Annual and Lifetime Health Care Limit Elimination Act of 2009

Mr. President, I am reintroducing the Independence at Home Act together with colleagues in the Senate and the House. Mr. Burr, Mr. Whitehouse, Mr. Cardin and I are proud to join forces with our House colleagues, Mr. Markey, and his cosponsor, Mr. Smith, to move forward with this important legislation to provide a coordinated team-based approach to primary care for chronically ill Medicare beneficiaries in their own homes. Returning to basics like paying doctors for home visits to vulnerable patients, and following them through the course of their illness while saving taxpayers money, is the kind of legislation I am proud to introduce.

The Independence at Home, or IAH, Act comes at the perfect time. The American people and the federal government need to save money on health care, while having more choices and getting better results. This delivery model has a proven track record of doing just this. Similar ``house calls'' programs, currently operating across the country, are reducing costs, improving care quality, and helping people remain independent as long as possible. This delivery model is also providing much needed relief to caregivers who are often juggling a full-time job while caring for their very ill family member. This is medical care Americans want and deserve.

It is not too often that health policy has good outcome results before the pilot program phase begins, but that is exactly the case with the IAH Act. Similar home health delivery models, such as the Veterans Administration's Home-Based Primary Care, Boston, Massachusetts' Urban Medical's House Calls Program, and Portland, Oregon's Housecall Providers have been so successful in improving quality and reducing costs, that our bill guarantees 5 percent savings to Medicare.

These successful home health programs have demonstrated that the optimal way to address the challenges of caring for persons with chronic conditions is to better integrate their care and to work with their caregivers. Medical problems are best managed and coordinated by health care professionals who know their patients, their problems, their medications, and their other health care providers. Using this approach, the Independence at Home Act provides a better, more cost- effective way for Medicare patients with chronic conditions to get the care they need. It further advances Medicare reform by creating incentives for providers to develop better and lower cost health care for the highest cost beneficiaries.

This bipartisan, bicameral bill would create a pilot program to improve in-home care availability for beneficiaries with multiple chronic conditions. This is a win-win for all involved. It will help people remain in their homes for longer periods of time, it will improve the quality of care, and physicians will receive a bundled payment for coordinating this care with a team of healthcare providers.

More specifically, the Independence at Home Act establishes a two- phase three-year Medicare pilot project that uses a patient-centered health care delivery model to ensure that Medicare beneficiaries with multiple chronic conditions can remain independent for as long as possible in a comfortable environment. By incorporating lessons from past Medicare demonstration projects and from current home health

models, this bill provides for programs that hold providers accountable for quality, mandatory annual minimum savings, and patient satisfaction. Savings are generated by providing better care to Medicare beneficiaries with multiple chronic conditions and reducing duplicative and unnecessary services, hospitalization, and other health care costs.

Persons eligible for the program include Medicare beneficiaries with functional impairments, two or more chronic health problems, and recent use of other health services. Each IAH patient will receive a comprehensive assessment at least annually. The assessment will inform a plan for care that is directed by an IAH physician, nurse- practitioner, or physician's assistant. The plan is developed by an IAH plan coordinator in collaboration with the patient and caregiver. Medication management is provided by pharmacists due to their expertise in pharmacology, and electronic medical records and health information technology will be employed to improve patient care and reduce costs.

The two-phase pilot program will take place in the thirteen highest- cost states plus thirteen additional states. After review of Phase I and the evaluation report, the Secretary may elect to expand the program nationwide so it could then become an ongoing benefit for Medicare beneficiaries.

A shared-savings agreement incentive program allows this innovative delivery model to attract and maintain providers. The IAH organization will be required to demonstrate savings of at least 5 percent annually compared with the costs of serving non-participating Medicare chronically ill beneficiaries. The IAH organization may keep 80 percent of savings beyond the required 5 percent savings as an incentive to maximize the financial benefits of being an IAH organization. Any savings beyond 25 percent would be split, with 50 percent directed to the IAH organization and 50 percent to Medicare. In Phase II, the Secretary may modify the payment incentive structure to increase savings to the Medicare Trust Fund only if it will not impede access to IAH services to eligible beneficiaries.

I would like to thank my fellow Senate cosponsors, Richard Burr, Sheldon Whitehouse, and Benjamin Cardin, and my cosponsor in the House, Representative Ed Markey, and his cosponsor, Chris Smith, for their support. I also thank Rahm Emanuel for his support of IAH in the last Congress. I would also like to thank all our staff who worked so hard on this legislation, particularly Gregory Hinrichsen in my office. Finally, I would like to thank the following groups for voicing their support for this legislation: The American Academy of Home Care Physicians; The American Academy of Neurology; The AARP; The Alzheimer's Association; The Alzheimer's Foundation of America; The American Academy of Nurse Practitioners; The American College of Nurse Practitioners; American Academy of Physician Assistants; The American Society of Consultant Pharmacists; The National Family Caregivers Association; The Family Caregiver Alliance/National Center on Caregiving; The American Association of Homes and Services for the Aging; The Housecalls Doctors of Texas; The Maryland-National Capital Home Care Association; The Visiting Nurse Associations of America; Housecall Providers, Inc. of Portland, OR; Intel Corp.; The National Council on Aging; U.S. PIRG; Massachusetts Neurologic Society; Naples Health Care Associates; Urban Medical House Calls of Boston, MA; MD2U Doctors Who Make Housecalls (Louisville, KY); Wyeth Pharmaceuticals.

I urge all of my colleagues to support this important legislation to help Medicare patients get better care at lower cost.

