A bill to amend title XVIII of the Social Security Act to increase the per resident payment floor for direct graduate medical education payments under the Medicare program.

Mr. President, today I am pleased again to join my friend and colleague Senator Kit Bond of Missouri in bringing to the Senate another matter of importance to the missions of the National Guard and to the dedicated men and women of the Guard who perform these missions.

Today we are introducing the National Guard Empowerment and State- National Defense Integration Act of 2008. We introduce this legislation on behalf of the 91-member U.S. Senate National Guard Caucus, which we co-chair. The military is still not structured properly to respond to the domestic emergencies that we know will come again. This legislation would take us tangible steps forward in correcting that. Our bill would sharpen the Defense Department's focus on helping the National Guard respond to domestic emergencies.

This legislation is a new phase in our bipartisan and bicameral drive to empower the Guard for successfully meeting the challenges that our States and the Nation are asking the Guard to meet. It would clear away bureaucratic cobwebs in the Defense Department's organizational structure to improve decision making on homeland defense issues that involve the Guard. This bill builds on some of the strong provisions enacted from the previous version of the Guard Empowerment Bill in the recently enacted fiscal year 2008 Defense Authorization Bill. By empowering the National Guard through more responsibilities, authorities, and new lines of control, this bill focuses the Defense Department's attention on this critical realm of domestic defense. The bill structures potential military operations within the U.S. in a way outlined by the Constitution, ensuring local and State control--not Federal control--in these emergencies.

We know that the military--the active duty force, the National Guard, and the Reserves--has an important role in responding to emergencies at home, events like natural disasters. The events of Hurricane Katrina and so many other situations have amply underscored that reality. Our civilian authorities will continue to want to tap into the resources, personnel, and expertise, and there is no question that we need a system that permits that. The debate taking place, mostly behind the scenes and within the walls of the Pentagon, has been about how we structure that response. The goal must be an effective response in line with the Constitution. Our national charter protects our basic liberties and places sovereignty in the hands of the people through government with adequate checks and balances, splitting administration among Federal, State, and local levels.

This Empowerment Bill would be effective because it drives to enhance the National Guard, our first military responders. This force has stepped up during dire situations time and time again. The National Guard takes its responsibility to carry out relief missions at home as seriously as it takes its missions abroad as the nation's primary military reserve. The National Guard is a locally based force, spread out in armories and readiness centers across the country. The Guard can flow forces among States through the Emergency Management Assistance Compacts process, which helped make the force one of the few shining lights in the darkness of the response to Hurricane Katrina. The National Guard has units that specialize in civil support, including highly trained, full-time teams located in every one of our States. The bottom line is that the Guard has shown that it can do this mission and do it superbly.

The approach of the Empowerment Bill is constitutional because it properly involves every layer of Government. It is our mayors, our public safety chiefs, and our Governors who are responsible for the security of their communities. Under our governmental system, they are the ones that should be in control of emergency situations and any Federal assets that come in should be strictly in support of them-- certainly not the other way around. The Guard is a State force that works closely with these civilian authorities all the time. The Guard, which serves under the command of the Governors, is part and parcel of the community. The Guard knows that it is civilians, including their elected leaders and the populace, who are the ultimate decision-makers in these situations.

Our bill includes several key provisions. To improve the quality of advice at the highest levels, the Chief of the National Guard Bureau would gain a full seat on the Joint Chief of Staff, a key advisory body where insufficient attention is paid to homeland defense matters. The bill would ensure that U.S. Northern Command remains a Federal military headquarters that truly supports the Governors and the initial Guard response in an emergency, providing for the Governors to have tactical control over any active duty and Reserve assets that might be operating in their home State during an emergency. The National Guard Bureau is enhanced in another section which specifically gives the National Guard a separate budget to purchase domestic defense-oriented items. The Bureau would carry out its responsibilities in close cooperation with a newly

established planning committee and council that integrally involves the States' Adjutants General. And the bill assigns several key command and deputy command positions to National Guard officers who have experience in homeland defense and domestic emergency response matters.

This fiscal year 2008 Defense Authorization Bill ushered in several improvements to the National Guard, including an elevation of the Bureau Chief to the rank of four-star general. The National Guard Bureau is now more a joint agency than a sub-branch of the Army and the Air Force, though the Guard remains a key part of the Army and Air Force's Total Force. The Deputy Commander or Commander of U.S. Northern Command now must come from the ranks of the National Guard. These are far-reaching steps, though I remain concerned that the Department has yet to implement these provisions, not even filling the four-star position yet.

