A bill to include the State of Idaho as an affected area under the Radiation Exposure Compensation Act (42 U.S.C. 2210 note).

Mr. President, I am somewhat troubled. Not more than 10 minutes ago, I say to my colleague, you sat right here and I sat right there. We struck an understanding that tomorrow we would rejoin on the floor to explain the situation. I said, by that time, as it was my understanding that the House would likely have acted upon the measure which was passed by the Senate last night, sponsored by the distinguished Senator from Michigan, who accepted my amendment. I am not sure why we are here at this time discussing this matter. My understanding was very clearly we would take it up tomorrow morning. Just by chance I caught the screen when I walked back to my office.

Would you kindly advise the Senator from Virginia what took place in the 10-minute interval since we left here?

Mr. President, but we solved, basically, the procedure. What troubles me is that the Senate took considerable time last night to resolve this issue--in favor of the Senator from Michigan and in favor of the Senator from Virginia.

There is a perfectly adequate bill sitting on the desk at the House of Representatives. It can be passed in 5 minutes if not less.

If my distinguished colleague will kindly grant me a few more minutes?

I repeat, there is a bill that has been acted upon unanimously by the Senate. It is at the House desk.

This morning was the first time I ever heard that the Congresswoman, in whose district this courthouse is, desires to have her bill--not your bill. Is that my understanding?

Why can't the Congressional Record of the debate, the traditional report language that accompanies the bill, explain, give her full credit or whatever she desires? But to continually come back and forth and raise the specter that people are trying to interfere with this important legislation in this Chamber, it seems to me, is not fair.

This is a matter that is being followed with great interest because of the magnificent Rosa Parks, and the outpouring of empathy and sympathy, and so forth. I don't wish to have the institution of the Senate appear that it has not acted promptly. It did so last night. There is a perfectly legitimate bill at the House desk which could be passed in a matter of 5 minutes and be sent to the President for signature to honor both Mrs. Parks and Judge Bryant. In report language the Senator from Michigan and the good Congresswoman can solve it in any way they may wish as to allocate the credit.

I think to keep coming back to the Senate implying that we can't use the bill this body passed yesterday evening is, in a way, diminishing the previous action of this institution. It is my understanding that tomorrow the House of Representatives will take up and pass the Senator from Michigan's bill, as passed by the Senate, to name a federal building in Michigan for Rosa Parks and name the new courthouse annex here in Washington for Judge William Bryant.

I must tell you, I have been very patient about this matter. But I hope that we understand the agreement between the two bodies to proceed in this manner. It has been cleared by both the House and the Senate and, as such, is the appropriate course of action.

For the past three years I have been working with my colleagues, Congresswoman Eleanor Holmes Norton and Senator Leahy to name the new annex to the Prettyman Courthouse here in Washington, DC for Judge William Bryant. As I have stated numerous times before, there are rules in the Senate Environment and Public Works Committee that prohibit moving through that Committee naming bills for individuals that are still living. Prior to the current Chairman of the Committee, the rule was waived in certain instances and I certainly feel that the case of Judge Bryant warrants such discretion. The Senate spoke yesterday that both Rosa Parks and William Bryant are deserving of this great honor.

I wish to share with the Senate again the story of this distinguished jurist, Judge William Bryant.

A product of Washington, DC public schools, William B. Bryant graduated from Howard University in 1936, a classmate of Thurgood Marshall and Appellate Judge Spotswood Robinson. He graduated from Howard Law School first in his class and then, with no real opportunities for African-American attorneys in the District of Columbia, served as chief research assistant to Ralph Bunche, who later won the Nobel Prize. From 1943 to 1947, he was in the Army and rose to the rank of lieutenant colonel during World War II. He was a criminal defense attorney, Assistant U.S. Attorney, the first African American ever to be an Assistant U.S. Attorney in the Nation's Capital. I was privileged to be in the U.S. Attorney's Office during some of his tenure there and worked with him. He was a teacher to me and many others. He was appointed to the U.S. District Court in 1965. In 1977, he was appointed the first African American to be chief judge of the U.S. District Court.

Now at the age of 94, Judge Bryant is serving as a Senior Judge on the United States District Court for the District of Columbia. This man, like Rosa Parks, suffered from discriminatory practices and persevered, therefore breaking new ground for African-Americans to come. When he first began trying cases as an Assistant U.S. Attorney in 1951, the Bar Association of D.C. did not allow African-American members. William Bryant, while trying cases in District Court was unable to access the law library at the Courthouse like his white colleagues. Despite the obstacles, William Bryant succeeded.

Over the years this man has been a fixture at that courthouse, first trying cases, and for the past 40 years, hearing them as a judge. The D.C. Bar and his colleagues have unanimously endorsed the legislation I offer today as a tribute to this man's truly extraordinary life, legendary career, and service to this nation's judicial system. I wish at this point to print into the Record a September 2004 article from the Washington Post about Judge Bryant and our efforts to name this new annex in his honor:

A Lifetime of Faith in the Law; At 93, Senior Judge William

Bryant Still Wins Plaudits for Dedication to Justice, Carol

Leonnig, Washington Post Staff Writer--September 16, 2004

A few days after the new U.S. District Courthouse opened on

Constitution Avenue in the fall of 1952, Bill Bryant walked

in to start work as a recently hired federal prosecutor.

More than a half-century has passed, and Bryant's life

remains centered on that stately granite building in the

shadow of the U.S. Capitol. It's in those halls that he

became a groundbreaking criminal defense attorney, a federal

judge, and then the court's chief judge--the first African

American in that position.

Today, at the age of 93, U.S. District Court Senior Judge

William Bryant still drives himself to work at the courthouse

four days a week and pushes his walker to his courtroom.

At a recent birthday party for Bryant hosted by Vernon

Jordan, fellow Senior U.S. District Court Judge Louis

Oberdorfer remarked that there were ``only two people in the

world who really understood the Constitution'' and how it

touched the lives of real people.

``That's Hugo Black and Bill Bryant,'' said Oberdorfer. He

had clerked for Justice Hugo L. Black, who retired as an

associate justice in 1971 after serving on the Supreme

Court for 34 years.

To honor Bryant's life's work, his fellow judges this past

spring unanimously recommended that a nearly completed

courthouse annex be named for him. The $110 million, 351,000-

square-foot addition will add nine state-of-the-art

courtrooms and judges' offices to the courthouse and is

designed to meet the court's expansion needs for the next 30

years. It is slated to open next spring.

In urging that the building be named for Bryant, his

supporters cite his devotion to the Constitution and his

belief that the law will produce a just result.

During a rare interview in his sixth-floor office in the

federal courthouse, Bryant reached out for a pocket version

of the Constitution covered in torn green plastic lying on

the top of his desk. Holding it aloft in his right hand, he

told stories of his struggling former clients and made legal

phrases--``due process'' and ``equal protection''--seem like

life-saving staples.

Though he needs his law clerk's arm to get up the steps to

the bench, he is a fairly busy senior jurist. He handled more

criminal trials than any other senior judge last year and

still surprises new lawyers with his sharp retorts.

``I feel like I'm part of the woodwork,'' Bryant said. ``I

have to think hard to think of a time when I wasn't in this

courthouse.''

He started down his career path inspired by a Howard

University law professor who believed that lawyers could make

a difference in that time of racial segregation and

discrimination. Bryant said he remains convinced today that

lawyers can stop injustice whenever it arises.

``Without lawyers, this is just a piece of paper,'' Judge

Bryant said, gesturing with the well-worn Constitution. ``If

it weren't for lawyers, I'd still be three-fifths of a man.

If it weren't for lawyers, we'd still have signs directing

people this way and that, based on the color of their skin.

If it weren't for lawyers, you still wouldn't be able to

vote.

The most important professions are lawyer and teacher, in

my opinion,'' he said.

Some lawyers complain that Bryant is so rooted in his

criminal defense training that he shows some distrust of the

prosecution. And his practice of presiding over trials, but

asking other judges to sentence the people convicted, has

spurred some curiosity. He won't elaborate on the reason, but

his friends say he found the new federal sentencing

guidelines inflexible and harsh.