Mr. President, I am pleased to be joined by my colleague, the distinguished Senator from New Hampshire, Judd Gregg, to introduce an important bill that will put patients in the driver's seat of their medical care. Today, my fellow Oregonian Representative Earl Blumenauer is introducing the same bill in the House of Representatives.

On the Senate floor and in the Finance Committee and Health Education Labor and Pensions Committee, senators have been wrestling with health reform. The challenge before the Congress is to both expand quality, affordable coverage to all Americans while containing costs.

Cost containment requires a lot of tough choices because it will require changing how care is delivered. The time of paying for volume and low quality is past. Chairman Baucus rightly recognized the challenges in cost containment and took up this issue as the first area he wanted to address in the series of public roundtables held in the Finance Committee.

I believe the key to transforming the health care system and cost containment is to give patients more choices. Patients should have more choices of health insurance plans. Patients should have a choice of doctor. Patients should also have choices in their medical care.

The research by Dr. Jim Weinstein and Dr. John Wennberg with the Dartmouth Atlas Project has documented regional variations in medical care. They have found both underuse, or the failure to deliver needed evidence-based care, and overuse, or the delivery of unnecessary supply-sensitive care. Regional variations are driven by local medical opinion, rather than sound science or the preferences of well-informed patients. Just because doctors are licensed to have a hammer, doesn't make every patient a nail.

Using their research, Office of Management and Budget Director Peter Orszag and other experts have estimated that as much as 30 percent of medical spending today goes to care that is unnecessary. That is 30 percent of $2.5 trillion is $750 billion going to care that does not make patients healthier and may even harm them.

The current standard of medical care in the U.S. fails to adequately ensure that patients are informed about all their treatment options and the risks and benefits of those options. This leads to patients getting medical treatments they may not have wanted had they been fully informed of their treatment options and integrated into the decision making process. In order to deliver the right care at the right time, informed patient choice should be the goal of medical care.

Shared decision making is a collaborative process between the doctor and patient when they discuss the trade-offs among treatment options and discuss the patient's preferences and values. Shared decision making uses patient decision aids, an educational tool like a video or pamphlet that helps patients understand, communicate their beliefs and preferences related to their treatment options, and decide what medical treatments are best for them with their provider based on their medical treatment options, scientific evidence, circumstances, beliefs and preferences.

Informed patients choice depends on clinical comparative effectiveness research that compares the effectiveness of health care treatments. Shared decision making and patient decision aids use clinical comparative effectiveness research so that doctors and patients together make the right medical treatment choice for each individual patient.

This bill creates a three stage phase in of patient decision aids and shared decision making into the Medicare program. Phase I of the pilot is a 3-year period allowing `early adopting' providers--those who already have experience using patient decision aids and incorporating them into their clinical practices--to participate in the pilot providing data for the Secretary and also serve as Shared Decision Making Resource Centers. During this period, an independent entity will develop consensus based standards for patient decision aids and a certification process to ensure decision aids are effective and provide unbiased information. An expert panel then recommends to the Secretary which patient decision aids may be used in this program.

Phase II is a 3-year period during which providers will be eligible to receive reimbursement for the use of certified patient decision aids. New providers may be added on an annual basis allowing for the gradual and voluntary expansion of shared decision making and patient decision aids to a large portion of the country.

The final stage requires all Medicare providers to ensure that Medicare beneficiaries receive shared decision making and patient decision aids prior to receiving treatment for a preference sensitive condition. If a provider does not ensure that a patient receives a patient decision aid then the provider's reimbursement may be reduced by no more than 20 percent.

This legislation is built on a shared savings model distributing 50 percent of the savings to participating providers based on their participation and performance on quality measures. Twenty-five percent of the savings are used to expand provider participation providing financial support to the Shared Decision Making Centers and providers. The final 25 percent savings are returned to the Medicare program. As shared decision making becomes the standard of practice, the shared savings percentages phases out.

I believe that this simple approach to informed patient choice is critically important to giving patients real choices by engaging them in their health care. As we look to expand access to health coverage, this bill provides a bipartisan, sensible path to putting patients in the driver's seat.

I hope my colleagues will join me in supporting this bill, and I look forward to working with Chairman Baucus and Ranking Member Grassley and other members of the Finance Committee to secure passage of this important bill.

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

Mr. President, today I am pleased to introduce two bills that will provide two important communities in rural Oregon with the means to promote their cultural history and their economic development opportunities, S. 1139 and S. 1140.

Like anywhere in America, the leaders in rural communities in my state are working every day to build the best place they can. And in many rural communities in my state, that means not much happens without the Federal Government involved. Like many places in the Western United States, the Federal Government owns much of the land surrounding these small communities. To be sure, many of these lands are treasures; they are the source of a vibrant tourism economy; an attraction for individuals and businesses to move to the region; and the daily outlet for the people lucky enough to live there.

By the same token, this high percentage of Federal land ownership sometimes limits the ability of local governments and civic leaders to solve problems and serve the public. The Federal Government can and should be an active partner in advancing communities and improving a region's quality of life.

So today I am introducing legislation that demonstrates the possibilities that can come from a quality Federal Government partnership with a proactive, innovative community that faces challenging economic conditions and a dominant pattern of Federal land ownership.

My first bill, the La Pine Land Conveyance Act, would convey two parcels of property to Deschutes County, Oregon. The bill directs the transfer of Bureau of Land Management BLM, lands to Deschutes County, that will enable the small town of La Pine to develop rodeo and equestrian facilities, public parks, and other recreation facilities.

La Pine has a set of unique challenges well known to the people of Deschutes County. The town recently incorporated, and with incorporation has come a feeling in the community that good things can happen if they work together to make their town as good as it can possibly be.