Together, last year's enacted organizational changes and those put forth in this bill will fundamentally improve our preparations for an emergency, and ensure an effective, swift, and constitutional response when another emergency occurs.

Our National Guard has never let our country down, and--once again-- we cannot let our Guard down. I urge prompt attention and action on this vital legislation.

Mr. President, I ask unanimous consent that the text of the bill and supporting material be printed in the Record.

Mr. President, today, I join with Senator Hatch to introduce a bipartisan bill to address the resource needs of our men and women on the Federal judiciary and people around the country by authorizing additional U.S. courts of appeals and district court judgeships. It has been 18 years since the last time a comprehensive judgeship bill was enacted to address the growth in the workload of the Federal judiciary by adding new Federal judgeships. That legislation established 11 additional circuit court judgeships and 61 permanent and 13 temporary district court judgeships.

Since 1990, case filings in our Federal appellate courts have increased by 55 percent and case filings on our district courts have risen by 29 percent. Without a comprehensive bill, Congress has proceeded to authorize only a few additional district court judgeships and extend temporary judgeships when it could. For instance, in 2002 we were able to provide for 15 new judgeships in the Department of Justice authorization bill. However no additional circuit court judgeships have been created since 1990 despite their increased workload.

In 2006, the weighted number of filings in district courts, which takes into account an assessment of case complexity, were 464 per judgeship, well above the Judicial Conference's standard. The same year, the national average circuit court caseload per three-judge panel approached the record number of 1,230 cases, recorded a year earlier.

Our Federal judges are working harder than ever, but in order to maintain the integrity of the Federal courts and the promptness that justice demands, judges must have a manageable workload. The bill that we are introducing today would add 12 permanent circuit court judgeships, 38 permanent district court judgeships, and convert five existing temporary judgeships into permanent positions. These additional judgeships would address the significant increase in caseloads that the Federal courts have seen over the nearly two decades since the last comprehensive judgeship bill was enacted. It is based on the recommendations of the Judicial Conference and its analysis of caseloads and needs.

Our bipartisan bill would also add 14 temporary district court judgeships, two temporary circuit court judgeships, and extend one existing temporary district court judgeship. These additional temporary judgeships allow Congress some flexibility with regard

to future judgeship needs. If caseloads continue to increase, Congress has the option to introduce legislation making permanent or renewing these temporary judgeships.

By providing that these new judgeships become effective the day after the inauguration of the next President, we attempt to insulate this effort from partisan politics.

This bill has the support of the Judicial Conference and Senators on both sides of the aisle. I thank Senators Feinstein and Schumer for joining us in this effort. A comprehensive bill to respond to the increasing workload of our Federal judiciary is long overdue.

Mr. President, I ask unanimous consent that text of the bill be printed in the Record.

Mr. President, I am pleased to introduce the Medicare Rural Health Access Improvement Act of 2008.

The purpose of this legislation is to continue ongoing efforts to ensure that Americans in rural areas have access to health care services. Much has been done in the past to improve access to rural providers such as hospitals and doctors. Much more still needs to be done.

I hold town meetings in each of the 99 counties in the great State of Iowa every year. As many know, Iowa is largely a rural State, and a significant concern that I consistently hear during these meetings is the difficulty my constituents experience in accessing health care services. As the former chairman and currently the ranking member of the Finance Committee, it has, therefore, been a priority for me to improve the availability of health care in rural areas.

In Iowa, as in many rural areas across the country, hospitals are often

not only the sole provider of health care in rural areas, but also employers and purchasers in the community. Moreover, the presence of a hospital is essential for purposes of economic development because businesses check to see if a hospital is in the community in which they might set up shop. As you can see, it is vital that these institutions are able to keep their doors open.

In previous legislation, Congress has been able to improve the financial viability of rural hospitals. For instance, the creation and subsequent improvements to the Critical Access Hospital designation has greatly improved the financial health of certain small rural hospitals and ensured that community residents have access to health care.

However, there are still a group of rural hospitals that need help. I am referring to what are known as ``tweener'' hospitals, which are too large to be Critical Access Hospitals, but too small to be financially viable under the Medicare hospital prospective payment systems. These facilities are struggling to stay afloat despite their tireless efforts. Like in many communities across the country, the staff of tweener hospitals and their community residents take great pride in the quality of care at these facilities. I have heard countless stories of the exemplary work tweener hospitals in Iowa perform not only as providers of essential health care, but also as responsible members of their communities. It is for this reason that many provisions in this bill are intended to improve the financial health of tweener hospitals and ensure that people have access to health care.