A 1993 study found Bryant was reversed 17 percent of the

time by appellate judges--the average reversal rate for the

trial court.

Chief Judge Thomas F. Hogan presented the proposal to name

the annex after Bryant to Del. Eleanor Holmes Norton and Sen.

Patrick Leahy (D-Vt.) earlier this year, and they are now

trying to get Congress to approve the naming this fall. One

member, Sen. James M. Inhofe (R-Okla.), has tried to block

it, with his staff pointing to a D.C. policy that buildings

not be named after living people.

Norton said numerous courts around the country have been

named in honor of living judges, and she said she looks

forward to meeting with Inhofe in person to convince him of

the wisdom of naming this building, designed by renowned

architect Michael Graves, after a barrier-breaking judge.

``This is no ordinary naming,'' she said. ``This is a truly

great African American judge whose accomplishments are

singular. First African American assistant U.S. attorney.

First African American chief judge.''

E. Barrett Prettyman Jr., the son of the jurist for whom

the federal courthouse in

Washington is named, also applauds the proposed annex naming.

He said his father ``admired Judge Bryant tremendously'' and

would have endorsed it, too.

``Whenever it's discussed, people brighten right up and

think it's a great idea,'' said Prettyman, himself a former

president of the D.C. Bar Association. ``I'm sorry it's hit

this snag. . . . If you were going to have an exception, my

personal opinion is you could not have a better exception

than for Judge Bryant.''

William Benson Bryant is hailed as a true product of

Washington. Though he was born in a rural town in Alabama, he

moved to the city soon after turning 1. His grandfather,

fleeing a white lynch mob, relocated the extended family

here, including Bryant's father, a railroad porter, and his

mother, a housewife. They all made their first home on

Benning Road, which was then a dirt path hugging the eastern

shore of the Anacostia River.

Bryant attended D.C. public schools when the city's black

children were taught in separate and grossly substandard

facilities. Still he flourished, studying politics at the

city's premier black high school, Dunbar, then going on to

Howard University. While working at night as an elevator

operator, he studied law and met his future wife, Astaire.

They were married for 60 years, until her death in 1997.

He and his law classmates--the future civil rights

movement's intellectual warriors--worked at their dreams in

the basement office of their law professor, Charles Houston.

Houston promised the group, which included the future Supreme

Court Justice Thurgood Marshall and appellate judge

Spottswood Robinson, that lawyers armed with quick minds and

the Constitution could end segregated schools and unjust

convictions of innocent black men.

``I kind of got fascinated by that,'' he said. ``We all

did.''

But when Bryant graduated first in his class from Howard's

law school, there were no jobs for a black lawyer. He became

a chief research assistant to Ralph Bunche, an African

American diplomat who later was awarded the Nobel Peace

Prize, on a landmark study of American race relations; he

then fought in World War II and was discharged from the Army

as a lieutenant colonel in 1947.

His first step was to take the bar exam, then hang out a

shingle as a criminal defense lawyer in 1948. His skills soon

drew the attention of prosecutors in the U.S. Attorney's

Office, who liked him even though they kept losing cases to

him, and they recommended that their boss hire him. During a

job interview, Bryant made a request of George Fay, then the

U.S. attorney: ``Mr. Fay, if I cut the mustard in municipal

court, can I go over to the big court like the other guys?''

No black prosecutor had ever practiced in the federal

court--or ``big court,'' as it was called--but Fay agreed.

Bryant signed on in 1951 and was handling grand jury

indictments in the new federal courthouse the next year.

Bryant vividly recalls a case from that time involving an

apartment building caretaker who was on trial on charges of

raping the babysitter of one tenant's family.

``I went for him as hard as I could,'' Bryant said,

squaring his shoulders. ``I didn't like him, and I didn't

like what he did to that girl.''

So the young prosecutor sought the death penalty, an option

then for first-degree murder and rape. He left the courtroom

after closing arguments ``feeling pretty good about my case''

and awaited the jury's verdict in his third-floor court

office. But when a marshal later called out, ``Bryant, jury's

back,'' the judge said, ``I broke out in a sweat.''

He peeked anxiously into the court, saw the jury foreman

mouth only the word ``guilty.'' Bryant learned seconds later

that the jurors had spared the man's life.

``I was so relieved,'' he said. ``When you're young, you

don't know anything. . . . Now I think, murder is murder, no

matter who is doing it.''

He left the prosecutor's office in 1954 and returned to

criminal defense with fellow classmate William Gardner in an

F Street law office later bulldozed for the MCI Center. They

were partners in Houston, Bryant and Gardner, a legendarily

powerful African American firm. Ten judges would eventually

come from its ranks.

In those days, Bryant chuckled, he didn't feel so powerful.

Judges who remembered his prosecution work kept appointing

him to represent defendants who had no money. That was before

the 1963 Supreme Court's Gideon decision requiring that

indigent defendants be represented by a lawyer--at public

expense, if necessary.

The judge would say, ``Mr. So and So, you say you don't

have any money to hire an attorney?'' Bryant recalled.

``Well, then, the court appoints Mr. Bryant to represent

you.''

Some paid $25 or $50. Some paid nothing.

``There were weeks we paid the help and split the little

bit left over for our groceries,'' he said.

Bill Schultz, Bryant's former law clerk, said Bryant took

the cases ``out of this sense of obligation to the court and

legal system. He was very aware of discrimination, and he

always fought for the criminal defendants.''

At the time, blacks were barred from the D.C. Bar

Association and its law library. Bryant went in anyway, and

the black librarian let him.

One of his pro bono clients was Andrew Roosevelt Mallory, a

19-year-old who confessed to a rape after an eight-hour

interrogation in a police station. Mallory was convicted and

sent to death row. Defending Mallory's rights, a case Bryant

took all the way to the Supreme Court in 1957, made him both

nervous and famous.

He said he fretted constantly about his client facing the

electric chair during the two years the case dragged on.

``You talk about worried,'' he said. ``It's something I can't

forget.''

But the Supreme Court agreed with Bryant that a man accused

of a crime is entitled to be taken promptly before a

magistrate to hear the charges against him. The court

overturned Mallory's conviction and handed down a landmark

decision on defendants' rights.

U.S. District Judge Paul Friedman, a longtime fan of

Bryant's, said Bryant's legal talents are on display every

day in his courtroom, but lawyers are still taken aback by

his factual resolve and clear logic when hearing an audiotape

recording of his Supreme Court argument in the Mallory case.

``He's clearly a terrific lawyer, but he's mostly a

terrific human being,'' Friedman said. ``He sees the best in

people, and he really cares about what happens to people.''

Bryant remembers that when President Lyndon B. Johnson

nominated him to be a judge, he felt elated, confident he had

earned his opportunity. But Bryant said a different feeling

came over him the day he donned the robes.

``I was sworn in in the morning that day, and Oliver Gasch

was sworn in that afternoon,'' Bryant recalled. ``I told

Oliver, `You know, I've been a lawyer for many years, but

putting on this robe, I don't feel so sure. This is a serious

responsibility.' ''

Gasch smiled: ``Bill, I don't think it's going to be that

hard for you. You know right from wrong.''

Bryant oversaw some famous cases, and he freely shared his

thoughts when he thought something was wrong.

After presiding over the 1981 trial of Richard Kelly, a

Republican congressman caught on videotape taking money from

federal agents in a sting operation, Bryant complained that

the FBI had set an ``outrageous'' trap for the Florida

representative by stuffing cash in his pocket after he'd

refused the bribe several times. He set aside Kelly's

conviction.

``The investigation . . . has an odor to it that is

absolutely repulsive,'' Bryant said then. ``It stinks.''

In handling the longest-running case in the court's

history, a 25-year-old case about inhumane and filthy

conditions in the D.C. jail, the judge chastised city leaders

in 1995. He said he had been listening to their broken

promises to fix the problems ``since the Big Dipper was a

thimble.''