My bill proposes the transfer of 320 acres of BLM land contiguous to the La Pine city limit, on its western boundary. Ownership of this location will enable construction of public equestrian and rodeo facilities that have become increasingly important in La Pine. The property is within reasonable walking distance of downtown, creating an ideal parade route for the annual 4th of July Frontier Days parade. In addition, the land will provide a location for development of ball fields, parks, and recreation facilities, which can be developed as the town grows and budgets allow.

The La Pine Rodeo and Frontier Days events are currently facing the last year they can hold their events on the currently utilized location because that private property is being developed for other uses. So looking towards the Federal Government, who controls the vast majority of land in the La Pine area, to find a solution provides the right kind of partnership between the federal and local government.

My bill also directs the transfer of approximately 750 acres of BLM lands to Deschutes County for the purpose of expanding the town's wastewater treatment operation.

More than two years ago my office participated in discussions between the La Pine community leaders and the BLM concerning the La Pine community's need for land to serve public purposes. Due to staffing limitations, BLM asked the City to choose one top priority for a land transfer under the Recreation and Public Purposes Act. The La Pine City Council responded immediately that its top priority was

the acquisition of land to enable expansion of their sewer district.

To date, the land has not been transferred, which make this small community unable to be competitive for state and federal economic stimulus funds.

This project is too important to let languish. Perhaps the most important issue affecting water quality in Deschutes County involves the threat to groundwater and the Deschutes River from household septic systems in southern Deschutes County, the region around La Pine. This project directly reduces nitrate loading into south county groundwater in two ways. First, by enabling expansion of the District service boundary to residential areas where septic systems are generating elevated groundwater nitrate levels; and second, by closing the current location for spreading treated effluent, over a relatively high groundwater area, to this new location which is judged not to threaten groundwater. That is why I am introducing legislation today to make sure this transfer moves forward.

My second bill, the Wallowa Forest Service Compound Conveyance Act would convey an old Forest Service Ranger Station compound to the City of Wallowa, Oregon. In Wallowa County, this Forest Service compound was built by the Civilian Conservation Corps in the 1930's. For many years it was the center of town and this site continues to represent the natural and cultural history of one of eastern Oregon's most beautiful communities. The City of Wallowa, along with County Commissioners, the local arts organizations, and a broad group of community leaders intend to restore this important example of Pacific Northwest rustic architecture and tribute to bygone times, making a valuable community interpretive center at this site. The conveyance of this property will allow the community to move forward with this project. The community is currently working to list the Ranger Station on the National Register of Historic Places, and ownership by the City will allow this coalition to restore the buildings and again develop a vibrant community center. Oregon Public Broadcasting aired a segment depicting an early 20th century railroad logging community--a significant part of the rich and diverse history and traditions that will be preserved and celebrated as this Forest Service Compound is developed as an interpretive center.

I want to express my thanks to all the citizens and community leaders that have worked to build their communities and develop these projects. They represent the pioneering spirit and vision that defines my State.

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

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

Mr. President, I rise today to introduce the Annual and Lifetime Health Care Limit Elimination Act of 2009, legislation that would prohibit insurance companies from imposing any annual or lifetime limit on any individual or group health insurance policy, thus providing continuity and affordability of health care coverage for those with serious chronic conditions.

Each year, thousands of insured Americans face daunting medical expenses and challenges when they reach the annual or lifetime limit on their individual or employer-sponsored health insurance plan. Once a beneficiary's medical costs have exceeded the annual or lifetime limit of their plan, the insurance company no longer pays for the medical costs incurred by that individual.

In April, I held a roundtable discussion on health care in Raleigh County. There, I met a woman who had myelodysplastic syndrome, which is a non-curable pre-leukemia type disease. Unfortunately, her husband's insurance policy had a lifetime limit of $300,000, which she had reached. Another young West Virginian, born with serious congenital heart defects, reached the $1 million limit on his mother's insurance policy within the first nine months of his life. The limits on their health insurance plans have left these families struggling to find a way to pay for the expensive and life-sustaining treatments their loved ones desperately need.

Unfortunately, these two West Virginia families are not alone. In 2007, it was estimated that 55 percent of all people who obtain health benefits from their employer have some type of lifetime limit on their plan, an increase of approximately 4 percent since 2004. More than 23 percent of people have health insurance plans that impose limits of $2 million or less. Also, some health insurance policies renew less frequently than annually and contain annual limits to reduce the medical expenses paid by insurance companies. It is estimated that approximately 20,000 to 25,000 people no longer have health care benefits through their employers because of lifetime limits on their employer-sponsored health care plans.

When individuals with serious chronic conditions--such as transplant recipients, patients living with hemophilia, and newborns with life- threatening illnesses--hit the annual or lifetime limits on their policies, they are often left with very few options to meet their health care needs. Individuals and families that can afford it can try to pay for their health care costs completely out-of-pocket. However, this is rarely financially feasible; therefore, many people are forced to leave good, stable jobs and seek different employment in an effort to obtain new employer-sponsored coverage. Unfortunately, new enrollees are often subject to a waiting period for coverage if there was any break in their previous health care coverage.

Should an individual try to find health insurance in the individual market, coverage is likely to be prohibitively expensive. More often then not, these individuals are denied coverage altogether because of the insurer's pre-existing condition exclusion. Annual or lifetime limits can force people to turn to public programs such as Medicaid, or spend down their savings to meet the financial restrictions of the program. Others are forced to forgo treatment altogether, which can lead to serious complications and greater long-term health care costs.

It is time to stop health insurance companies from imposing annual or lifetime limits on health insurance policies. The beneficiaries affected by these limits have paid their premiums, deductibles, and copays faithfully, only to lose access to life-saving treatment when they need care the most. This is unacceptable and I encourage my colleagues to join me in supporting the Annual and Lifetime Health Care Limit Elimination Act.

