senator enzi is going and also the extensive work he's done this with senator bachus. i'm just apprehensive about what a health court does. so let's continue that this afternoon. >> i may suggest 12:30, my intention is to take a break and come back at 2:30. let me just inform our colleagues. of this is the eighth amendm

if you're senator enzi's doctor and you get outside that pasture, that decision again is rationing. i have personal experience with this in that regard. so that's my concern and i'm going to quit and i appreciate the time. >> very, very very quickly. >> i'll be brief because i'm prepared to vote. but look, there's no use kidding. we know that ahrq is there now. we all all know it's that going to cms and that cms is under tremendous pressure to cut costs and that's what's wrong with this language and bill. it's going to lead to rationing and and people getting less health and care than they get now. if i could ask one other thing, mr. chairman, i have to leave after the vote but i know our staffs have been talking about a few of my amendments, hatch 27, hatch 9 and hatch 21 as modified. my majority will consider those --. i'm ready to vote. >> i am considering those. just as i said over and over again, i don't know of anyone on this committee who's for health ration i rationing, it's used all the time and it's not offensive. we're not for health rationing, we're for driving down the

enzi number six? i-25? just so we get to bingo, i'm fine, okay? but again, i want to thank our staffs for working through the lunch break and i think this was a great set of accomplishments and we thank you for them. it actually improves the bill. >> senator, we thank you. senator enzi, senator murkowski, senator roberts, who were involved in that and their staffs, respectively. what i'm going to do is a couple of these were as modified but i will ask consent that the amendments as identified by senator mikulski be considered. without objection, so ordered. the amendments are adopted. that includes the seven we did this morning, so that's about 20 amendments. there were 59 introduced originally but we're moving on this. granted, it's not luke skywalker speed, senator roberts, as you mentioned earlier today, but we're moving here. pretty good pace. we have a vote that's just started and i will be -- in fact, i entertain another amendment to at least be offered and we can start for a few minutes the conversation, then come back after the vote. >> is

enzi, or their designees. mr. dodd: i'm going to ask consent that a colloquy between senator mark warner of virginia and myself be printed in the record. the presiding officer: without objection, so ordered. mr. dodd: i see my good friend from ohio, senator brown, who has been a champion of this issue. not only as a member of this body but in his previous incarnation as a member of the other body and before that has cared about this issue very much and spoken on illinois quently already so -- spoken on it eloquently already so let me defer to him. and senator enzi will be here shortly and we will go back and forth. mr. brown: i thank senator dodd. the presiding officer: the senator from ohio is recognized. mr. brown: mr. president, i've watched with great admiration, senator dodd's work on this. i worked with chairman, with henry waxman in the house of representatives. and senator kennedy, senatorred ssenatordodd and congressman wae never given up and i am appear tich particularly to senator dodd. i boil this issu

>> it's enzi's amendment with 94 with his permission. >> oh, senator enzi number 94. senator enzi. but it's with his permission. and only with his

i am sorry, the enzi amendment. [roll call] [roll call] >> the amendment is not agreed to and let me say to senator enzi, is an interesting observation and the pride that hrsa thinks it has been discouraging to people to go and was persuasive to maim. it is one of the issues another is a debate about it but i think we have certainly had a eighth straight pal empty for a long while and we're not getting the results. >> mr. chairman, the senator rakowski will be offering an amendment we can all agree on that is graduated rate we have been working on it a really good alternative. >> i think for the contribution. >> mr. chairman, i do have an amendment agreed upon, senator burkowski and i ask unanimous consent it be accepted? >> yes, burkowski never 40. >> i think it has been cleared on both sides. >> member 40. >> not the one i referred to. >> i think it is clear that on both sides -- tom, do you want to see it? i am going to recognize senator miracle for an amendment. just a second, we're looking at a burkowski amendm

i know senator enzi had some comments before. we were dealing with senator mccain's amendment so i wanted to just respond to a couple of things. first of all, i wanted to commend the way senator enzi, along with our chairman has conducted himself in this whole process over these many days and weeks, and grateful for the way he approached this bill, as difficult as it is. and as much as there is conflict on a lot of major elements. with regard to the fraud and abuse section, i wanted to do a couple of things very briefly. this will just take a few moments. one is to highlight and enter into the record, and i would ask consent that two letters be entered into the record. one is from the american -- america's health insurance plans dated june 24th, 2009, a letter to chairman kennedy and ranking member enzi about the fraud and abuse section. that's number one. number two, the second letter dated the same date june 24th of this year from the national insurance crime bureau, the coalition against insurance fraud and the national health