Most tweener hospital are currently designated as Medicare Dependent Hospitals and Sole Community Hospitals under the Medicare program. There are provisions, both temporary and permanent, included in this bill that would improve Medicare payments for both types of hospitals. This includes improvements to the payment methodologies so that inpatient payments to these facilities would better reflect the costs they incur in providing care. Improvements are also proposed in this bill to Medicare hospital outpatient payments for both Medicare Dependent Hospitals and Sole Community Hospitals so they would both share the benefit of hold harmless payments and add-on payments.

Also, a major driver of the financial difficulties that tweener hospitals face is the fact that many have relatively low volumes of inpatient admissions. This bill would improve the existing low-volume add-on payment for hospitals so that more rural facilities with low volumes would receive the assistance they desperately need.

Over the years, many have commented that it is simply unfair for many rural hospitals to receive only a limited amount of Medicare Disproportionate Share Hospital, or DSH, payments while many urban hospitals are not subject to such a cap. This bill would eliminate the cap for DSH payments for those rural hospitals for a 2-year period.

There are also other provisions that would continue to help rural hospitals. The rural flexibility program would be extended for an additional year. Certain rural hospitals that are paid on a cost basis for the outpatient laboratory services they provide would continue to do so on a permanent basis. And Critical Access Hospitals that provide outpatient laboratory services would be paid 101 percent of their costs regardless of whether the specimen was collected from a patient of the CAH or whether the specimen was collected in a skilled nursing facility or clinic associated with the CAH.

This legislation also seeks to improve incentives for physicians located in rural areas and increase beneficiaries' access to rural health care providers. It includes provisions designed to reduce inequitable disparities in physician payment resulting from the Geographic Practice Cost Indices, or adjusters, known as GPCIs. Medicare payment for physician services varies from one area to another based on the geographic adjustments for a particular area. Geographic adjustments are intended to reflect cost differences in a given area compared to a national average of 1.0 so that an area with costs above the national average would have an index greater than 1.0, and an area below the national average would have an index less than 1.0. There are currently three geographic adjustments: for physician work, practice expense, and malpractice expense.

Unfortunately, the existing geographic adjusters result in significant disparities in physician reimbursement which penalize, rather than equalize, physician payment in Iowa and other rural states. These geographic disparities in payment lead to rural states experiencing significant difficulties in recruiting and retaining physicians and other health care professionals due to their significantly lower reimbursement rates.

These disparities have perverse effects when it comes to realigning Medicare payment to reward quality of care. Let me put that into context. Iowa is widely recognized as providing some of the highest quality health care in the country yet Iowa physicians receive some of the lowest Medicare reimbursement due to these inequitable geographic adjustments. Medicare reimbursement for some procedures is at least 30 percent lower in Iowa than payment for those very procedures in other parts of the country. That is a significant disincentive for Iowa physicians who are providing some of the best quality care in the country, and it is fundamentally unfair. Congress needs to reduce these disparities in payment and focus on rewarding physicians who provide high quality care.

The inequitable geographic payment formulas have also exacerbated the problems that rural areas face in terms of access to health care. Rural America today has far fewer physicians per capita than urban areas. The GPCI formulas are a dismal failure in promoting an adequate supply of physicians in States such as Iowa, and more severe physician shortages in rural areas are predicted in the future.

The legislation I am introducing today makes changes in the GPCI formulas for work and practice expense to reverse this trend. It establishes a 1.0 floor for the physician work and practice expense adjustments. It also revises the calculation of the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. We must act now to help rural States recruit and retain more physicians so that beneficiaries will continue to have access to needed health care.

Congress has previously enacted a number of other provisions to improve Medicare payment for health care professionals and providers in rural areas that will expire soon. This bill extends the five percent incentive payments for primary care and specialty physicians in scarcity areas through December 2009. It also extends the existing payment arrangements which allow independent laboratories to bill Medicare directly for certain physician pathology services.

The bill includes several new provisions to improve beneficiary access to health care services. It increases rural ambulance payments by 5 percent for the next 18 months. It permanently increases the payment limits for rural health clinics. It allows hospital-based renal dialysis centers and skilled nursing facilities to provide telehealth services. It also allows physician assistants to order post-hospital extended care services and to serve hospice patients.