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

Mr. President, I rise today with my friends and colleagues--Senators Collins, Kohl, Wyden and Carper--to introduce the Advance Planning and Compassionate Care Act of 2009, comprehensive legislation that recognizes the critical importance of advance care planning and quality end-of-life care. Senator Collins and I have worked on this legislation for over a decade--with the ultimate goal of one day passing comprehensive end-of-life care legislation. We are encouraged by the prospect of comprehensive health reform this year and believe that it is absolutely critical that end-of-life care provisions be included.

In preparation for the impending health reform debate, Senator Collins and I decided last year that it was time to update our Advance Planning and Compassionate Care Act to incorporate all of the best ideas out there on improving end-of-life care--including new and innovative approaches being implemented in the states, approaches suggested by scholars in this field, and recommendations based on our own experiences with loved ones facing the end of life. This new and improved bill is truly a labor of love and we are certainly hopeful that we can finally get something comprehensive and meaningful done for the millions of individuals and families faced with the agonizing issues surrounding the end of life.

A modern health care delivery system is well within our reach and something that we can start to achieve this year. A critical component of a modernized health system is the ability to address the health care needs of patients across the life-span--especially at the end of life. Death is a serious, personal, and complicated part of the life cycle. Yet, care at the end of life is eventually relevant to everyone. Americans deserve end-of-life care that is effective in providing information about diagnosis and prognosis, integrating appropriate support services, fulfilling individual wishes, and avoiding unnecessary disputes.

The bitter dispute that played out publicly for Terri Schiavo and her family is an agonizing experience that countless other families quietly face over the care of a loved one because clear advance directives are not in place. End-of-life care is a very delicate, yet important, issue and we must act to ensure that all Americans have the dignity and comfort they deserve at the end of life. Services should be available to help patients and their families with the medical, psychological, spiritual, and practical issues surrounding death.

Most people want to discuss advance directives when they are healthy and they want their families involved in the process. Yet, the vast majority of Americans have not completed an advance directive expressing their final wishes. In 2007, RAND conducted a comprehensive review of academic literature relating to end-of-life decision-making. This review found that only 18 to 30 percent of Americans have completed some type of advance directive expressing their end-of-life wishes. RAND also found that acutely ill individuals, for whom these decisions are particularly relevant, complete advance directives at only slightly higher rates--35 percent of dialysis patients and 32 percent of Chronic Obstructive Pulmonary Disease, COPD, patients. Perhaps most alarmingly, between 65 and 76 percent of physicians whose patients had an advance directive were unaware of its existence.

In its present form, end-of-life planning and care for most Americans is perplexing, disjointed, and lacking an active dialogue. In its 1997 report entitled Approaching Death: Improving Care at the End of Life, the Institute of Medicine found several barriers to effective advance planning and end-of-life care that still persist today.

In addition to the substantial burden of suffering experienced by many at the end of life, there are also significant financial consequences for family members and society as a whole that stem from ineffective end-of-life care. According to one Federal evaluation, 80 percent of all deaths occur in hospitals--the most costly setting to deliver care--even though most people would prefer to die at home. Current studies indicate that around 25 percent of all Medicare spending occurs in the last year of life. Largely because of their poorer health status, dually eligible beneficiaries have Medicare costs that are about 1.5 times that of other Medicare beneficiaries. Research also shows significant variation in expenditures at the end-of-life by geography and hospital, without evidence that greater expenditures are associated with better outcomes or satisfaction.

We must find ways to improve the quality of end-of-life care. Quality measures provide not only information for oversight, but data with which to improve care practices and models. No core sets of end-of-life quality measures are required across provider settings. Even for certified hospices, reporting of quality measures has only recently been required, with each hospice deciding its own indicators. Hospice surveys are behind schedule and not conducted frequently enough.

Facilitating greater advance planning and improving care at the end of life also requires an adequate workforce. Unfortunately, there is a substantial shortage of health professionals who specialize in palliative care. There is a severe shortage of physicians and advance practice nurses trained in palliative medicine. Contributing to these shortages is a shortage of medical and nursing school faculty in palliative medicine and care. There is also a lack of content about end-of-life care in medical school curricula. Medical students in general receive very little formal end-of-life education. Almost half of medical residents in a survey felt unprepared to address patients' fears of dying. For Americans to have a full range of choices in end- of-life care, we must strengthen our health care workforce, including palliative care education of physicians and other health professionals.

Care at the end-of-life can, and should, be better and more consistent with what Americans want. The Advance Planning and Compassionate Care Act takes enormous steps forward to fully inform consumers of their treatment options at the end of life and to actually address patient end-of-life care needs when the time comes. To promote advance care planning, this legislation provides both patients and their physicians with the information and tools to help them in this most personal and often difficult discussion.

Last year's Medicare Improvements for Patients and Providers Act, PL 110-275, took a significant step forward toward improving advance care planning. MIPPA included a provision that I authored, requiring physicians to provide an advance care planning consultation as part of the Welcome to Medicare physical exam. Unfortunately, less than 10 percent of new enrollees use the Welcome to Medicare visit. The MIPPA provision also does not address the advance care planning needs of existing Medicare enrollees.

The legislation we are introducing today establishes physician payment under Medicare, Medicaid, and CHIP for vital patient advance care planning conversations. It provides help in documenting decisions from these conversations in the form of advance directives and in the form of actionable orders for life sustaining treatment. It also takes steps to address the problem of accessing advance directives when needed, including state grants for electronic registries.