In weighing the case of a group of black farmers with

similar discrimination complaints against the U.S. Department

of Agriculture in 2000, Bryant warned a government lawyer

that his argument against a class-action discrimination suit

wasn't working: ``Either you're dense or I'm dense,'' he

said.

Schultz said the judge simply trusted the combination of

facts and the law.

``He always said, `Don't fight the facts,' '' Schultz said.

``He thought most of the time the law would end up in the

right place.''

Bryant acknowledges it's hard sometimes to see lawyers

struggle to make their arguments when they have the law and

the facts on their side.

``A judge has a stationary gun, and he's looking through

the sights,'' he said. ``Unless the lawyer brings the case

into the bull's-eye, the judge can't pull the trigger. Good

lawyers bring the case into the sights.''

Bryant said he was preceded by many great lawyers, which is

why the new plan to put his name on a piece of the courthouse

gives him conflicting feelings.

``I was flattered, but I thought they shouldn't have done

it,'' Bryant said. ``There are so many people who were really

giants. I stand on their shoulders.''

I hope that henceforth there is senatorial courtesy--when we decide to proceed in a specific manner as we discussed, we would do it in the morning, I relied on that, and was about to go handle another matter when I noticed that the Senator was on the floor. I am somewhat concerned about that.

I wish to thank the Senator from Michigan for her courtesy in combining these two tributes and look forward to the action of the House tomorrow. It is truly a wonderful opportunity for the Congress to honor two American pioneers. Rosa Parks and Judge William Bryant both deserve to be recognized for their lives and contributions our nation's heritage. I have no objection to this bill moving forward as amended and look forward with great pride to both buildings being named shortly for these two pillars of the civil rights movement that brought so much to our country.

I yield the floor.

Mr. President, I rise today to join Chairman Grassley in introducing the Hospital Fair Competition Act of 2005.

This bill, based primarily on recommendations of the Medicare Payment Advisory Commission (MedPAC), will improve the accuracy of Medicare's inpatient hospital prospective payment system (PPS); prevent the establishment of new specialty hospitals to which physician-owners can self-

refer, while allowing existing physician-owned specialty hospitals to continue with restrictions; and allow ``gainsharing'' arrangements to foster improved physician-hospital efficiency. This legislation is important for patients, taxpayers, and the Medicare program, and I urge my colleagues to support it.

About 17 months ago, Congress passed the Medicare Modernization Act-- the MMA. This 400-page bill included many important provisions, including long-awaited outpatient drug benefits under Medicare.

The MMA also included a small provision--Section 507--related to the construction of physician-owned specialty hospitals. These facilities specialize in cardiac, orthopedic or general surgical care, and are partly- or wholly-owned by physicians. The provision was a response to growing concerns over physician self-referral, and placed a moratorium on the construction of new, physician-owned specialty hospitals, while ``grandfathering'' existing facilities and those in development.

Having reviewed several independent analyses on this issue, I believe Congress was right to place a moratorium on specialty hospital construction. And I also believe that moratorium should effectively be extended permanently, while allowing existing facilities to continue operating in their current capacity.

Some view specialty hospitals as innovative, focused factories for high-quality, specialized care. Advocates for these facilities say that by focusing on a limited number of services, specialty hospitals provide excellent care at a good price, while adding competition to the health care marketplace.

Others say specialty hospitals flourish because they exploit a Medicare loophole allowing physician-owners to select patients who are healthier and, therefore, more profitable.

For my part, I don't want to stand in the way of innovation or competition. For example, I'm glad that Congress brought innovation to Medicare in the form of outpatient drug benefits. That was long overdue.

And hospitals and physicians should work together in innovative ways to improve efficiency in health care. The U.S. spends twice as much--or more--per-person on health care compared to any other developed country. And yet, our health outcomes are worse than theirs. We should get a better bang for our health-care buck, and we can take steps to that end by encouraging quality and accountability in health care.

That's why I am pushing to advance incentives for quality improvement in Medicare, so patients--and taxpayers--get the most for their money. I introduced legislation last year to require that Medicare pay dialysis providers and Medicare managed care plans based on the quality of care they provide. And I am working on legislation to extend these principles of paying for quality to other parts of Medicare.

As for competition, I'm all for it--as long as it's carried out on a level playing field. But when it comes to physician ownership of specialty hospitals, I'm not convinced the playing field is level. That's because physicians alone choose where patients go on the playing field--either to community hospitals or specialty hospitals. Some liken physician-owners of specialty hospitals to coaches who choose the starting lineup for both teams--in this case, the specialty hospital team and the community hospital team.

And for the third time, a Federal agency has told us that the healthiest teams, that is, the most profitable patients, end up at physician-owned specialty hospitals.

In 2003, the non-partisan Government Accountability Office (GAO) reported that, by and large, specialty hospitals care for relatively healthier patients than their community hospital counterparts. GAO surveyed 25 specialty hospitals, and found that 21 of the 25 had a less acute mix patients than community hospitals. GAO determined that of the hospitals studied, 17 percent cardiac patients seen by specialty hospitals could be classified as severe cases, compared with 22 percent in general hospitals. And about 5 percent of orthopedic cases in specialty hospitals were severe, compared with 8 percent in community hospitals.

Earlier this year, on March 8, MedPAC issued its MMA-mandated report on specialty hospitals, and arrived at findings similar to those of the GAO. MedPAC found that despite shorter lengths of stay, physician-owned specialty hospitals are not more cost efficient than community hospitals. MedPAC found that specialty hospitals tend to treat lower shares of Medicaid patients than community hospitals. And, just as GAO did, MedPAC found that specialty hospitals treat patients who are generally less sick--and therefore, more profitable--compared to community hospitals.

And while the Department of Health and Human Services has not officially issued its MMA-mandated report on the topic--but is expected to shortly--HHS reported on March 8 that, based on the small number of facilities it studied, specialty hospitals tend to care for a healthier patient population than their community hospital counterparts.

I believe the phenomenon of specialty hospitals treating healthier patients is the result of a loophole in the Stark self-referral law. This loophole--related to the ``whole hospital exception''--is one that should be closed. If it is not closed, Congress will effectively sanction the practice of physician self-referral that has been prohibited for years.

In 1989, the HHS Inspector General reported that patients of referring physicians who owned or invested in independent clinical labs received 45% more lab services than Medicare patients in general.

In 1992, a study found that physical therapy visits per patient were 39% to 45% higher in facilities with physician ownership compared to those without. In short, the authors of the study found that utilization and charges per-patient were higher when facilities were owned by physicians with an ownership interest.

In response to these studies and others like them, Congress passed the Stark laws, to prevent physician self-referral, first in the area of clinical labs, and subsequently in 10 other areas, including physical therapy and certain imaging procedures.

But the Stark laws did not address the issue of physician self- referral to specialty hospitals. In part, that's because there weren't many specialty hospitals at the time. As the GAO pointed out in its 2003 report, the vast majority of specialty hospitals were built in 1992 or later.

Instead, the Stark law included a provision that has come to be known as the ``whole hospital exception.'' While the Stark law prohibits physicians with ownership interest in only a hospital department from referring patients to that department, the law does allow physicians to refer to a facility they partially own, under two conditions. First, the physician must have admitting privileges in that hospital. Second, the physician must have a financial interest in the ``whole hospital,'' not just a department of the hospital.

As the GAO explained in 2003:

``The premise [of the whole hospital exception] is that any

referral or decision made by a physician who has a stake in

an entire hospital would produce little personal economic

gain because hospitals tend to provide a diverse and large

group of services. However, the Stark law does prohibit

physicians who have ownership interest only in a hospital

subdivision from referring patients to that subdivision. With

respect to specialty hospitals, the concern exists that, as

these hospitals are usually much smaller in size and scope

than general hospitals and closer in size to hospital

departments, the exception to Stark could allow physician

owners to influence their hospitals'--and therefore their own

financial gain through practice patterns and referrals.''