Finally, the bill would protect rural areas from being adversely affected by the new Medicare competitive bidding program for durable medical equipment. It would ensure that home medical equipment suppliers who provide equipment and services in rural areas and small metropolitan statistical areas, MSAs, with a population of 600,000 or less can continue to serve the Medicare program by exempting these areas from competitive bidding. We must ensure that rural areas continue to have medical equipment suppliers available to serve beneficiaries in these areas.

Mr. President, as you can see, we still have much to do when it comes to ensuring access to health care in rural America. I look forward to working with my colleagues on this important matter.

Mr. President, I ask unanimous consent to have printed in the Record a summary of the bill.

Mr. President, I rise today with my colleagues Senator Hatch and Senator Specter to introduce the Child Protection Improvements Act of 2008. This bill will expand and make permanent the national child safety pilot program that we passed as part of the PROTECT Act back in 2003. This bill is, in my view, an absolutely essential step towards developing a comprehensive approach to protect our Nation's children.

Human service organizations rely on volunteers and employees to provide services and care to children. These individuals coach soccer games, mentor young people, run youth camps, and much more. Approximately 61 million adults currently volunteer--with 27 percent dedicating their volunteer service to education and youth programs. By volunteering, they necessarily gain very close, often unsupervised access to our children. Of course, the vast majority of these people have the best interest of our children at heart--and we need as many volunteers as we can get. But, at the same time, we have to understand that bad people will take any step they can to gain access to children and many attempt to do this by volunteering.

Congress has previously attempted to ensure that States make FBI criminal history record checks available to organizations seeking to screen employees and volunteers who work with children, through the National Child Protection Act of 1993 and the Volunteers for Children Act. However, according to a report from the Attorney General, these laws ``did not have the intended impact of broadening the availability of checks.'' A 2007 survey conducted by MENTOR/National Mentoring Partnership found that only 18 States allowed youth mentoring organizations to access nationwide Federal Bureau of Investigation background searches. And, even when states do provide access to background checks, it can be expensive and time consuming.

With the PROTECT Act pilot we decided to give some groups a direct line towards obtaining a national background check from the FBI and obtaining a fitness determination by the National Center for Missing and Exploited Children to see whether the applicant could present a potential threat to children. Thanks to the hard work and commitment of NCMEC, the FBI, MENTOR/National Mentoring Partnership, and others this pilot program has proven incredibly effective. During the course of the pilot, we conducted roughly 37,000 background checks. Of these checks, 6.1 percent of prospective volunteers were found to have a criminal record of concern--including very serious offenses like sexual abuse of minors, assaults, murder, and serious drug offenses. In all, this represents over 2,200 dangerous people we prevented from working as volunteers with children. In addition, over 40 percent of the individuals with criminal records had committed an offense in a state other than where they were applying to volunteer, meaning that a state- only search would not have found relevant criminal records. In my view, this speaks to the urgent need of expanding this pilot to more groups and towards making the program permanent.

Despite these successes, the pilot was limited in several respects. The pilot was limited in scope with only a few youth-serving entities able to participate, and irregularities with respect to the annual appropriations process made it extremely difficult to operate the program to its fullest extent. With the legislation, we are introducing today, we build upon the lessons learned by taking the following steps: make the program permanent, which will help ensure that long-term investments are made to make the program effective and inexpensive; establish an Applicant Processing Center, APC, to assist youth serving organizations with the administrative tasks related to accessing the system, such as obtaining a fingerprint and handling billing with the FBI; and permanently establish and upgrade the fitness determination process at the National Center for Missing and Exploited Children.

In addition, we authorize the collection of a small surcharge to pay the FBI fee and offset the expenses incurred by National Center for Missing and Exploited Children and the Applicant Processing Center. With literally millions of volunteers working with our Nation's youth every year, it is imperative to provide a mechanism to allow more youth-serving organizations access and ensure a steady stream of resources to allow the program to grow toward the goal of protecting more children. This bill will do that.

Before closing, I want to touch on fee for service component which is added to this bill. Of course, the goal has always been that the checks have to be fast, inexpensive, and accurate for these checks to be suitable for non-profit organizations. By adding a small surcharge to the fee the FBI charges, we maintain that goal while expanding access. The bottom line is this--youth-serving organizations have told us that the ability to consistently obtain background checks and fitness determinations is critical and they will pay a little more to have access. Because Federal resources are simply not sufficient to provide wide access, and because the ebb and flow of the appropriations process creates instability with respect to how many checks can be completed, we felt that a small surcharge was the right approach.