This legislation establishes a National Geriatric and Palliative Care Service Corps, modeled after the National Health Service Corps, to increase the woefully inadequate supply

of geriatric and palliative specialists and to even out their geographic distribution. It adopts MedPAC's 2009 hospice payment reforms aimed at aligning payment with the actual trajectory of resources expended over hospice episodes of care, while remaining within the constraints of current reimbursement. Demonstration projects are funded to explore ways to better meet the needs of patients over longer time periods than the 6-month prognoses inherent in the hospice benefit.

Certification standards and processes are developed for hospital- based palliative care teams. Such teams are critical to providing consultation and care to dying patients. Quality measurement and oversight are strengthened, with development of end-of-life measures across care settings and greater data reporting requirements of hospices--so that we can make sure the hospice benefit is keeping pace with the changing diagnostic mix of patients that hospice serves.

Finally, this bill takes the important step of establishing a National Center on Palliative and End-of-Life Care within the NIH. This is a vital step toward prioritizing biomedical research in the areas of palliative and end-of-life care. It will also serve as a symbol to remind us that, as in other phases of life, we need care at the end of life that addresses our individual needs and circumstances.

Death is a serious, personal, and complicated issue that is eventually relevant to each and every one of us. Americans deserve end- of-life care that is effective in fulfilling individual wishes, avoiding unnecessary disputes, and, most importantly, providing quality end-of-life care. Therefore, I urge my colleagues to join us in improving end-of-life care and reducing the amount of grief that inevitably comes with losing those who we hold dear.

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

Mr. President, today I am pleased to introduce with my distinguished colleague Senator Olympia Snowe, bipartisan legislation known as the State Child Well-Being Research Act of 2009. Companion legislation has already been introduced in the House by Congressmen Fattah and Camp. This bill is designed to enhance child well-being by requiring the Secretary of Health and Human Services to facilitate the collection of state-specific data based on a defined set of indicators. The well-being of children is important to both national and State governments. Therefore, data collection is a priority that cannot be ignored if we hope to make informed decisions on public policy.

In 1996, Congress passed bold legislation, which I supported to dramatically change our welfare system. The driving force behind this reform was to promote the work and self-sufficiency of families and to provide the flexibility to States necessary to achieve these goals. States, which is where most child and family legislation takes place, have used this flexibility to design different programs that work better for the families who rely on them. The design and benefits available under other programs that serve children, ranging from the Children Health Insurance Program, CHIP, to child welfare services, can vary widely among States.

It is obvious that in order for policy makers to evaluate child well- being, we need state-specific data on child well-being to measure the results. Current surveys provide minimal data on some important indicators of child well-being, but insufficient data is available on low-income families, geographic variation, and young children. Additionally, the information is not provided in a timely manner, which impedes legislators' ability to effectively measure child well-being and design effective programs to support our children.

The State Child Well-Being Research Act of 2009 is intended to fill this information gap by collecting up-to-date, State-specific data that can be used by policymakers, researchers, and child advocates to assess the well-being of children. As we strive to promote quality programs, we need basic benchmarks to measure outcomes. Our bill would require that a survey examine the physical and emotional health of children, adequately represent the experiences of families in individual states, be consistent across states, be collected annually, articulate results in easy to understand terms, and focus on low-income children and families. This legislation also establishes an advisory committee, consisting of a panel of experts who specialize in survey methodology and indicators of child well-being, and the application of this data to ensure that the purpose is being achieved.

Further, this bill avoids some of the problems in the current system by making data files easier to use and more readily available to the public. As a result, the information will be more useful for policy- makers managing welfare reform and programs for children and families. Finally, this legislation also offers the potential for the Health and Human Service Department to partner with private charitable foundations, like the Annie E. Casey Foundations, which has already expressed an interest in forming a partnership to provide outreach, support and a guarantee that the data collected would be broadly disseminated. This type of public-private partnership helps to leverage additional resources for children and families and increases the study's impact. Given the tight budget we face, partnerships make sense to meet this essential need.

I hope my colleagues review this legislation carefully and choose to support it so that Federal and state policy makers and advocates have the information necessary to make good decisions for children.

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

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

Mr. President, an educated workforce is crucial to the success of the American economy. A recent report from the consulting firm McKinsey, ``The Economic Impact of the Achievement Gap in America's Schools,'' concludes that if America had raised the educational attainment of our students to those of high-performing nations like Finland and South Korea between 1983 and 1998, U.S. G.D.P. in 2008 would have been between $1.3 trillion and $2.3 trillion higher than it is today. If the gap between low-income American students and American students of higher means had been narrowed, G.D.P. in 2008 would have been $400 billion to $670 billion higher.

If we want to be economically competitive and avoid future recessions, we need to close the achievement gap in education for all Americans. In his first speech to Congress, President Obama set a goal of having the highest college graduation rate in the world by 2020. Too many students are not receiving a college education, and we will have to do far better to reach the President's goal.

Of students who were in eighth grade in 2000, only 20 percent of the lowest-income students will earn a college degree by 2012, compared to 68 percent of the highest income group. Every student who wants to go to college should have that opportunity, and we should provide them with the tools they need.

Today, I am introducing the Pathways to College Act with Senator Burr, which creates grants for school districts to help them increase the number of low-income students who are entering and succeeding in college.

Lack of guidance and information about college has a real effect on students in poor schools. The Consortium

on Chicago School Research released a report last year, ``Potholes on the Road to College,'' that looks at the difficulties Chicago Public School students face during the college application process. The Consortium discovered that only 41 percent of Chicago Public School students who wanted to go to college took the steps necessary to apply to and enroll in a 4-year college. Only one-third of students enrolled in a college that matched their qualifications. Of the students who had the grades and test scores to attend a selective college, 29 percent went to a community college or skipped college entirely.