. >> and if i could speak to senator isakson, and i would like senator enzi and their colleagues on the other side to hear this. in consultation both with the people we have to administer what isakson would like as well as the aarp, there was a very serious concern about the unintended and adverse consequences for medicare beneficiaries and their families mandating that he must have an advance directive before you would be eligible for medicare. there are several bills pending, with both the administration and aarp, a very good way to accomplish this objective. rather than vote on isakson, where i would have to oppose the mandate around eligibility for medicare, i would like to be able to promise, and as the subcommittee chairman on aging, with my colleague, senator burr, the ranking member, that we review the legislation that is spending, that helps deal with this issue of encouraging the development of advanced medical directives. in other words most people getting the directives. and look at the existing legislation. with various legislative proposals that are being recommended, it s

let me turn to senator enzi for offering the first amendment. >> mr. chairman, i call amendment 55 and this amendment strikes section 421 which modifies the student loan rates -- you still can't hear me? i thought they fixed that while we were on break. is that better? i called amendment 55 which strikes section 421 which modifiers student loan rates for medical profession guidelines and the purpose of this amendment is to -- there are changes being suggested that are in the bill, the current wall we operate under has a fixed interest rate of 5% and it would change that to be 1.4%. the current law has 18% fixed interest rate for students who default and this bill reduces that to 5.6%. the current law requires individuals to remain in an underserved area and told the loan is repaid and the bill changes that ten years when the loan is repaid and number four, prohibits hrsa to using par entel financial information to determine student need. i think we have some agreement on the numbers two and three but not on how one and four and i can understand why we

is this enzi 80? >> yes. okay. so i'd offer enzi amendment 50. >> enzi amendment 50. i have 51. >> while that is being passed out, i would say that is to ensure that the secretary conducts workplace wellness evaluations in publicly funded programs before evaluating the privately-funded programs. i'm not sure why we are having cdc evaluate programs outside of the government when we haven't evaluated the ones in the government, so this would ensure that we would have evaluated our own programs before we starts a cessing the value of the impact of the privately conducted programs and that only seems fair to me that we talked a lot about the ongoing evaluations and stuff, but it is not one where we have evaluated. so i don't think that the taxpayers ought to be supporting ineffective programs in the government and then spending money to evaluate whether the private sector is doing the right thing or not. so i think that we ought to have that evaluation. >> mike? >> yes. >> i'm getting that section, but i remember when we were drafting this, the purpose of this was as we f

i thank senator enzi. with the agreement on that, those amendments will be agreed to. >> i need to go to nc 4 and 6 on administrative simplification. i want to say to my good friend from wyoming that in consultation with the white house on this because what nc 6 does is want to strike the word operations procedures in the administrative simplification, there is concern that if weism lement -- well, senator, you want to explain what the 4 and 6 are and then -- rather than me explaining what it is and what it is about it. >> thank you. yes, we certainly agree that we need to simplify the administration of health care and that that will make a huge difference, so i actually filed three amendments on this section. number five strikes a section because i didn't think it would work the way the authors intended, but i use number six to modify it so that i didn't need to do number five and that allows that at a minimum that do no harm and the final amendment was amendment number four which replaces the underlying

grateful to senator enzi, mike enzi, we've worked together on other matters, who's worked so well withenator kennedy. i want to proceed the way everyone feels comfortable about how we're proceeding. and may not end -- we may end up with differences of opinion on some of these issues. but i want to make sure that everybody has a chance to be heard, that ideas will be debated and thoroughly discussed. and then proceed along those lines. so i'll turn to senator enzi for the closing comments he wants to make but then we'll adjourn for the evening and pick up in the morning. >> i want to thank you for your tremendous leadership. i want to thank you for the flexibility that you've build in so that people can be heard, so that we can get it a as right as possible. there's no such thing as a perfect bill. this won't be either. but we'll come as close as we possibly can and i think there's agreement on body sides to work together to meet that. and the flexibility that you built in will help us to get there easier, and i think in a less contentious way than might be done otherwise. so that's rea