Even with the surcharge, we still keep the cost very low. The bill calls for a fee no greater than $25 or the actual costs of preparing the application, running the background check by the FBI, and making the fitness determination by NCMEC for nonprofits. The applicant processing center created in this bill will collect this fee and make sure that all the costs are offset. And the goal is that this fee will offset all of the costs so that we can grow a system that is available to a wide range of entities that work with children. As of today, the American Camp Association, the Afterschool Alliance, the America's Promise Alliance, Big Brothers Big Sisters of America, Boys and Girls Clubs of America, Communities In Schools, Inc., First Focus, MENTOR/ National Mentoring Partnership, and YMCA of the USA all agree with this approach.

In addition, the bill authorizes $5 million in 2009 for startup costs and to develop new processes and technologies to automate and streamline the functions to keep costs down. And, while it's not a part of this legislation, I hope that we can get some of our great technology companies to help us with this effort by possibly donating some of their time, expertise, and ingenuity towards helping us automate the process--especially with the fitness determination process at the National Center for Missing and Exploited Children which is a time consuming, labor-intensive process involving the manual review of criminal rap sheets. We formed a similar public-private partnership when we established the National Domestic Violence Hotline, and I hope we will be able to replicate that success here. Once we get this bill passed, I will be reaching out to some of our best technology companies to see if they can help us ensure that these checks remain inexpensive and

available for as many youth-serving groups as possible.

I would once again like to thank my colleagues Senator Hatch's and Senator Specter's work on crafting this bill. We proved that we can help protect children at a low cost with the pilot program, and I believe that this bill will help expand access to a greater number of groups so that we can grow that number of protected children exponentially. To me, this is exactly the kind of service that the government owes to its people, and I look forward to its prompt passage before the expiration of the pilot program on July 30th, later this summer.

Mr. President, I ask unanimous consent that the text of the bill be printed in the Record.

Mr. President, I rise today to introduce legislation to enhance opportunities for low-income children entering school. Today, I am introducing the Sandy Feldman Kindergarten Plus Act of 2008.

The Kindergarten Plus Act will provide children below 185 percent of the poverty line with additional time in school during the summer before, and the summer after, their traditional kindergarten school year to ensure that they enter school ready to succeed.

Too many low-income children enter school unprepared because they have not had access to educational resources such as books and other tools for learning. Arriving at school already behind, many of these children find it difficult, if not impossible, to catch up academically to their more affluent peers.

When we consider the achievement gap between low-income children and their wealthier peers, it immediately becomes clear that we must do a better job of preparing these children for school. To prepare them for success, we need to expose them to classroom practices earlier, introduce them to critical educational concepts, and familiarize them with school activities such as story or circle time. Ultimately, we need to provide these students with a solid foundation that allows them to enter school with the skills necessary to become strong students.

Only 39 percent of low-income children, compared to about 85 percent of high-income children, can recognize letters of the alphabet upon arrival in kindergarten. Moreover, low-income children often have a more limited vocabulary. By the time they are in first grade, children in low-income families have, on average, 5,000 words in their vocabulary. In contrast, children from more affluent families enter school with vocabularies of about 20,000 words. These startling discrepancies should tell us that more needs to be done to help all children enter school with an equal opportunity for success. Kindergarten Plus strives to provide these opportunities and to lessen the achievement gap by providing low-income children more support and additional exposure to high-quality schooling.

This legislation was named after Sandy Feldman. As many of you know, Sandy was a tireless advocate for children and public education. Her commitment to social justice and her focus on early childhood education led her to develop the concept for this legislation, and it was Sandy who spent countless hours developing the details to ensure this would be a high-quality initiative. I was honored to have worked with Sandy in developing the initial legislation and am proud that this bill bears her name.

I am joined today in introducing this legislation by my colleagues Senators Lieberman and Durbin. This bill is supported by the American Federation of Teachers, National Education Association, Council of Great City Schools, the Children's Defense Fund, Service Employees International Union, American Federation of State, County and Municipal Employees, National Association of Child Care Resource and Referral Agencies, and Easter Seals. I urge my colleagues to join my effort and cosponsor this legislation. I encourage them to help launch low-income children on the path to school success.

Mr. President, I ask unanimous consent that the text of this bill be printed in the Record.