The Pathways to College Act would create a grant program for school districts serving low-income students to increase their college- enrollment rates. The Consortium's ``Potholes'' report found that the most important factor in whether students enroll in a four-year college is if they attended a school where teachers create a strong college- going culture and help students with the process of applying. The Pathways to College Act would provide the funding to help school districts improve the college-going culture in schools and guide students through the college admissions process.

The Pathways to College Act provides flexibility to school districts to achieve higher college enrollment rates, but requires that each school accurately track their results so we can learn from what works. Chicago Public Schools is doing a great job--both in tackling the problem and in documenting progress. Under the leadership of Arne Duncan, Chicago Public Schools responded aggressively to the ``Potholes'' report.

A team of postsecondary coaches were deployed in high schools to work with students and counselors. To ensure that financial aid is not a roadblock, FAFSA completion rates are tracked so that counselors can follow-up with students. A spring-break college tour took 500 students to see colleges across the country. Because Chicago Public Schools tracks its college enrollment rates, we know that their efforts are working.

Half of the 2007 graduating class enrolled in college, an increase of 6.5 percent in 4 years. The national increase was less than 1 percent in the same time-frame. Nationally, the number of African-American graduates going to college has decreased by 6 percent over the last 4 years while the Chicago rate has increased by almost 8 percent.

Applying to college is not easy. Low-income students often need the most help to achieve their college dreams. When schools focus on college and provide the tools to get there, students make the connection between the work they are doing now and their future goals in college and life. Students in those schools are more likely enroll in college and are also more likely to work hard in high school to be prepared for college when they arrive. The bill we are introducing today tries to ensure that lack of information never prevents a student from achieving his or her college dream.

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

Mr. President, the people who work in public health are responsible for some of the most important jobs that protect the lives and health of ordinary Americans. The scope of public health includes preventing the spread of communicable diseases and pandemics, managing the health system's response to biological and chemical attacks, fighting food-borne illnesses, assisting communities in preparing for disasters, and promoting best health practices.

The recent outbreak of Influenza A H1N1 virus reminds us how much we depend on the people who work in public health. This virus has infected thousands of people and caused nearly a hundred deaths worldwide. The American people have looked to the Centers for Disease Control and Prevention and their State and local health departments to collect data, monitor the threat, provide accurate information, and prepare to respond if the situation worsens. But even when a pandemic or other widespread threat is not imminent, the public health workforce remains on the front lines in promoting healthy lifestyles and preventing chronic disease.

Our ability to prevent, respond to, and recover from a pandemic or other health challenges depends largely on a strong pipeline of public health professionals. Unfortunately, a critical--and growing--shortage of public health workers is putting our nation at risk.

The Association of Schools of Public Health recently reported that there were 50,000 fewer public health workers in 2000 than there were in 1980. In my home State of Illinois, the average Illinois Department of Public Health worker is 48 years old, and 39 percent of the staff will be eligible to retire within 5 years. Compounding this problem is the fact that 13 percent of agency positions are vacant, and when a new hire is found, the average age is 41. The ``graying'' workforce and weak pipeline of new public health graduates are problems across all levels of government. Nearly half of the federal employees in occupations critical to U.S. biodefense will be eligible to retire by 2012.

We cannot stay on the same trajectory in the future. We are not educating enough people in public health to replace retiring public health workers, and the salaries for those who do work in public health disciplines are not competitive with comparable employment in the private sector. The Association of State and Territorial Health Officials reports that in 2004, most of the approximately 6,400 graduates from accredited schools of public health took jobs in the private sector.

I am pleased to introduce the Public Health Workforce Development Act of 2009 today to help address this challenge. This legislation provides several common-sense solutions to develop a strong pipeline of public health professionals. This bill would provide scholarships to students going into public health and provide loan repayment for current public health workers in exchange for a commitment to additional years of service in public health.

The legislation also encourages states to set up their own public health training programs and creates a scholarship program for mid- career professionals to maintain or upgrade their training. Finally, it creates an online clearinghouse of public health jobs available in the Federal Government. Together, these programs will help attract young people to a career in public health and give current public health professionals incentives to remain in the field in the long-term

Our health care system today focuses too much on treating sickness, at the expense of preserving wellness. As the process of health reform moves forward, two key concerns are improving health care quality, while holding health care costs down. To do this, we need to focus on wellness, preventive care, and effective management of chronic conditions, all of which are hallmarks of the public health system. This bill will help maintain a strong and effective public health system by alleviating the dangerous shortage of public health workers

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

Mr. President, I rise on behalf of myself and Senator Boxer to introduce the Bay Area Regional Water Recycling Program Expansion Act of 2009, which will reduce demand for limited fresh water supplies by providing recycled water to 6 communities across the Bay Area.

It will make 6 additional Bay Area recycled water projects eligible for a 25 percent Federal cost-share, and expand the authorizations for two more, totaling $38,075,000. The activities authorized by the new legislation include installing new piping, storage tanks, and pump stations to convey the recycled water to a number of cities across the Bay Area.

These projects collectively will save 2.6 billion gallons per year of regional water supply by providing a new water supply of clean treated wastewater for irrigation and industrial use. It will free up the amount needed to supply 24,225 households in the growing Bay Area region. And to the regional agencies, over 3,500 local green jobs will be supported by this legislation.

The adoption of water recycling technology is an invaluable conservation method which will result in 8,000 acre-feet of new and reliable water which will reduce demand on fresh water from the Delta.

California is facing phenomenal water supply challenges that are affecting our economy, our communities and our environment.

California's water infrastructure is woefully out of date. Drought, population growth, climate variability, ecosystem needs and a broken Delta are making it even more difficult to manage our water system and deliver reliable supplies.