The problem with the ``whole hospital'' loophole is that it treats a 10-bed surgical facility the same as a 500-bed community hospital, even though that 10-bed facility more resembles a department of the 500-bed hospital than it does the hospital itself. This loophole is unfair, and our bill closes it, by preventing the establishment of new specialty hospitals to which physician-owners can self-refer.

Let me note that our bill does nothing to prevent the construction of new specialty hospitals--as long as self-referral is not part of the business model. Hospitals specializing in one type of care or another have existed in this country for years, and should be encouraged--as long as their owners and referrers are not one and the same.

Opponents of this bill will likely make at least three claims. First, they

will state that preventing the construction of new, physician-owned specialty hospitals is anticompetitive. Second, they will suggest that since the average physician-owner's share in a specialty hospital is small, economic incentives to self-refer are minimal. Third, they will claim the bill thwarts health care quality. Let me take these claims in turn.

As I stated previously, I am all for competition--as long as it's fair. But I don't think it's fair to further a system in which physician-owners can send healthier and more profitable patients to facilities they own, while sending sicker, less-profitable ones to hospitals they don't own. There's a reason Congress acted to mitigate the effects of physician self referral over 15 years ago, and I see no reason why that principle should not be extended to the specialty hospital setting.

On the issue of economic incentives, some argue that physician self- referral to specialty hospitals is a non-issue, since physicians typically own a very small share of a particular facility. In fact, MedPAC found that in about one-third of specialty hospitals they surveyed, the largest share owned by a single physician was just two percent. And as a group, physicians own just over a third of the typical heart hospital. But MedPAC also pointed out that about one- third of orthopedic and surgical hospitals were owned almost entirely by their physicians. Perhaps more important, MedPAC showed that even a relatively small ownership interest can reap large profits for an individual physician investor. Page 21 of MedPAC's March report on specialty hospitals says:

What is the order of magnitude of physicians financial

incentives to increase utilization when they own a hospital?

What follows is a hypothetical example of the marginal profit

associated with a group of cardiologists each referring just

one additional patient (above the current patient load) for

coronary artery bypass graft (CABG) surgery. In fiscal year

2002, the base payment for CABG surgery with cardiac

catheterization (DRG 107) was roughly $24,000. Our

examination of Medicare cost reports and hospital financial

statements suggests that variable costs equal approximately

60 percent of the DRG payment, roughly $14,400. Hence the

marginal profit--payments minus variable cost--would be

$9,600 per patient ($24,000-$14,400). If 10 cardiologists

owned a 3 percent interest each and they all induced one

additional surgery per year, each cardiologist's income would

increase by $2,880 ($9,600 3% 10).''

In other words, even a small ownership share--just three percent--can provide a strong profit motive--and a strong incentive toward self- referral.

Finally, let me address the third claim that will likely be made against this bill--that it thwarts the provision of quality care. Specialty hospital advocates claim that due to the focused nature of their mission, physician-owned specialty hospitals provide better quality and outcomes than their community hospital counterparts. But recently the New England Journal of Medicine published a study showing that patients undergoing certain heart procedures in specialty hospitals were less likely to have coexisting conditions than those being treated at general hospitals. The authors of the study stated, ``. . . given that we found no significant differences in outcomes between specialty and general hospitals with similar volumes or between specialty cardiac hospitals and specialized general hospitals, it could be argued that the specialty-hospital model itself does not yield better outcomes.'' They also said, ``. . . our study provides no definitive evidence that cardiac specialty hospitals provide better or more efficient care than general hospitals with similar procedural volumes.''

In short, there is solid evidence that despite being less efficient, physician-owned specialty hospitals care for healthier, more-profitable patients, leaving community hospitals to care for sicker, less- profitable ones. Economic incentives toward physician self-referral in specialty hospitals are significant. And there is slim evidence that specialty hospitals provide better care than community hospitals.

Given this evidence, it's clear that Congress should not facilitate the construction of more physician-owned specialty hospitals. And while we support ``grandfathering'' existing facilities, let me make clear that we do not intend to create another grandfathering period if the legislation is not enacted before June 8, 2005. The intent of this bill, even if it passes after June 8, is to effectively make permanent the MMA-mandated moratorium.

But this bill does more than simply prevent the establishment of new, physician-owned specialty hospitals. It also takes steps to mitigate ill incentives in the inpatient PPS, by making the PPS more accurate for all providers of hospital care--community hospitals and `grandfathered' specialty hospitals alike.

Medicare spends about $100 billion per year on inpatient hospital services, and it's important that this system be accurate. Accordingly, MedPAC recommended a number of steps to improve the accuracy of the Medicare inpatient payment system. These recommendations should mitigate incentives for all hospitals to choose healthy patients over sick ones, and to focus on some diagnoses at the expense of others.

Medicare pays hospitals for inpatient services based on roughly 500 Diagnosis Related Groups (DRGs), which bundle services needed to treat a patient with a particular disease. DRGs cover most routine operating costs attributable to patient care, including routine nursing services, room and board, and diagnostic and ancillary services. Under current law, just over five percent of the base payment for all DRGs is set aside for inpatient outlier payments, even though some DRGs have almost no outlier cases. The Hospital Fair Competition Act directs the Secretary to adjust the DRG relative weights to account for differences in the prevalence of high-cost outlier cases, thereby removing their disproportionate impact on the payment system.

The bill also improves accuracy of the DRG weights. Currently DRG weights are based on the national average of hospital charges for a particular DRG. The rate of growth for these charges may vary dramatically, depending on the service. For example, MedPAC has found that hospital markups for ancillary services (e.g., supplies, operating room time) tend to be higher than those of routine services (e.g., room and board, nursing care). As these ancillary and routine charges grow at different rates, the DRGs reflect that growth, gradually skewing the system away from the true costs of providing care. In short, a charge- based system causes Medicare to pay too much for some services, not enough for others. The Hospital Fair Competition Act directs the Secretary to substitute the charge-based system with one based on hospitals' costs, as well as base the DRG weights on the national average of hospitals' relative values in each DRG.

Mind you, we believe that the Secretary currently has the authority to make the payment changes outlined above. The Hospital Fair Competition Act simply directs the Secretary to do so. We also believe the Secretary has the authority to promulgate regulations defining what a ``whole hospital'' is. When Congress passed the ``whole hospital exception'', it did not intend to allow self-referral to facilities that are effectively the equivalent of a hospital wing or department. We believe the Secretary can and should exercise his authority to close the ``whole hospital'' loophole by regulation.

Mr. President, some say that the proliferation of physician-owned specialty hospitals is a function of physicians' desire for control over their workplace. They argue that physicians typically have no say in day-to-day hospital operations, and thus little incentive to improve the quality or efficiency of the care they provide in the hospital. MedPAC's recommendations for ``gainsharing'' stand to alleviate some of that concern, by giving physicians more control over their workplace.

Gainsharing arrangements allow physicians and hospitals to improve hospital efficiency without the undesirable effects of physician self- referral. In a gainsharing arrangement, hospitals and physicians share cost-savings gained by means such as streamlining the purchase of medical devices, substituting less-costly items used in surgical procedures, and maximizing operating room efficiency. While gainsharing arrangements must be developed carefully so as not to compromise quality of patient care, gain sharing has the potential to align physician-hospital incentives so that care

can be delivered in the most cost-effective manner.

I realize that gainsharing arrangements are not a panacea toward improving physician-hospital relations. We can and should do more to give providers of all types a better stake in improving their workplace and the quality of care they provide. That's why I am pushing initiatives to tie Medicare payment to quality, so that--unlike the current system--the best providers are not paid the same rates as mediocre ones. This system of paying for quality stands to improve accountability across the spectrum of Medicare provider types, and give both patients and the government more for their money.

We all know that Medicare's long-term fiscal future is much in doubt. Hardly a day passes without a warning about Medicare's finances and the retirement of the Baby Boom generation that will complicate the long- term financial picture of the program.

Given these warnings, it's imperative that we make the most of the resources at hand, and--where possible--make Medicare a better more responsible buyer of health care. By leveling the playing field regarding patient referrals; improving the accuracy of Medicare's inpatient hospital payments; and giving physicians a larger stake in their hospital workplaces, this bill stands to do that.