we talked around that with the foregoing enzi amendment. but this is the specifics of the trust fund itself. it establishes an expanded and sustained national investment and prevention and public health programs. again, it dedicated stable funding stream of $10 billion a year from 2010 to 2019. now if you'll notice in there, because of the lack of workforce and so we don't put the money in there right away, we ramp it up so the fiscal year 2010 it will be $2 billion, then for each year we go up by two to four to six to eight to ten and then continue with $10 billion for the -- from then on. so we ramp it up over a period of one, two, three, four, five -- five years up that $10 billion level. and, again, i don't know that i need to say a heck of a lot more about. this we already talked a lot about it. the reason that we have this amendment, it's also in the underlying title, the reason for my amendment is to answer some of the concerns that senator greg had in terms of being subject to the budget committee. and though we don't have this poin

enzi: madam president? the presiding officer: the senator from wyoming. mr. enzi: and i want to thank the senator from connecticut, senator dodd, who is working as the chairman on this committee, and for his passion, enthusiasm and for listening to us on these things. and we do have a few things that are in the bill. but there are several other things that ought to be considered in this. we want the bill to be as good as possible. when we do cloture we cut off that possibility. i have a couple of amendments that i think if were addressed -- i know one has been on both sides, but we can't get them in. that's a frustration, and we shouldn't be having frustrations on something as important as this bill. it's important that we stop kids from starting smoking and we get people who are already smoking to stop smoking. it's a cost-shift that we're experiencing. it's not good for their health. and then there are family members who are having secondary smoke, and people don't realize the problems they're having for their family members by doing that. i do oppose clotu

we have numbers in joint tax and i want to think that senator enzi. i sat on this committee as well. senator gregg and cheered as well so we had a number of former chairs so they all have some appreciation to try and keep people together and someone once described this is like keeping frogs in a wheelbarrow and the have a tendency to jump out so i appreciate they have stated it in the wheel barrow i hope everyone has a healthy independence day break an accord to see my colleagues on the sixth of july. up next pennsylvania senator specter talks about supreme court nominee. his remarks on the floor are about 10 minutes. >> i have sought recognition to comment briefly on the pending nomination of a speech to to be an associate justice on the supreme court of the united states. i have made it in a practice to write to nominees in advance of the hearings. in order to give advance notice to the nominee so that the nominee will be in a position to respond to questions raised without going back to read cases are considering the issues and facilitate the proce

i now turn to senator enzi. >> thank you mr. chairman. it's been an interesting discussion this morning and our side is going to expedite a little bit of the morning's process partly because senator coburn is also and the defense markup that senator mccain is in and has seen what happens with a number of his amendments. @ @ @ @ @ @ @@@@@@ comments on the bill and a couple of comments on some of the amendments that could have been offered and we can have senator mccain come in and present his amendment, i guess. i want to thank senator sanders for his comments. i do need to point out the criminal charges and settlements that he described involved medicare and medicaid, both which are government-run plans, and perhaps the problem is with government-run plans and their underinvestment administrative controls and distortions that are caused by their price controls, and i w or ones that are prosecuted and won during the bush administration had. so there has been some oversight and some activity there. the difficulty with fraud and abuse sectio

there is a lot of what senator enzi said that i agree with. when it comes to prevention and wellness we have a scatter gun approach. we don't really have any real structures to this that are delineated by the people that no one works. we don't have any real guide posts out there. that is what we're trying to do in this bill, and this title is to add some form and structure to its, not in a way of telling people what they can and can't do, but to make it easier to be healthy. to change the system and structure so that people find there are more incentives by not telling people what they can and can't do. as i said yesterday i repeat for emphasis sick when dr. andrew wiles said the human body wants to be healthy, it is in our dna to be healthy but we have corrected all the structures that make it difficult to be healthy so it is hard to be healthy and easy to be unhealthy. we need to kind of change that around. i would say to my friend from wyoming that we have to entities in the preventive services task force has been in existence since 1984 an