Mr. President, I rise today to introduce legislation to add judicial discretion to the Higher Education Act Aid Elimination Penalty. Since 1998 the law prevents any student convicted of possession of a controlled substance from receiving Federal financial aid.

Since the penalty was enacted, approximately 200,000 low to middle income students seeking a college education have been disqualified from receiving Federal financial assistance. In many cases, these are committed young people who simply want to make better lives for themselves. In order to be eligible for financial aid in the first place, these students have proven they can perform academically. Unfortunately, they have made the mistake many young people have made experimenting with drugs.

Just like every Senator in this chamber, I want to help keep America's young people from making this mistake and jeopardizing their health and their futures. We should all work to enact policies that effectively deter dangerous drug use. But this is a sophisticated and complicated issue and it cannot be solved by blunt measures such as the Aid Elimination Penalty.

Any drug abuse expert will tell you that helping someone get off of drugs or stay away from trying them requires a variety of approaches. In some cases the fear of consequences, such as the Aid Elimination Penalty, may be enough. But in many other cases, counseling, rehabilitation, and positive reinforcement may offer more effective ways to achieve this goal.

Our laws should reflect the need for varied approaches. Unfortunately, the Aid Elimination Penalty does not. It is a blunt tool that sweeps all cases into the same one size fits all solution. There is little distinction under this law as to whether the drug possession is a major or minor violation and to what degree the infraction affects the community at large; Teenagers bowing to peer-pressure for the first time are treated the same as serious drug users disrupting their communities. This means that while in some cases we are penalizing chronic drug abusers, we are also penalizing good students who will mature and have a better chance of rectifying their mistakes by continuing their education.

What is most disturbing is how the consequences of the penalty can negatively impact the course of a student's life. Many students affected by the Aid Elimination Penalty are forced to leave school since it is no longer affordable without financial assistance. Data from the National Center of Education Statistics demonstrates that many of these students will not continue their education: 36 percent of students who leave 4-year institutions do not return within 5 years and 50 percent of students who leave 2-year institutions do not return within 5 years. For these students, denial of Federal college assistance will only force them from school, and may set them on an even more self destructive course of increased drug use and abuse. In these cases, the Aid Elimination Penalty actually backfires and serves to undermine our efforts to prevent the use and abuse of drugs.

That is why I am introducing this legislation to insert judicial discretion into the current law. My bill would make the penalty dependent on the ruling of a judge, allowing them to weigh the value of implementing the penalty as part of other sanctions and punishments on a case by case basis. This will enable the judge to deny student financial aid if the situation merits it, and if he or she believes it is the most effective or even the only way to help a student get control of his or her life. This legislation would also grant judges the ability, based on the circumstances, to determine that continuation of a college education, in conjunction with rehabilitation and possibly other sanctions, offers both the student and the community the best possible outcome. This is the way the rest of the criminal justice system works and it is the way the Aid Elimination Penalty should be implemented. With this change we can fine tune our approach to this problem and minimize the negative unintended consequences of current law. I urge my colleagues to see the wisdom of this approach and help me to refine the law to be more effective in protecting our communities and ensuring deserving students the opportunity to advance their education.

Mr. President, I ask unanimous consent that the text of the bill be printed in the Record.

Mr. President, I rise today to call attention to the reauthorization of the President's Emergency Plan for AIDS Relief, also known as PEPFAR.

The program authorized in 2003 provided $15 billion over 5 years to the cause of AIDS relief in parts of the world ravaged by that disease. PEPFAR was a demonstration of the American people's desire to help those in need.

The 2003 legislation was also a demonstration of the American people's desire that their generosity not be wasted, as they have seen before with so many other aid programs. To that end, the legislation required that the lion's share of the funds be devoted to treatment of patients in need.

It encouraged accountability and transparency and it funded programs that could demonstrate results, such as the requirement that one third of prevention funds be spent on abstinence education programs--a decision that has kept countless persons from getting infected with HIV since 2003.

It is therefore mind boggling to me that recent reauthorization proposals the bill passed by the House Foreign Affairs Committee last week and the bill scheduled for mark up by the Senate Foreign Relations Committee today--would take such giant steps backward.

The bill originally introduced in the House would have eliminated the conscience clause, which protects humanitarian and medical professionals involved in these programs from having to participate in prevention and treatment methods that they find morally or religiously objectionable. Wisely, this provision was kept in the bill passed by the House committee, though it is substantially watered down--to the point of being nonbinding--in the Senate Foreign Relations Committee bill.