Chairman Grassley and I believe these changes will go a long way toward improving much of what ails hospital payment under Medicare, and we urge our colleagues' support for this important legislation.

Mr. President, very briefly, Senator Harkin is due great credit for this very important amendment, having taken the lead in establishing the fund. We have structured it, after consultation with a number of our colleagues, so that funds will be expended at the discretion of the President, after consultation with certain named Members of both the House and the Senate. This is in anticipation of the administration sending over a proposal in which we should have ample time to give due consideration before the conference.

This is a very significant step forward so that we do not face a crisis where the administration wants something done, but only the Congress, under the Constitution, has the authority to appropriate the funds.

I salute my colleague, Senator Harkin, and all those who worked on the amendment.

We jointly urge its adoption.

Amendment No. 2283, As Further Modified

I move to reconsider the vote.

Mr. President, we are now in a position to move to a number of amendments on which there is agreement. As we review the bidding here, there are prospects for several more rollcall votes. It is, as usual, impossible to tell whether we will need the rollcall votes. We are calling the Senators rather than identifying them on the floor--identifying them on the floor is the next step--but Senators know who they are, where they are on the prospect of rollcall votes, and they ought to come to the Chamber because we have had many inquiries as to when we are going to conclude this bill. We are getting very close.

Amendment No. 2324

Mr. President, I call up amendment No. 2324 on behalf of Senators Warner and Allen. This amendment expresses the sense of the Senate that the Administrator of the Centers for Medicare and Medicaid Services work with the Commonwealth of Virginia to resolve their Medicaid issues.

I urge adoption of the amendment. It has been cleared with Senator Harkin.

Mr. President, I now call up Senator Feingold's amendment No. 2279, as modified.

Mr. President, I now call up amendment No. 2299, proposed by Senator Cochran, and ask for its immediate consideration.

Mr. President, I now call up amendment No. 2301, proposed by Senator Obama, and ask for its immediate consideration.

Mr. President, I now call up amendment No. 2327, proposed by the distinguished Senator from Minnesota, Mr. Coleman, and the distinguished Senator from New Mexico, Mr. Bingaman, and ask for its immediate consideration.

Mr. President, I now call up amendment No. 2248, as modified, for Senator Landrieu.

Mr. President, I now call up amendment No. 2250, as modified, proposed by Senator Landrieu.

Mr. President, I call up amendment No. 2215, as further modified, proposed by Senator Sununu.

Mr. President, I now call up amendment No. 2276, as modified, proposed by Senator Domenici.

Mr. President, I now call up amendment No. 2262, as modified, proposed by Senator Bingaman.

Mr. President, this amendment provides for an additional $75 million from the AIDS Drug Assistance Program. The bill currently contains $797,521,000. It has an increase of $10 million over last year. As is the case with so many of the items, it is a very good program. We would like to have more money, but we simply do not have an offset.

If the sponsors of the amendment have some offset and want to talk about priorities, we will be glad to listen, but on this state of the record, we are constrained to oppose the amendment.

I suggest the absence of a quorum.

Mr. President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. President, I make a point of order under section 302(f) of the Congressional Budget Act that the amendment provides spending in excess of the subcommittee's 302(b) allocation under the fiscal year 2005 concurrent resolution on the budget.

Mr. President, I move to reconsider the vote.

Mr. President, the Senator from Massachusetts has an amendment which Senator Harkin and I have discussed with him. I believe it is acceptable. I yield now to Senator Kerry so he can state his amendment.

Mr. President, will the Senator yield for a question?

We have an amendment by the Senator from California, Mrs. Boxer, who is on the floor and ready to go with her amendment. My suggestion would be--we have culled the list, we have called everyone, we know of no other rollcall votes--that we move to third reading when we conclude the Boxer amendment.

We have had continuous requests, multiple requests. Senators want to know when we are going to conclude. We are very close to concluding. Let us, if it is agreeable to my ranking member, take up the Boxer amendment, and then have an interlude for anybody else who has an amendment. Then we will go to third reading and final passage.

As previously announced, Senator Boxer is next. Then we have the amendment of the Senator from Nevada, Mr. Ensign. We will have two back-to-back rollcall votes on Senator Boxer's amendment and Senator Ensign's amendment. Then we will be in a position to have some additional voice votes on about half a dozen amendments. Then we are in a position to go

to final passage. Our colleagues can be informed that we are moving right along. That should conclude the bill.

Mr. President, I commend the Senator from California for offering this amendment on afterschool funding. I agree with her about the importance of the program. It is a line of community support which I have recognized for several decades since I was district attorney for Philadelphia, since I saw firsthand the high incidence of crime committed during the hours between the time students leave school and the time they see their parents. Senator Harkin and I have been very solicitous about this program and have made very substantial increases going back to 1998 when we added $39 million; in 1999, we added $160 million; in 2000, we added $253 million; in 2001, we added $392 million; in 2002, we added $154 million. We took a program which was funded at $40 million in 1998 and we brought it right up to the billion dollar mark. It is a tremendous program.

One of the grave difficulties of managing this bill is to oppose so many amendments which are good. We had to oppose Senator Byrd's $5 billion for title II, Senator Kennedy's addition to Pell grants, Senator Dodd on daycare, Senator Clinton on special education, and so it goes. If you want to amass a terrible voting record, be chairman of the Appropriations Subcommittee on Labor, Health and Human Services and Education. It is a great place to do it.

I wish we had more of an allocation. I know how sincere the Senator from California is about this program. I very much regret being constrained to oppose it.

I do.

We will keep a sharp eye on this program in conference. If there is any way to increase the funding to any extent, Senator Harkin and I will be very sympathetic.

Mr. President, with reluctance, I have to raise a point of order. This will push us over the brink. Under section 302(f) of the Budget Act, this amendment would create a situation where the authority and outlays would be in excess of the subcommittee 302(b) allocation for the fiscal year 2006. I expect the Senator from California to move to waive.

Mr. President, we will now proceed to the amendment of the Senator from Nevada. It is the anticipation of the managers following that amendment that we will have two rollcall votes.

I ask unanimous consent that after the yeas and nays have been ordered, the first rollcall vote be 15 minutes plus 5 and the second a 10-minute rollcall vote, 10 minutes plus 5.

Mr. President, at the request of Senator Ensign, I ask unanimous consent that his name be taken off as a cosponsor of the Boxer amendment because there was a change in the modification.

Mr. President, my comments will be very limited as to the pending amendment.

Last year, in the conference report, there was a direction that the Department not fund any grant that will compete directly with the private sector, and further that the Department report to the Committees on Appropriation of the House and the Senate on the activities undertaken on this project. It is my understanding that no funds were used on this project last year.

It is a little hard to evaluate the factual basis as I listen to the arguments of the Senator from Tennessee and the Senator from Nevada. However, my own judgment in looking at the record is that it is unlikely any funds are going to be spent which would--we will include the same kind of conference language next year, this year, that we had, which should maintain and should respond to the concerns about any grant which will compete with the private sector, and it leaves the Department of Education at their discretion to use this system if they conclude it will help Chinese students of any age to learn English.

On the basis of a very limited record, my vote will be cast with the Senator from Tennessee.

In the absence of further debate, can we proceed to two amendments?

Mr. President, the plan at this point, under the unanimous consent agreement already reached, is to have a 15-minute plus 5 rollcall vote on the Boxer amendment, a 10-minute rollcall vote plus 5 on the Ensign amendment, and then we will be very close to final passage.

The concern has been to submit the colloquies and have a few voice votes now, but I want to be sure when our colleagues come to vote on these two amendments we know the lay of the land, in case anybody has not been notified and wants to have a further consideration. But it would be the anticipation of the managers, following these two votes, there would be a very brief period of time, and then we would go to final passage and conclude the bill.

I yield the floor.

Vote on Amendment No. 2287, as Modified

Mr. President, I move to reconsider the vote and to lay that motion on the table.

The motion to lay on the table was agreed to.