enzi: mr. president, i'd ask unanimous consent i be allowed to speak as if in morning business for such time as i might consume. the presiding officer: without objection, so ordered. mr. enzi: thank you, mr. president. i rise today to speak on the need to reform our nation's health care system. if we're to be successful we must undertake this effort with the greatest of care and deliberation. when it comes to health care reform we've started down this road before. last congress i proposed legislation called ten steps to transform health care in america in an effort to provide a blueprint from which we could begin to address the challenge of improving our health care system. i might mention that the way that came about is that senator kennedy was the chairman of thee health, education, labor and pensions committee and i was ranking member and he and i worked together on a number of bills. in fact, have quite a record for being able to work in a bipartisan way to get bills completed. we were very

so this becomes an off-budget event for all intents and purposes. >> senator enzi, i think that's right. i thought we'd worked that out. i thought we'd worked that out. >> so you can actually score this. >> that's right. but before, i still congratulate the creativity of the staff. >> if the objection is to mandatory spending, well, then, i plead guilty. of course, it's mandatory spending if that's your objection. i thought you had a different type of objection. my objection is it's mandatory. you'd think as an -- that i would be opposed to a mandatory funding, but sometimes i think it's necessary, and i repeat for emphasis sake why it's necessary. if you pit prevention moneys and wellness moneys that we're talking about here against the immediate needs of people who aren't sick, you'll lose. it will suck up the money and we'll never, never get this system changed. so i just -- that's why you need a separate mandatory stream of money that goes in and can only go for prevention. >> no, that's not true. >> what should happen here is exactly what senator colburn has been talking about whic

areas and will move into these other matters as a long and in the meantime i mentioned to senator enziwe might have an opportunity to meet with our former leaders that have produced a paper themselves and senator daschle and senator dole, senator baker and senator mitchell. demise said at a breakfast meeting for members to meet with them to have a discussion about their various ids which could be helpful and do that maybe in the middle of next week and see how things are moving along and chat with mike enzi in terms of timing. but let me turn to senator mikulski and thank her immensely for the job that tom harkin and jeff bingaman and patty murray have done all along with others in developing these ideas and quality prevention coverage as well as workforce issues. i'm going to ask senator mikulski to lead the debate on this and we recognize her. >> thank you very much senator dodd and good morning to all of my colleagues here this morning we are taking up title to, the quality section. and after that i believe senator dodd it wants to proceed and prevention. these two titles go hand-in

of proceeding. >> if i could be heard as well after senator enzi. i'll be short. >> go ahead. >> mr. chairman, one of the reasons we're having difficulty here is we're trying to do this in too few word, and it is a big issue. i had -- i had -- well, there were a number of amendments in on this that deal with a piece and it's a small -- each of them were just a small concern, but this -- one of the reasons that mandate bothers us is mandate, in my opinion means everybody, but what if you just lob off a little piece and it's not the mandate, it's the exception and my amendment number 7 deals with quality adjusted life year measures that the government could use and that's -- that's exactly what we're worried about with the european situation where they block breast cancer patients from receiving breakthrough drugs and they force patients to wait extra years before they can get treatments and they kept alzheimer's patients from receiving early treatment and they've had life for longing kidney cancer patients and all of these things. that's quality-adju

senator enzi agrees on this. the question of how we get there and how we do this is where the debate is. it is hardly a debate completed or overwith or a fate decome plea, and grappling with the numbers so that it is is a pay or play, and stay in the employer-based plans. that is critically important, if we end up with a massive migration out of the employer-based plans, we have a whole other issue to grapple with. i am the first to admit, this is a difficult set of problems to grapple with and identify, and it has defied solution for over half a solution. but the fact is that 14,000 people a day are losing their health care coverage and those who have it can't afford it, and if they have it, out of pocket expenses make it impossible to play. 80 to 90 million of our fellow citizens in a calendar year are without health insurance coverage. every one of us here in the desk have health coverage and we have the federal health benefit package and while we are worried about the crisis, none of us have to worry about pa

let me turn to senator enzi for offering the first amendment. >> mr. chairman, i call amendment 55 and this amendment strikes section 421 which modifies the student loan rates -- you still can't hear me? i thought they fixed that while we were on break. is that better? i called amendment 55 which strikes section 421 which modifiers student loan rates for medical profession guidelines and the purpose of this amendment is to -- there are changes being suggested that are in the bill, the current wall we operate under has a fixed interest rate of 5% and it would change that to be 1.4%. the current law has 18% fixed