The original House bill struck the requirement that organizations that receive PEPFAR grants be opposed to prostitution and sex trafficking. That these commonsense provisions were even in danger of being dropped in the reauthorization of PEPFAR is sadly telling. It appears the Senate Foreign Relations Committee chose not to challenge such an unimpeachable provision of law.

And, unlike the majority on the House Foreign Affairs Committee, which backed down from including many troubling provisions on abortion and family planning demanded by far left groups, it appears the Senate Committee bill would pander to the so-called ``family planning'' agenda.

I am also deeply troubled that both the House Foreign Affairs Committee and Senate Foreign Relations Committee reauthorization proposals remove the requirement that at least fifty-five percent of the funds in the program be spent on treatment of AIDS patients. This provision was an important check on bureaucratic wastefulness and ``make work'' and it must be preserved.

Additionally, the requirement that thirty-three percent of PEPFAR prevention funds be spent on abstinence education, removed by the majority in last year's omnibus appropriations process, has not been restored in either of these two reauthorization proposals. In fact, all that remains in the tatters of that requirement in either of these bills is something only a bureaucrat could love: in the event a future AIDS coordinator chooses to ignore abstinence education, a report must be sent to Congress.

What is more, both of these reauthorization proposals include provisions that appear to undermine protections for intellectual property, the same protections that are necessary to ensure that innovation and research into life-saving medications continue.

While I am sure the sponsors of these two proposals are well-meaning, they further increase support for TB and malaria programs, even though the U.S. is already the largest contributor to TB and malaria programs through the Global Fund. Sadly, the Global Fund has become synonymous with graft and multilateral bureaucratic waste in many countries. We should not be duplicating those existing programs. We owe it to the American taxpayer, and those people suffering from these dreaded diseases, to fix the problems that abound in the Global Fund.

Lastly, but most significantly, both reauthorization proposals more than triple the expenditure for PEPFAR--something we simply cannot afford. PEPFAR 2003 authorized $15 billion over 5 years for emergency AIDS relief. Not satisfied with a mere doubling of this program as requested, both of these proposals would provide $50 billion over 5 years.

As I have noted already, the American people are a generous people. Our annual foreign aid budget reflects this generosity. However, this ability to give is not limitless.

Need I remind my colleagues, our economy is in distress. The presidential candidates on the other side are calling for a Federal Government bailout of homeowners facing foreclosure: with $50 billion, we could provide 235,157 homeowners with such a bailout.

Moreover, Congress just passed, and the president just signed, a program to provide Americans with checks intended to stimulate the economy. While I have doubts that this plan will succeed, I note that with this $50 billion, 157 million tax filers could be given rebate checks of $318.47.

Alternatively, with $50 billion, we could ``fully fund'' both No Child Left Behind and the Individuals with Disabilities Education Act at their authorized levels for one year.

Congress is beginning the annual budget cycle and we are daily confronted with requests for more and more federal spending. Already, key leaders in the budget process are threatening that if they don't get their way on domestic spending, they will add their spending to the forthcoming but overdue War Supplemental or will short circuit the budget process with a continuing resolution or yet another omnibus. Agreeing to this massive increase is not the way to discipline what is already shaping up to be a budget train wreck.

Governing is about choosing. By agreeing to this increase to $50 billion, neither the House nor Senate committees are governing. They are taking the easy course of action: spending.

I supported the President's Emergency Plan for AIDS Relief in 2003. I could reluctantly support doubling that amount over the next five years. But adding another $20 billion on top of that is too much.

We cannot lose sight of the sacrifices of millions of Americans who work hard and pay the taxes that support these programs. $50 billion is too much.

I cannot support a bill that so dramatically spends beyond what we can afford and so wantonly ignores accountability and transparency tools that safeguard the generosity of the American people.

This legislation can still be salvaged.

Yesterday, I cosponsored legislation with the Senator from Oklahoma, Dr. Coburn, and the Senator from North Carolina, Mr. Burr, that sets some key principles that must be a part of the reauthorization.

Earlier today, I introduced a bill that would prohibit the extension of PEPFAR funds away from their core purpose, helping the neediest countries. This legislation must also be a part of the reauthorization of PEPFAR.

I support the PEPFAR program and I believe that it is worth passage if funded at a responsible authorization level with at least the kind of commonsense policy, accountability, and transparency provided in the 2003 bill.