Iran Refined Petroleum Sanctions Act

Mr. President, I ask unanimous consent to set aside the pending Thune amendment and call up my amendment No. 1597.

I ask unanimous consent that reading of the amendment be dispensed with.

Mr. President, this is a bipartisan amendment put forward by Senator Bayh and myself. I ask unanimous consent that Senators Kyl and Inhofe be added as cosponsors.

This is a bipartisan resolution and sense of the Senate that the administration should relist North Korea as a state sponsor of terrorism. As my colleagues know, the Bush administration, through a great deal of hoopla, listed North Korea as a state sponsor of terrorism. They took them off the list in spite of such terrible and erratic behavior as nuclear weapons, missile technology, and now taking U.S. citizens hostage and holding them. Nonetheless, the Bush administration, as part of the six-party talks, did an agreement, a deal to delist them as a state sponsor of terrorism. All that got us was more nuclear weapons, more missiles being sent off, more provocative action by the North Koreans, and a dismal situation.

What we are asking with the amendment is that it is a sense of the Senate that North Korea should be relisted as a state sponsor of terrorism.

In that regard, I wish to enter a few items in the Record to be printed at the end of my presentation that are currently in the news. This is yesterday's front page of the Washington Post where it talks about ``[North] Korea's Hard-Labor Camps: On the Diplomatic Back Burner.''

I ask unanimous consent that this full article be printed in the Record.

That is an old story. Unfortunately, we know very well about the gulags that exist in North Korea and the 200,000 people we believe are in those. Here is today's Washington Post. This was new information I found shocking: North Korea building mysterious military ties with the military junta in Burma now taking place and the possibility of them giving military equipment and supplies, I suppose possibly even nuclear arms and missile technology, to the military government in Burma.

I ask unanimous consent that this be printed in the Record at the end of my statement.

If that is not enough to relist them as a state sponsor of terrorism, I don't know what is. But there is a full record we can go forward with on relisting North Korea as a state sponsor of terrorism. At the outset, I think we ought to look at this and say this is an extremely tough situation for the United States. It is one on which we need to take aggressive action to confront them on what they are doing to militarize some of the worst places and worst actors around the world and what North Korea is doing to threaten interests of the United States.

All this is taking place while Kim Jong Il is ill. To what degree, we don't know for sure. A succession is being discussed. Of what nature, we are not sure. But clearly North Korea is doing the most provocative things they have probably done in the history of that provocative nation. It is taking place right now. We should notice it and recognize these are terrorist actions. We should clearly call for them to be relisted.

I have, many times, spoken before regarding the long and outrageous list of crimes of the Kim regime. I will not go through those again at great length. But I will say the crimes committed by the North Korean regime include not only those external and diplomatic of nature-- violating agreements, treaties, conventions, and proliferating dangerous technologies to the world's worst actors--but the regime has also committed massive and unspeakable crimes against the North Korean people themselves who for decades have been beaten, tortured, raped, trafficked, starved, used as medical experiments, subjected to collective familial punishment, and executed in the most brutal and painful ways. If you want further details on that, read yesterday's Washington Post article.

Hundreds of thousands languish in the gulag and concentration camps spread out over the entire country. All the while, the world watches and wrings its collective hands. As we pledged never again, we watch as yet again another criminal regime commits a genocide. Never again becomes yet again.

I have introduced legislation to address these issues. I hope the Foreign Relations Committee can find time to take it up.

The amendment before us today deals with another aspect of the North Korean criminal state, its longstanding and robust sponsorship of international terrorism. The amendment would place the Senate on record as standing for the proposition that North Korea's hostile and provocative actions will not be ignored. Indeed, they will have meaningful consequences under the law. This amendment, of which Senator Bayh is the lead cosponsor, expresses the sense of the Senate that the Secretary of State should redesignate North Korea as a state sponsor of terrorism based on its nuclear and missile

proliferation, abductions, and material support for terrorist groups.

On October 11, 2008, the State Department removed North Korea from the list of state sponsors of terrorism on which it had been placed since 1988. At the time, this is what President Bush said to the North Korean regime upon announcing that North Korea would be removed. He said:

We will trust you only to the extent that you fulfill your

promises. If North Korea makes the wrong choices, the United

States will act accordingly.

They have made the wrong choices. We should act accordingly.

At the same time, then Candidate Obama said:

Sanctions are a critical part of our leverage to pressure

North Korea to act. They should only be lifted based on North

Korean performance. If the North Koreans do not meet their

obligations, we should move quickly to reimpose sanctions

that have been waived and consider new restrictions going

forward.

They have not lived up to their obligations. They have continued provocative actions. They should be relisted.

Let's examine how well the North Korean regime has lived up to its commitment since being removed from the list. Since removal last October, the North Korean regime has done the following: launched a multistage ballistic missile over Japan in violation of U.N. Security Council sanctions; kidnapped and imprisoned two American journalists and sentenced them to 12 years of hard labor in a North Korean prison camp; pulled out of the six-party talks vowing never to return; kicked out international nuclear inspectors and American monitors; restarted its nuclear facilities; renounced the 50-year armistice with South Korea; detonated a second illegal nuclear weapon; launched additional short-range missiles; is preparing to launch long-range missiles capable of reaching the United States; and today news accounts are reporting about North Korean proliferation to the Burmese junta, including perhaps nuclear proliferation.