senator enzi, we cleared out some matters. we had a long debate this morning. it is a very important bill and one that we'll be discussing and working on over the coming weeks as this process moves forward. we'll come back at 2:15 and continue this afternoon. senator sanders has an amendment he would like to offer and i'll make that the -- my first amendment after we get back very good. 2:30, not 2:15. we stand in recess. wñww >> this makes modest changes on page 367 dealing with school-based health. all that it does is underschool-based health clinics, what we talk about is comprehensive health assessments, diagnosis and treatment of minor, acute and chronic medical conditions and referrals to and follow-up for specialty care and what this amendment adds is and, a-n-d, oral health services. so essentially all that it does, when we're talking about school-based health care, let's remember, i know that in my state, i expect that in many of your states, a lot of kids are having a very serious problem getting the dental care that they need. when we talk about heal

. >> i think maybe senator enzi has an amendment. rather than start that, why don't we take a recess for 15 minutes. come back at 5:00. try to do another hour. i want to see some sense, too, if we could ask majority and minority staffs, give us a sense of how we're doing here. obviously if we can move through or people decide they don't have to offer certain amendments. i'd like if we had a chance to complete title 2 would be very, very helpful. a few outstanding issues to come back to. if we can be wrapping up title 2 and then tomorrow -- we have that event this evening. yeah, that's true. we'll re enzi. >> we'll recess for 15 minutes. >> we'll come to order if we can, please. i see there are some young people in the audience. i'm told there's an ice cream deal across the street. i don't know what you'd rather do, listen about healthcare or have an ice cream treat. >> mr. chairman, i just thought i'd respond to liam fox, a member of parliament from great britain. here's his quote, "nice is simply a rationing system." let me continue

my understanding, it's been reviewed by the enzi staff. they incorporate limited technical clarifications to title 1. they're minor changes. they don't affect substantive policy. they're like typing, editing typos. there's note able clarification which is includes corrections to the definitions of a patient-centered medical home. it includes senator dodd's clarification regarding evidence-informed information rather than evidence-behaved information. i understand that comes from the national academy of pediatrics? >> theash. >> we also included senator hatch's clarify amendment to include chiropractors as part of the community health teams, which is more than agreeable to us. it adds the standard of i.o.m. to define what is

one program that i've really worked on that i've enjoyed is with senator enzi to prevent elder falls. a substantial number of hospital admissions are due to either dehydration or to a fall. we worked on it. even people minimized their effort. part of that is you go to -- they are community based programs to create safe pathways for seniors either in their home or in the street. now you could also be funding some of those elder fall prevention programs that require physical infrastructure in a community transition grant, or it could also be part of national service with those bright, smart, hard working kids. so i want to be careful we don't have unintended consequences because you might have this initiative to prevent elder falls might be actually happening both in the elder fall category but could also be happening at national service. see what i mean? >> that's a problem. >> so that's why -- >> the job -- look, this is difficult. i mean, look. we have a rather large federal government that's not highly efficient. >> yeah, i know. look at defense. >> i made the point while you were o

i know the issue has been raised by senator enzi. that is the question of whether or not, whether it was the cochran or roberts language -- is it part of this bill or not? i don't know the answer to that? >> according to senator mccain's staff, it is not in here. they put safety provisions in there. they always mention that. i have gotten a copy of the cochran-roberts language which places some requirements for safety certification before the bill can go into effect, which is what we've always passed when this bill has come up. at some point they figure that with that amendment in there, it's a worthless bill. but i would ask unanimous consent to be able to offer this second degree amendment to the mccain amendment. >> mr. chairman, it's fine with me. let's have no doubt who wrote that, pharma and no doubt about the effect of it. it will kill the bill. you can vote for it, but it kills the ability to re-import drugs. let's not have the charade. i would be glad to do whatever the committee's wishes are. have no doubt it would have the