Mr. President, I ask unanimous consent to move to the vote on the Ensign amendment.

Mr. President, I thank my colleagues. That last 15- minute vote was 14 minutes. We now have a very brief period for colloquies and some agreed-to amendments. Senator Harkin and I wanted to be sure that we hadn't missed anybody, so we did not do this in advance of the last two votes, but we will take only a few minutes and I anticipate that we will start this vote before 6 o'clock, which is not too bad for Labor-HHS on a Thursday afternoon.

Amendment Nos. 2322, 2285, 2277, and 2233, Withdrawn

Mr. President, I ask unanimous consent that amendment Nos. 2322, 2285, 2277, and 2233 be withdrawn.

Mr. President, I urge adoption of the Coburn amendment No. 2230, as modified.

Mr. President, Senator Levin's amendment No. 2282 provides for the Secretary to undertake a family unification effort. No funding is involved. It is language only. It has been cleared by Senator Harkin.

Mr. President, I call up amendment No. 2289, as modified, proposed by Senator Dayton.

Mr. President, I call up Senator Enzi's amendment No. 2295, as modified.

Mr. President, I call up Senator Coburn's amendment No. 2234, as modified.

Mr. President, I call up Senator Harkin's amendment No. 2280.

Mr. President, I call up amendment No. 2272, proposed by Senator Nelson of Nebraska.

Mr. President, if no other Senator has any amendment to offer, we are now ready for final passage.

I yield to Senator Frist.

Mr. President, as a final word, Senator Harkin and I thank our very devoted staff: Bettilou Taylor, Ellen Murray, Jim Sourwine, Mark Laisch, Sudip Parikh, Lisa Bernhardt, Candice Rogers, Rachel Jones, Erik Fatemi, and Adrienne Hallett.

I notice Senator Grassley is waving his arm. He is here 6 minutes early. Let the record show it is 5:53.

I say to my colleague that I am aware of these examples and I share his concern.

I have. And I say to the Senator that the bill before us provides funding for a number of programs that are consistent with the academy's report. One such program I know my colleague is familiar with is the Mathematics and Science Partnership, MSP, program that provides grants to improve basic student performance in math and science through a variety of programs and activities. Many of the program's allowable activities, like summer institutes for teacher training, are specific activities the National Academy recommends we pursue in order to enhance our children's development in science and math. The committee has provided a total of $178.5 million for mathematics and science programs in fiscal year 2006. The House-passed bill includes $190 million for this program.

We are, of course, working under a tight budget with this bill, but I want my colleague to know that as we move to conference, I will work to ensure this program, and other similar math and science programs receive the highest possible amount of funding.

I thank my good friend from Georgia for his remarks. I am very proud of the role the committee has played in establishing and expanding the arthritis program at CDC. I believe deeply in the vital role of the CDC and its partners in this important battle and, yes, the committee has provided funds to sustain this cooperative relationship.

I thank the senior Senator from North Carolina for her continued interest in this critical program. I want to assure her that the Senate Appropriations Committee strongly opposes the House rescission to the Community-Based Job Training Grants, and we are committed to funding the program at the highest level possible within the existing budgetary constraints. I thank the senior Senator from North Carolina.

I, too, recognize the importance of correct information, prevention, and early detection in health care. Clearly, efforts must be made to encourage men to address their health problems in a confident, timely, and meaningful manner. I encourage the administration to work with my distinguished colleague to establish an Office of Men's Health within the Department of Health and Human Services.

I yield to the Senator.

I appreciate the Senator's interest in this issue and recognize that he has legislation pending in Congress to address the needs of affected Idahoans. I say to my friend and colleague that I will work with him to identify necessary improvements and to respond to findings contained in the NAS report. I also urge the administration to work diligently to help those still in need.

I am aware of this issue too. I note that thimerosal has been out of childhood vaccines since 2001. I understand that the AAP doesn't think there is a link between thimerosal and autism and that an Institute of Medicine, IOM, report indicated that the committee didn't believe thimerosal caused autism. Of course, this does not mean there isn't an association. We should recognize that few diseases have direct causes attributed to them.

I agree we should make an additional effort to resolve this issue.

I will work hard to make this happen.

Mr. President, I very much appreciate those very generous remarks by Senator Harkin, and I appreciate even more his cooperation and leadership on this important subcommittee, working with health and education, the two major capital assets of Americans, and labor and related agencies. It is an important bill, and I think we have crafted it about as well as you can, given the limitations of the resources.

There is a lot more I could say, but Senator Byrd is waiting to speak, so I will just reference the appointment of conferees.

I ask unanimous consent that the Senate insist on its amendments to H.R. 3010, request a conference with the House of Representatives on the disagreeing votes thereon, and that the Chair be authorized to appoint conferees on the part of the Senate.

I thank my distinguished colleague, and I yield the floor.

Mr. President, I am not fully conversant with all of the details on the issues raised by the Senator from Michigan. I have been asked by staff to lodge an objection.

I was present yesterday when we took up that issue. I have not seen the level of confusion in this Chamber in the 25 years I have been here that was present when the Senator from Michigan asked unanimous consent, the Senator from Virginia asked to add on, and then the Senator from New Mexico ultimately spoke about holds. It was utter confusion in the midst of rollcall votes, trying to move this bill along.

I respect the standing of the Senator from Michigan to make this unanimous consent request, but I suggest she defer it until next week when the Senators are on the floor who understand what the issues are. You have jurisdiction on the Committee on Environment and Public Works, I believe, and Senator Inhofe and I were talking about it today. I do not want to stop whatever the Senator from Michigan wants to accomplish, but the proper Senators ought to be here to address the issue.

I am the last Mohican around here for Republicans, although they could have gotten the Chair, Senator Chafee, to raise an objection. The Presiding Officer could suggest the absence of a quorum and raise the objection. In fact, I might just refer to him to raise the objection.

However, having said what I said, I do object, and it is my hope the Senator from Michigan will give notice to the Senators who are involved and know what is going on, give them notice and a chance to hear what you have to say and then the matter can be resolved.

But I do object.

Mr. President, I would like to take this opportunity to congratulate Senator Specter and Senator Harkin and their staff on moving the avian influenza amendment forward in a bipartisan manner. They have done a tremendous job on coming to an agreement.

Senator Harkin and Senator Specter's amendment includes my proposal for funding for migratory wild bird surveillance which I would like to take a moment to outline more thoroughly.

As we all know, the potential for an influenza pandemic is increasing as the H5N1 virus has now moved swiftly across Asia, Russia, Turkey and now the EU, killing millions of domesticated poultry and over 60 humans to date. History and science tell us that wild birds are the ones that spread deadly avian influenza viruses. It happened before during the 1918 influenza epidemic that killed an estimated 40 million people worldwide. We must act now to ensure that this does not happen again. We have the tools. We just need to increase and strengthen them.

My proposal seeks to provide funds supporting an early warning system for global influenza that starts with wild birds. This is a major gap in our flu tracking system. The proposed warning system would track and monitor avian viruses and their mutations carried by wild birds by expanding the Centers of Disease Control's wild bird surveillance efforts which are currently not extensive. The CDC's efforts must be tied together with the network of global organizations, including nongovernmental organizations that have the capacity to expand and comprehensively collect and disseminate these tracking data from around the world.

Just as we track hurricanes as they begin as a tropical storm, we must track wild birds and the viral storms they carry over oceans and continents and share that data with the world.

The purposes of my proposal are to support efforts: to more rapidly and efficiently detect, verify, and report on the presence of H5N1 and other highly pathogenic avian influenzas and infectious diseases in migratory wild birds and waterfowl; to use information on viral strains found in wild birds to better delineate any mutations in the virus; to use information on when and where highly pathogenic avian influenza viruses and other infectious diseases are identified in migratory birds to better guide preparedness in the U.S. and around the world, to carry out a comprehensive migratory bird surveillance program that will provide early warning to specific areas to enhance poultry biosecurity and surveillance, and other human protective measures as necessary; to create an open access database where information on highly pathogenic avian influenza viruses and other infectious diseases identified in migratory birds are shared in as close to real time as possible; to protect the health and safety of U.S. citizens and officials traveling and living abroad; and to protect the economic interests of the U.S. and its partners from threats to health, agriculture, and natural resources.