And unless we take action to address climate change, we could lose a significant portion of the Sierra snowpack, which stores water for 2/3 of California, by 2100.

Increasing the capability for and use of recycled water will help address California's cycles of drought and reduce dependence on water from the troubled Bay-Delta ecosystem.

Water recycling projects are already under way in several local Bay Area communities, and have qualified for Federal funding under the Bay Area Regional Water Recycling Program. This program allows local water managers to treat wastewater and use the clean, recycled water for landscape irrigation and other uses, including at golf courses, schools, city parks and other municipal facilities. Under the new legislation, the six additional Bay Area communities would be allowed to work with the Federal Bureau of Reclamation to use water supplies more efficiently.

With the increasing strain on Bay-Delta and other natural resources, it is vital that we look to adopt innovative water recycling technologies which sustain permanent clean water supplies and support existing water resources and local economies.

Nine Bay Area congressional representatives in the House put this regional approach together, and I'd like to recognize and thank them for their leadership: George Miller, D-Martinez, Pete Stark, D-Fremont, Ellen Tauscher, D-Concord, Anna Eshoo, D-Palo Alto, Mike Honda, D-San Jose, Lynn Woolsey, D-Petaluma, Jerry McNerney, D-Pleasanton, Zoe Lofgren, D-San Jose and Jackie Speier, D-San Mateo, worked together to address the Bay Area's water needs.

This bill reflects a federal-local partnership and will provide communities in the San Francisco Bay Area with reliable and sustainable water supplies, and be a benchmark for other major American cities.

Declining water supplies affects people from all across the United States. Now is the time to invest in new water technologies, such as water recycling, to meet increasing needs. Wastewater recycling is an important part of a multifaceted water supply strategy that also includes surface and groundwater storage, improved conveyance, conservation, and desalination.

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

Mr. President, I rise today with Senator Bond to introduce the Tariff Relief Assistance for Developing Economies Act of 2009 to help some of the world's poorest countries sustain vital export industries and promote economic growth and political stability.

I worked with former senator Gordon Smith on this bill in the past and I am proud to move it forward in the 111th Congress.

This legislation will provide duty free and quota free benefits for garments and other products similar to those afforded to beneficiary countries under the Africa Growth and Opportunity Act, AGOA.

The countries covered by this legislation are the 14 Least Developed Countries, LDCs, as defined by the United Nations and the U.S. State Department, which are not covered by any current U.S. trade preference program: Afghanistan, Bangladesh, Bhutan, Cambodia, Kiribati, Laos, Maldives, Nepal, Samoa, Solomon Islands, East Timor, Tuvalu, Vanuatu, and Yemen.

The bill also includes Sri Lanka as an eligible country.

To be eligible for the benefits provided under our bill, a country must demonstrate that it is making continual progress toward establishing rule of law, political pluralism, the right to due process, and a market-based economy that protects private property rights. Our legislation would help promote democracy while sustaining vital export industries and creating employment opportunities.

The beneficiary countries of this legislation are among the poorest countries in the world.

Nepal has per capita income of $240. Unemployment in Bangladesh stands at 40 percent. Approximately 36 percent of Cambodia's population lives below the poverty line.

Each country faces critical challenges in the years ahead including poor health care, insufficient educational opportunities, high HIV/AIDS rates, and the effects of war and civil strife.

The U.S. must take a leadership role in providing much needed assistance to the people of these countries.

Yet humanitarian and development assistance should not be the sum total of our efforts to put these countries on the road to economic prosperity and political stability.

Indeed, the key for sustained growth and rising standards of living will be the ability of each of these countries to create vital export industries to compete in a free and open global marketplace.

We should help these countries help themselves by opening the U.S. market to their exports.

Success in that endeavor will ultimately allow these countries to become less dependent on foreign aid and allow the U.S. to provide assistance to countries in greater need.

The garment industry is a key part of the manufacturing sector in some of these countries.

In Nepal, the garment industry is entirely export oriented and accounts for 40 percent of foreign exchange earnings. It employs over 100,000 workers--half of them women--and sustains the livelihood of over 350,000 people.

The United States is the largest market for Nepalese garments and accounts for 80-90 percent of Nepal's total exports every year.

In Cambodia, approximately 250,000 Cambodians work in the garment industry supporting approximately one million dependents. The garment industry accounts for more than 90 percent of Cambodia's export earnings.

In Bangladesh, the garment industry accounts for 75 percent of export earnings. The industry employs 1.8 million people, 90 percent of whom are women, and sustains the livelihoods of 10 to 15 million people.

Despite the poverty seen in these countries and the importance of the garment industry and the U.S. market, they face some of the highest U.S. tariffs in the world, averaging over 15 percent. In contrast, countries like Japan and our European partners face tariffs that are nearly zero.

Surely we can do better. This legislation will help these countries compete in the U.S. market and let their citizens know that Americans are committed to helping them realize a better future for themselves and their families.

Doing so is consistent with U.S. goals to combat poverty, instability, and terrorism in a critical part of the world. We should not forget that of the approximately 265 million people that live in the TRADE Act countries, almost 200 million are Muslim.

The impact on U.S. jobs will be minimal. Currently, the beneficiary countries under this legislation account for only 4 percent of U.S. textile and apparel imports, compared to 24 percent for China, and 72 percent for the rest of the world.

These countries will continue to be small players in the U.S. market, but the benefits of this legislation will have a major impact on their export economies.

At a time when we are trying to rebuild the image of the U.S. around the world, we need legislation such as this to show the best of America and American values. It will provide a vital component to our development strategy and add another tool to the war on terror. I urge my colleagues to support this bill.