i believe in it because i know mike enzi and he is determined to be part of a solution and virtually every one of you, i have worked with every one of the on the issues and when it comes down to it we have a common determination to get this right. i know my colleagues on the democratic side very well are deeply committed to these issues and we are going to stick with this and the only way to do it is not walk away. i mentioned to the other day about having my office saying from edward r. murrow because it is true of everything else, he once said the ones is that history will never forgive you for is a problem was too hard and. this is hard, but history will not forgive us because we thought it was too hard. it is hard, it wouldn't be if it weren't, but our job is to move for the. >> mr. chairman, i take him at his word and in this bill we drastically change erisa to note where many of the successes and safer is that my talked about aren't going to be able to do what they did. and now like to work with you personally to make sure that is the successes of people out there providing hea

obviously votes another committee responsibilities every member has and i'm grateful to senator enzi who has sat. virtually every session to work through this and my colleagues as well. just to mention a couple housekeeping matters with eminence agreed to in title i of the bill but not touched on time one we have to do that we have had accepted an 85 of our eminence of the republicans signed by unanimous consent and another 17 and then once worked out in the long term care section. my hope to deal with that section and i hope that our not bring up a section and not have scored a. and while cbo scores with some real savings which we have proposed up to now the scoring requires not only that to get numbers from cbo but also joint tax. the numbers we got from cbo we cannot get the joint tax and they have not scored it and so will not ask us to do that although senator gregg want to make comments about the session generally. there are 17 eminence we have agreed to and i commend the staff to have work to reach an agreement on those amendments and so will have to go back to the session. ag

>> 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

in the "help" committee, senator kennedy, senator dodd, senator enzi -- senator enzi serves on both committees -- are reflecting the same kind of good will. i've told the leaders of both of these committees, i'm going to do everything i can to bring to them the ideas that i've outlined today, that have strong bipartisan support, that have been scored by the congressional budget office as saving money and pushing the cost curve downward. i have great confidence in the leaders of those two committees because they are showing they want to spend the time to bring the united states senate together. a lot of us on this floor -- i see the distinguished senator from mai -- have worked together on health care over a lot of years and a lot of issues. this is a historic opportunity. this is the place, the united states senate, this is the time to get it done, and i believe democrats and republicans coming together can make it happen. mr. president, with that, i yield the floor. ms. snowe: mr. president? the presiding officer: the senator from maine. ms. snowe: i ask unanimous consent to speak for 15 minu

mike enzi has had a great relationship with senator kennedy. it is not only unacceptable the system exists as it does today, it is unsustainable, that we have to address this and get it right, and we're determined to do that. >> i thought the president was flexible except in one area, and that is get the job done. and we all want to get the job done. i believe that bipartisanship was spoken about a lot, and i would be unhappy if it hadn't been. i think the president wants to work in a bipartisan way. i expressed to the president that abipartisanship is it how senator baucus and i have done it for 10 years. we start with a blank sheet of paper and build a document. and that's the way we're doing it. bipartisanship is not a a democrat bill with five or six republicans going along with it. we're restructuring 17% of the gross national product. in anything we do in health care. that's something that's never been done by congress before in one piece of legislation. it should be done thoughtfully, it should be done on a con tens senseous basis, and b

what i thought i would do at the outset briefly before turning to senator inslee, mike enzi, is try to give you at least a layout of the plan for this week if we could come starting late today. i would like to be able to complete-- we have about five, six, seven amendments to complete as i am told. senator mikulski, how are you? i hope would be this afternoon that we could try to complete whatever-- where you want to sit. to try to complete the quality piece of the could this afternoon. we have it voted 5:30 annika could spend the next couple of hours and get through title to it would be great and start title iii tomorrow which is the prevention section and to work on that through tomorrow, and with the remaining sections dealing with the workforce, fraud and abuse of long-term care. every piece we are working on there are scored numbers for. we thought we would have cbo numbers back today. we don't yet have them john. i know you were interested in the subject matter but we hope to get them by early tomorrow. i am not going to go near the sections that we don't have scored but they wil

i know senator enzi has been driving us in that direction. and, i think the senator harkin for his attention to this. there are a couple of areas where we think prevention, the pressure prevention and a healthy lifestyle can be incentivize. and, especially in the area of hipaa we think the federal government disincentivizes bergen the area of the ability for people to pay cash rewards for folks who live healthier lifestyles we think there's this incentive in our system and we believe this bill in its present structure and i understand may be going through some mutation, moving during-- for direction of a healthy lifestyle and to allow communities of employees to participate in programs which basically give them the opportunity to live a healthy lifestyle and be rewarded in doing that. so, as the senator was saying there are groupings of amendments. there is certainly one grouping of amendments that i consider to be very important and i know many of my colleagues to. there is also a number of other issues in here. the issue of this preventive