It is the intent of my proposal that within 90 days of the appropriation, the Centers for Disease Control's influenza branch enter into a contract with one or more nongovernmental organizations chartered in the U.S. with extensive global wildlife health experience in tracking disease in wild birds, including free-ranging, captive, and wild bird species, with a proven ability in identifying avian influenza in birds, and with accredited zoological facilities in the U.S.

The influenza branch and the contracting nongovernmental organization(s) will collaborate with appropriate Federal and State agency partners, including the Department of Agriculture acting through the Agricultural Research Service and the Animal and Plant Health Inspection Service, the U.S. Geological Survey, and the U.S. Fish and Wildlife Service; various U.S. State wildlife agencies, multilateral agency partners, including the Food and Agriculture Organization, the World Health Organization, the Office International des Epizooties, and the World Conservation Union; conservation organizations with expertise in international and domestic bird monitoring surveillance; accredited colleges of veterinary medicine; and other national and international partners, as necessary.

The contracting nongovernmental organization, in coordination with the influenza branch of the CDC, shall manage an international surveillance program in which all partners named above are encouraged: to monitor and test for the presence or arrival of avian influenza and other significant avian pathogens at important bird areas around the world and in marketplaces with intense trade in wild birds; to use trained professionals to collect samples and other data and send samples to appropriate diagnostic centers; to use the international surveillance network to conduct disease surveillance activities on migratory birds worldwide, domestic and international field investigations on migratory birds, training and

capacity-building activities related to the relationships between human health, domestic and animal health, and wildlife health, and research on methods and approaches for the detection and enhanced surveillance of highly pathogenic avian influenza and other infectious diseases in migratory birds; and to send samples for avian influenza testing to certified laboratories that meet internationally established methods standards. These certified laboratories are located at the influenza branch of the CDC, the Office International des Epizooties, the Food and Agriculture Organization, the National Veterinary Services Laboratory of the Department of Agriculture, and the Agricultural Research Service. These findings should be reported back to the contracting nongovernmental organization and the international surveillance network partners.

The CDC's influenza branch and the eligible organization, in coordination with the partners of the international surveillance network, will use surveillance reports and other formal and informal sources of information to identify and investigate local disease outbreaks of avian influenza; will develop a long-term baseline of regional data related to highly pathogenic avian influenza and pathogens in migratory birds for analysis between and across sites to create a system to identify when and where outbreaks might occur and paths of dispersal; will provide technical assistance for disease prevention and control programs based on a scientific understanding of the relationships between wildlife health, animal health, and human health; will provide analytic disease findings regularly to the influenza branch of the CDC and other international network surveillance partners to prevent and combat diseases; and will conduct other activities as necessary to support the international network and its partners. The surveillance network will be coordinated from the headquarters of the contracting nongovernmental organization.

The CDC's influenza branch and the contracting nongovernmental organization, manage, map, and make available an online database containing all the results and information gathered through the international surveillance network. The database shall provide geographic data on wild bird populations and the movements of the populations. The laboratory test results will be available for viewing by any Federal agency, foreign country, multilateral institution, organization, or individual.

The CDC's influenza branch and the contracting nongovernmental organization, will request accredited colleges of veterinary medicine and other partners of the international surveillance network to monitor important bird areas around the world and to test for the presence or arrival of avian influenza and other significant avian pathogens of zoonotic concern.

Expanding the CDC's efforts by supporting an international surveillance network, allows us to focus limited resources and prepare communities in the infected wild birds' flight path. If we have this information, our menu of interventions can include: providing available antivirals or vaccines to those at-risk, protecting poultry farms, preparing hospitals to take on thousands of patients, and even keeping people indoors. By tracking wild birds we may even be able to produce an avian flu vaccine faster by understanding which influenza virus is the killer. The current H5N1 virus is not the one that could cause widespread devastation to humans because it hasn't led to sustained human to human transfer, yet.

This amendment provides $10,000,000 in 2006 to the CDC to work with U.S. and international partners to strengthen a global wild bird surveillance system. Ten million dollars is a small sum in comparison to the tens of billions of dollars for vaccine research and antiviral stockpiling. Vaccines and stockpiling are our current focus and we should be thinking about them, but it is equally important to think about being prepared for outbreaks and trying to keep a pandemic from ever hitting. This funding would enable the CDC's influenza branch to contract with one or more expert organizations with the capacity to quickly put into place the tracking and analytical systems we need.

As we speak, some countries and organizations have started to collect information in the U.S. and the world. But while we are collecting data, they are not being stored in any kind of organized manner to make it available for easy study and response.

To summarize, we have a major gap now in avian flu preparedness. We are not adequately tracking the wild birds that will be the flu transfer agents. We need to have a stronger and much better tracking system right now. Second, we have to do a much better job collecting and analyzing the information we have and will get so we can prepare our communities.

I thank Senators Harkin and Specter and their staff for their work preparing our Nation for a possible pandemic. My proposal, which they have incorporated into their amendment, is relatively small but addresses a big gap that no one is thinking about. It's the big bird in the room.

Addressing my distinguished colleagues from Pennsylvania and Iowa, the subcommittee Chairman and ranking member, I wanted to talk with you about the need to study further the issue of thimerosal in vaccines and whether there is any association with autism and other autism spectrum disorders. As you know, autism is a neuro- developmental disorder characterized by severe impairments in language development and socialization. The American Academy of Pediatrics, AAP, says that currently 1 in 166 children has autism or an autism spectrum disorder. Some in the autism community attribute this rise to changes in the vaccine schedule which began in 1990. Three of the four vaccines between 1990 and 2000 given to American children at the 2,4, and 6 month doctor visit contained thimerosal which is a vaccine preservative that is 50 percent mercury by weight. Mercury of course is a known neurotoxin.

I believe that we must at least consider an association between thimerosal exposure and autism. I understand the rate of autism has risen perhaps 800 percent since 1990 and although there could be a number of reasons including better diagnostics, this coincided with an increased exposure to thimerosal in vaccines, which again is 50 percent mercury by weight.

I have talked to Director Gerberding at the Centers for Disease Control and Prevention, CDC, which is our Nation's premier public health organization. She said that there is room for further study. I note that thimerosal is still in our influenza vaccine. And we want people to get that vaccine.

Under the Senator's distinguished leadership, the committee has increased the NIH budget to 29.4 billion dollars, an increase of over $1 billion from last year. I applaud those efforts. Accordingly, under his leadership the budget of the National Institute of Environmental Health Sciences, NIEHS, has increased from $644 to $667 million.

I would ask that the NIEHS lend its expertise in heavy metal toxicity and to work in cooperation with the CDC to study, using respected expert independent researchers, whether there is any association between thimerosal and autism.

I note that we now have a Vaccine Safety Datalink, VSD, a computerized CDC database that has followed 7 million vaccinated children in 7 managed care organizations throughout the United States from 1990 on to see if they develop diseases of any type, including neuro-developmental disorders. Some experts suggest this database could provide answers regarding the thimerosal-autism link. The Institute of Medicine, IOM, regards the VSD as a unique data base with which the public should become familiar. I would expect that the VSD would be used in further studies.

My staff and I have talked with two former NIEHS directors. They support additional effort to study the association between thimerosal and autism. They assure me that NIEHS would be able to administer a grant for carefully selected expert independent researchers to join in the study of the VSD with the CDC. And because transparency of research has been an issue in this debate, NIEHS cooperating with CDC would be able to put together a panel of toxicologists, doctors, expert representatives from the autism community, and public health advocates to advise the study. They did this with the NIEHS' Breast Cancer Research Centers Program. That is, they involved the affected community.

If this issue is resolved it will be because all sides are comfortable with the science and epidemiology of thimerosal and autism. The science and epidemiology of thimerosal and autism is not clear up to this point.