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

Mr. President, I am pleased to introduce today the Upper Connecticut River Partnership Act. This legislation will help bring recognition to New England's largest river ecosystem and one of our Nation's 14 American Heritage Rivers.

The purpose of this legislation is to help the communities along the river protect and enhance their rich cultural history, economic vitality, and the environmental integrity of the river.

From its origin in the mountains of northern New Hampshire, the Connecticut River runs over 400 miles and eventually empties into Long Island Sound. The river forms a natural boundary between my home state of Vermont and New Hampshire, and travels through the States of Massachusetts and Connecticut. The river and surrounding valley have long shaped and influenced development in the New England region. This river is one of America's earliest developed rivers, with European settlements going back over 350 years. The industrial revolution blossomed in the Connecticut River Valley, supported by new technologies such as canals and mills run by hydropower.

I am pleased that the entire Senate delegations from Vermont and New Hampshire have cosponsored this bill. For years our States have worked together, to help communities on both sides of the river develop local partnerships to protect the Connecticut River valley of Vermont and New Hampshire. While great improvements have been made to the river, its overall health remains threatened by water and air pollution, habitat loss, hydroelectric dams, and invasive species.

Historically, the people throughout the Upper Connecticut River Valley have functioned cooperatively and the river serves to unite Vermont and New Hampshire communities economically, culturally, and environmentally.

Citizens on both sides of the river know just how special this region is and have worked side by side for years to protect it. Efforts have been underway for some time to restore the Atlantic salmon fishery, protect threatened and endangered species, and support urban riverfront revitalization.

In 1989, Vermont and New Hampshire came together to create the Connecticut River Joint Commissions--a unique partnership between the states, local businesses, all levels of Government within the 2 States and citizens from all walks of life. This partnership helps coordinate the efforts of towns, watershed managers and other local groups to implement the Connecticut River Corridor Management Plan. This Plan has become the blueprint for how communities along the river can work with one another with Vermont and New Hampshire and with the federal government to protect the river's resources.

The Upper Connecticut River Partnership Act would help carry out the recommendations of the Connecticut River Corridor Management Plan, which was developed under New Hampshire law with the active participation of Vermont citizens and communities.

This act would also provide the Secretary of the Interior with the much needed ability to assist the States of New Hampshire and Vermont with technical and financial aid for the Upper Connecticut River Valley through the Connecticut River Joint Commissions. The act would also assist local communities with cultural heritage outreach and education programs while enriching the recreational activities already active in the Connecticut River Watershed of Vermont and New Hampshire.

Lastly, the bill will require that the Secretary of the Interior establish a Connecticut River Grants and Technical Assistance Program to help local community groups develop new projects as well as build on existing ones to enhance the river basin.

In the future, I hope this bill will help bring renewed recognition and increased efforts to conserve the Connecticut River as one of our Nation's great natural and economic resources.

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

Mr. President, in 2003, Senator Ben Nighthorse Campbell and I, along with 68 other Senators, introduced a bill to allow qualified retired or current law enforcement officers to carry a concealed firearm across State lines. The Senate passed our bill by unanimous consent, and it was signed into law in July 2004. Passage of the Law Enforcement Officers Safety Act indicated strong confidence in the men and women who serve to protect their communities and their Nation as the first line of defense in any emergency.

Introduction of this legislation to benefit active and retired law enforcement officers across the country is especially timely as the Congress and the country have just recognized National Peace Officers Memorial Day. I am proud to introduce this legislation today and thank Senator Kyl for joining me as a cosponsor.

This year, the Senate Judiciary Committee has turned its attention to State and local law enforcement. It has held hearings about the importance of Federal funding at the local level, and how strong community policing and positive community relationships are fundamental to a prosperous economy. I agree, and appreciated having the perspective at recent Judiciary Committee hearings of the State and local officials like Chief Michael Schirling and Lieutenant Kris Carlson from the Burlington, Vermont, Police Department. I hope the Senate will continue its strong support of our law enforcement officers with support for this legislation.

In 2007, the Senate Judiciary Committee twice reported the legislation I introduce today--once as a stand-alone bill and again as part of the School Safety and Law Enforcement Improvements Act. I hope the Senate will act in the interest of so many law enforcement officers across the United States by improving and building upon the current law.

Since enactment of the Law Enforcement Officers Safety Act, I have heard feedback from many in law enforcement that qualified retired officers have been subject to varying certification procedures from State to State. In many cases, differing interpretations have complicated the implementation of the law, and retired officers have experienced significant frustration in getting certified to lawfully carry a firearm under the law.

With the input of the law enforcement community, this bill proposes modest amendments to the current law, and will give retired officers more flexibility in obtaining certification. It also provides room for the variability in certification standards among the several States. For example, where a State has not set active duty standards, the retired officer can be certified pursuant to the standards set by a law enforcement agency in the State.

In addition to these changes, the bill makes clear that Amtrak officers, along with law enforcement officers of the Executive branch of the Federal Government, are covered by the law. The bill also reduces the years of service required for a retired officer to qualify under the law from 15 to 10. The bill now contains clearer standards to address mental health issues related to eligibility for officers who separate from service or retire. These are positive changes to the current law, and the requirements for eligibility would continue to require a significant term of service for a retired officer to qualify, a demonstrated commitment to law enforcement, and retirement in good standing.

The dedicated public servants who are trained to uphold the law and keep the peace deserve our support not just in their professional lives, but also when they are off-duty or retire. As a former prosecutor, I have great confidence in those who serve in law enforcement and their ability to exercise their privileges under this legislation safely and responsibly. The responsibilities they shoulder day to day on the job deserve our recognition and respect.

I hope all Senators will join us in support of this legislation.

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