it has been my relationship with mike enzi. so, i invite that kind of process in this mark-up and i thank all of you for your attacks on these issues and turn to senator enzi. >> thank you, mr. chairman. i appreciate the flexibility that you built into the program as we worked on it since you took over the reins less than two weeks ago. and i agree with about 80% of what you said, which is usually about where we agree on legislation, too. that 80% would make a huge difference for america. and that 80% would make a huge difference for america. there are some disagreements. i think those could be worked out. i don't think they can be worked out in this short a time frame as we're picturing all of this to happen. my republican colleagues and i have stood ready for months hoping to get a chance to help write a bill that would fundamentally reform the insurance market, that would offer new protections, to guarantee that consumers, all consumers could buy affordable high quality health insurance that includes people with pre-existing

. >> senator enzi it defines primary care provider in health care professionals -- i presume you mean by that that would include health care practitioners, nurses and so forth. >> no, he is talking only about doctors. >> only about doctors. >> that is aholt -- >> i am trying to help you. >> mr. chairman, that is the crux of the argument that in addition to there has to be primary-care held teams that talented and overworked providers also turn to someone. i can and social workers. >> but that is why repoire de the report by billion in into hundred million into primary care providers and that is what i'm trying to change the dynamic here. >> i think it changes in the wrong way but we are ready for the vote he mack i agree to an amendment he met all those in favor of the enzi amendment and those opposed say no apparent it does appear to have an amendment is not agreed to. it let me turn to senator sanders and then mr. cockburn. >> thank you mr. chairman. in this amendment is placed on page 445 line 21. what is essentially says that under the health care workforce. >> let me make sure ev

senator enzi and i have shown a willingness to work on this and others have as well and will continueo do so. and here is the bottom line. if we are not careful we could walk down a path for stories like a jack tag can become increasingly common in our great country. in 2006 jack tag a former world war ii pilot suffered from a severe case of a molecular -- macular degeneration. this is a guy who risked his life for all of us. the regional government bureaucrats rejected his request for treatment citing high costs and that is the disease that his other eye also appear in. it took three years to overturn that decision. three years. let's all remember that a family member with cancer in an intensive care units would probably rather have the time of the resources to appeal such an egregious bureaucratic decision. but that we're going to see a lot more of the something like this ever passes. and when a tremor of the real implications of these policies not simply in terms of political spin in interest but in terms of its impact on real people who are our mothers, fathers, husbands, wives, b

what is the thinking of you and senator enzi on this? >> mr. chairman, i am not familiar with our work committee doing for referring. i know there can be point of order is raised on the floor in a normal circumstance but it's my understanding this bill will not go through a normal circumstance. it has to be merged with the finance committee bill, and it's my understanding that on the process on that they are not going to take one bill or the other for fear it would look like they were favoring one kennedy over the other committee but there would be the merging of the bill and then there is i think will 44 that allows it to come to the floor and this might be an even bigger reason for not taking one bill or the other. there are no points of order against that no matter what committees are infringed or bothered with i think we ought to go ahead and solve and they would have an opportunity on the floor to make any comments to try to make any changes the same as anybody else but it's really something critical to this piece of the bill, and i would

. >> while we're on that particular point, though, hopefully the staff would take a look at enzi amendmentumber seven and eight because it deals with the same thing. again, worry about whether it's not construed but not prohibited and one of my number seven is about the quality adjusted life year, whether older people are going to be penalized by these guidelines. another one is using it to deny medicare benefits. and those -- >> they are all related. >> they are all exactly related to it. it shows the level of concern we have over that. i guess that one word. but that at least that section because we don't -- >> and i'm -- >> sorry. i apologize. i am more than willing. i am not a lawyer. words do have consequence both in life and in law. and i know because i was building on the american recovery package language, and also when we were talking to, again, the academies and others involved, everybody had at least some type of language that had already passed that we could discuss from. i just want to be clear that there's not some unintended here because if that cracks part of this open and