Can I have assurance that the chairman and ranking member will work to insert report language in conference that urges NIEHS to fund collaborative studies on the VSD between outside researchers and the

I thank the Senators.

Mr. President, today the Senate accepted two modified amendments that I authored.

Amendment 2230, as modified, will reduce the amount appropriated for travel, conference programs and related expenses at the Department of Health and Human Services, HHS, by $15 million. Currently $68 million is available for these activities.

The $15 million saved by this revised amendment would ensure sufficient funding for travel and conference expenses that may be necessary while recognizing that the current amount spent on these activities by HHS is excessive and can be reduced.

In 2005 alone, HHS spent $68.5 million on conferences. This is a 50 percent increase in conference spending during a 5-year period. At a time when our Nation is fighting a global war against terrorism, recovering from the most expensive natural disaster in our history, and facing an ever growing debt that now surpasses $8 trillion, we must be more frugal with the taxpayers' dollars we have been entrusted and prioritize how they are spent.

This amendment ensures that a greater amount of Federal health dollars will actually be spent on health care, which should be the goal of HHS.

In the context of the $2.5 trillion Federal budget, $15 million may not seem like much until you put it into a real world perspective.

According to the American Institute of Preventative Medicine, the average doctor visit costs $55. The $15 million saved by this amendment could be made available to pay for nearly 273,000 doctors visits in the next year.

The 2004 Census Bureau report on Income, Poverty, and Health Insurance in the United States shows that 45 million Americans are without health insurance.

The annual premium that a health insurer charges an employer for a health plan covering a family of four averaged $9,950 in 2004. For single coverage is $3,695 annual average premium.

The $15 million saved by this amendment could provide 1,500 American families of four or 4,060 single Americans with health insurance for a year.

HHS spends significantly more on conferences than any other Federal department. In fact, the total spent on conferences by HHS in 2005 is comparable to the amount spent by the Energy Department, Education Department, Environmental Protection Agency, Department of Housing and Urban Development, Labor Department and Transportation Department combined.

In 2002, HHS spent $3.6 million on a single conference, the International AIDS Conference, held in Barcelona, Spain, to which 236 HHS employees traveled to attend. Then-Secretary Tommy Thompson was among the HHS employees who traveled across the globe for this conference and was scheduled to speak. Yet he was prevented from doing so by activists that turned what was intended to be a scientific gathering into a political statement.

Members of Congress rightfully were outraged that the Secretary was treated so rudely at a conference that cost the U.S. taxpayer millions of dollars.

In a May, 2003, letter to members of Congress, Secretary Thompson reassured that HHS ``will work to further reduce our costs associated with that event, while continuing to assure essential scientific personnel can attend this meeting.'' He went on to note that ``the Department is currently revising the HHS travel manual, which will formalize international and domestic travel policies to ensure frugal use of taxpayer money. My staff is taking unprecedented steps to ensure American taxpayers will no longer be asked to foot the bill for wasteful HHS spending, including in the area of travel. . . . Every trip proposal is . . . evaluated on an individual basis by a member of my staff to guarantee that taxpayer money is not wasted.''

Despite this pledge, HHS has continued to spend more and more on conferences and to send hundreds of employees to participate in the same conferences.

In 2004, HHS sent 100 or more employees to at least 59 conferences, including 1,036 to a conference in Orlando, Florida.

Just this past August, HHS was listed as a primary sponsor of the 2005 conference of the Harm Reduction Project, an organization that supports tacit legalization of drugs. Among the sessions at this federally supported conference was ``We Don't Need a `War' on Methamphetamine'' and the discussion groups include ``Tweaking Tips for Party Boys.'' ``Tweaking'' is the most dangerous stage of meth abuse. A tweaker is a meth addict who probably has not slept in days, or weeks, and is irritable and paranoid.

HHS officials later denied ``sponsoring'' the conference, although the Department provided taxpayer dollars for it and sent six employees to participate.

As a practicing physician, I believe that Federal funds expended to support this conference would have been far better spent providing treatment to those suffering from addiction.

This is just one example of taxpayer dollars that have been misspent on conferences.

The bottom line remains that at a time when important health care programs are faced with financial difficulties, we do not have the luxury for excessive spending on conferences. While Congress is trying to control the growth of spending on important health programs like Medicaid and Medicare, we should first impose restraints on nonessential spending at HHS including conferences.

Conferences may provide interesting opportunities for bureaucrats and others to network and exchange information in person, but they do not make people well or provide life saving health care.

Furthermore, in the modern telecommunications era, it is unnecessary to spend time and resources to finance so many conferences. Teleconferences and video conferencing, for example, can save money while allowing the same type of interaction and information sharing at a mere fraction of the cost.

The second amendment, No. 2336 as modified, directs the Secretary of HHS and the Secretary of Education to estimate improper payments as required by the Improper Payments Information Act of 2002 and report to Congress on specific actions taken to estimate improper payments within 60 days of this bill being signed into law.

The Improper Payment Information Act was enacted in November 2002 for the purpose of finding and eliminating payments that should not have been made, or were made for incorrect amounts, by government agencies.

This law requires that all agencies, at the very least, perform a risk assessment of all programs and activities to determine whether or not a program is at risk of making ``significant'' improper payments.

``Significant'' as defined by the Office of Management and Budget means at least 2.5 percent of all payments made are improper, and the absolute dollar figure associated with that 2.5 percent or more, totals at least $10 million.

Federal programs and activities deemed to be at ``significant'' risk of making improper payments their respective agencies are required under the Improper Payments Information Act to first, develop a statistically valid estimate of improper payments; and second, develop a corrective action plan for all programs where the improper payment estimate exceeds $10 million annually. This corrective action plan must also contain annual targets for reducing improper payment levels.

At the end of each fiscal year, agencies are to report the results of the Improper Payments Information Act activities in their Performance and Accountability Report PAR; and submit them to Congress. The Improper Payments Information Act exempts no agency from compliance.

Improper payments--which include inadvertent, fraudulent, and irresponsible payments--are costing the taxpayers at the very least, over $45 billion each year. Even worse, this $45 billion represents only 17 of 70 agencies that are currently reporting improper payment information as required under law.

The Medicare program, which is already reporting, makes up nearly half--$21.7 billion--of the government's $45.4 billion reported improper payments for fiscal year 2004.

The magnitude of the Government's improper payment problem is not yet known because some of the largest programs are not reporting, as required by law.

Medicaid, with outlays that exceed $175 billion annually, is one of the programs that is not reporting. The Medicaid program has been required to report improper payments under the Office of Management and Budgets, OMB, A-11 Circular requirements since 2001; and under the Improper Payments Information Act since 2002, yet it still has made no estimate of its improper payments.

In its November 2002 Performance and Accountability Report, Centers for Medicare and Medicaid Services reported that it would be able to report improper payments for the Medicaid program by 2006; however, they have pushed that date back to 2008--six years after the date by which they were to have begun reporting improper payments.

Similarly, the Temporary Assistance for Needy Families, TANF, program has not even been able to estimate when it will be able to report improper payments for a law that has existed since 2002.

TANF spent over $17 billion in fiscal year 2005 ($18.6 in outlays).

Foster Care spent $6.4 billion in fiscal year 2005.

State Children's Insurance Program spent $5.129 billion in fiscal year 2005.

Child Care Development Fund spent $4.9 billion in fiscal year 2005.

Title I, within the Department of Education, spent $22.916 billion in fiscal year 2005, fiscal year 2005 outlays: $21.18 billion.

This amendment does not debate the merits of any of these programs, it simply demands compliance with transparency and accountability measurements for expenditures already in existing law.

After all, eliminating improper payments ensures more funds actually reach those who are intended to benefit from these programs while protecting the taxpayer. However, we must first understand the magnitude and source of the problem to correct it. We can only do this if all agencies are monitoring and reporting their improper payment information.

Together these amendments make small, yet important steps, towards making federal agencies more fiscally responsible and accountable.

I thank Chairman Specter for accepting these amendments and his commitment to fight for inclusion of these provisions in conference with the House of Representatives.