however, though, we have had testimony before this committee, senator enzi has pointed it out, in themittee similar testimony, the true number is about 27 million. i'm not going to argue that point. we're going to take the 47 million. and that seems to be the record that we're using in the public debate. but according to cbo, we'll only cover 16 million more americans. that doesn't seem like a very good return for a bill that seeks to cover three times that many people, with 37 million people projected to be uninsured in 10 years. in addition, the cbo says that 15 million people would lose their employer-sponsored insurance, and another 8 million would lose coverage from their current source. president obama has consistently promised that if you like the health insurance plan you have you can keep it. well, under this bill, according to cbo, 23 million americans who may like what they have, cannot in fact keep it. i can't even imagine how much more this bill will cost taxpayers when cbo figures in the rest of the initiatives in this bill. and those that are forthcoming tomorrow. and i

senator enzi from wyoming likes to talk about the 8020 rule. senator kennedy, a liberal member, and senator enzi, a scervellive member, they get a lot done in the health, labor, and pensions committee, focusing on the 80% they agree on and set aside the 20% they don't agree on and focus on where the most agreement is. we need a similar approach in the, as we prepare to mark up in the finance committee the health care bill to go along with areas and work in the help committee. i strongly agree with senator balk and senator grassley, we need a bipartisan bill. many democrats and republicans, we need a bipartisan bill. my fear is if we don't have a bipartisan bill we will not be successful. while there's -- most of the media coverage of the health care debate is focusing on the conflict, should we have a public plan or not? tax exclusion? what portion of our benefits should be excluded from taxation? should there be employer mandate? setting that aside, but there is huge agreement on a bunch of things that are important that are going to save mone

enzi. i get tired, i think the american people do, about hearing the word medicare fraud. the implication is we have people who work for medicare, who work for the government that are dishonest. we've done little research. it's not defensive. i am not aware of major examples where people who work for medicare, work for the government have been dishonest, have been on the take. there may be. when we talk about medicare fraud what we are really talking about is pharmaceutical industry fraud against medicare. insurance company fraud against medicare. private hospital insurance fraud against medicare. my hope is that we'll refer to fraud with medicare and medicaid we put our finger, who is committing the fraud? it's not medicare. i would hope we rephrase our language in that regard. >> i think it's medicare and medicaid that have the obligation to be doing the enforcement of it. >> that's fair enough. we don't and we can make that better. for example, if somebody doesn't pay their taxes and they go to jail or they don't get a government job, we don't say it's the irs fraud. we

i'm committed to it, i know mike enzi is. and we don't obviously agree on all these matters but you are always thoughtful, you know what you're talking about. you make a significant contribution and you've been with us virtually every day most of the time on these matters. and i want you to know i welcome that kind of participation as a newer member over the last several years. and judd greg and i have worked on countless issues over the years and i have great respect for him. i think virtually every one of you at one point or another we have worked on something together. i'm not going to rush anything on you. to try to get it done but i do want to keep working at it. if we could just hear on your amendment so we can move along. >> i will, but let me just express my concern. if we pass the wrong bill, if we're not thoughtful and think about all the contingencies we're going to do, we neert going to help health care, we're going to hurt it. the presumption on this bill is we're going to spend according to president obama $1.3

>> no. >> senator enzi? >> aye. >> senator gregg? >> aye. >> senator alexander? >> aye. >> senator burr? >> aye by proxy. >> senator mccain? senator hatch? senator murkowski. senator roberts? >> the senator is recorded. senator, would you like to be voted as aye? >> chairman kennedy? >> no by proxy. >> 14 ayes -- or no, 11 ayes, 14 noes. >> the amendment is not agreed to. senator murray? >> mr. chairman, we are now ready to accept murkowski number 23 as modified. ask unanimous consent it be accepted. >> any objections to senator murkowski number 23 as modified? without objection, the amendment is agreed to. next up? >> mr. chairman, we have a meeting. >> do you have a meeting. maybe it's just as wise at this juncture. my view would be as i said earlier, i know our republican friends have a meeting to attend. >> if i could ask, i know the republicans are going to leave, how many more amendments we expect on this? >> i have no idea where we are -- four? judd, do you have any further ones on this one? this section? >> on this title? >> so we have four -- >> we have