Add to this a long history of other ongoing illicit operations that finance the North Korean regime's budget, including the following: extensive drug smuggling; massive and complex operations to counterfeit U.S. currency, many of which are believed to be in wide circulation; money laundering; terrorist threats by the regime against the United States, Japanese, and South Korean civilians. That is what this regime and group has done and is doing. That is some of what they have done since they were delisted from the terrorist list.

What have we done in response? The U.N. Security Council has passed another sanctions resolution similar to the same resolution North Korea has brazenly violated to get us to this point. In 2006, the State Department, in its terrorism report, said this about keeping North Korea on the list: North Korea ``continued to maintain their ties to terrorist groups.''

They said:

Most worrisome is that some of these countries [including

North Korea] also have the capability to manufacture [weapons

of mass destruction] and other destabilizing technologies

that can get into the hands of terrorists.

If that was the justification for the terror list in 2006, certainly North Korea's actions today fit that standard--perhaps even more so than back then, and I believe it is more so.

We cannot have it both ways. If we removed North Korea from the terrorism list last year as a reward for its dubious cooperation on nuclear weapons, we would only be reversing that step by adding it back after the regime betrayed its commitments and followed up with hostile and provocative actions.

I would also like to address this issue: It often has been raised with me--and the Secretary of State herself has raised this indirectly with me--that the multiple statutes that control the list of state sponsors of terrorism do not provide the legal ability for the Secretary of State to redesignate. I think this argument is flawed, and I would like to summarize that by reading the relevant portions of each of these acts, because here is the key point on it, that they are saying: Well, we have to find factual basis that is different from the first round for us to do that. We are going through a legal review of doing this. But here the state sponsor of terrorism list is controlled under two different acts: the Arms Export Control Act and the Foreign Assistance Act.

As to countries covered by the prohibition, it says this. This is quoting from the Arms Export Control Act:

The prohibitions contained in this section apply with

respect to a country if the Secretary of State determines

that the government of that country has repeatedly provided

support for acts of international terrorism.

That is what it says in the Arms Export Control Act. The list I have just read goes through what has taken place, and they are clearly and repeatedly providing support for acts of international terrorism. It does not say anything about they cannot be relisted or we have to go through some elaborate finding process, that it cannot be based on actions they have done. These are the actions they have done in the last 6 months that are of public record. And it says the Secretary of State makes this determination and has fairly wide discretion to be able to do it.

Under section 628 of the Foreign Assistance Act, it says: The United States shall not provide any assistance to any country if the Secretary of State determines that the government of that country has repeatedly provided support for acts of international terrorism.

Again, the statute is very broad in its statement. It does not say anything about they cannot relist them. It says they can do this on the discretion of the Secretary of State.

I do not know why we need to wait any longer, with the actions this government has taken and even with these most recent ones reported today of working with Burma or of the publicly done ones we know about of nuclear weapons detonation or the ones of missile technology being launched. Why do we need to wait longer?

I recognize this is a sense of the Senate, so it is just a sense of this body. But this body has had a strong impact in prior actions when we took a sense-of-the-Senate resolution to list the Revolutionary Guard in Iran, that we believed they should be listed as a state sponsor of terrorism. The administration acted not long after that to list them as a state sponsor of terrorism.

I believe if this body took strong action here now and said we believe North Korea should be relisted as a state sponsor of terrorism, it would send a very strong and proper signal to the administration-- not that we are doing your job, but we believe this is the case and this is something that is meritorious toward North Korea and its actions.

That is why I urge my colleagues to support the bipartisan Bayh- Brownback amendment and vote for this amendment to the Defense authorization bill.

Mr. President, with that, I yield the floor.

Exhibit 1

[From the Washington Post, July 20, 2009]

N. Korea's Hard-Labor Camps: On the Diplomatic Back Burner

(By Blaine Harden)

Seoul.--Images and accounts of the North Korean gulag

become sharper, more harrowing and more accessible with each

passing year.

A distillation of testimony from survivors and former

guards, newly published by the Korean Bar Association,

details the daily lives of 200,000 political prisoners

estimated to be in the camps: Eating a diet of mostly corn

and salt, they lose their teeth, their gums turn black, their

bones weaken and, as they age, they hunch over at the waist.

Most work 12- to 15-hour days until they die of malnutrition-

related illnesses, usually around the age of 50. Allowed just

one set of clothes, they live and die in rags, without soap,

socks, underclothes or sanitary napkins.

The camps have never been visited by outsiders, so these

accounts cannot be independently verified. But high-

resolution satellite photographs, now accessible to anyone

with an Internet connection, reveal vast labor camps in the

mountains of North Korea. The photographs corroborate

survivors' stories, showing entrances to mines where former

prisoners said they worked as slaves, in-camp detention

centers where former guards said uncooperative prisoners were

tortured to death and parade grounds where former prisoners

said they were forced to watch executions. Guard towers and

electrified fences surround the camps, photographs show.

``We have this system of slavery right under our nose,''

said An Myeong Chul, a camp guard who defected to South

Korea. ``Human rights groups can't stop it. South Korea can't

stop it. The United States will have to take up this issue at

the negotiating table.''

But the camps have not been discussed in meetings between

U.S. diplomats and North Korean officials. By exploding

nuclear bombs, launching missiles and cultivating a

reputation for hair-trigger belligerence, the government of

Kim Jong Il has created a permanent security flash point on

the Korean Peninsula--and effectively shoved the issue of

human rights off the negotiating table.

``Talking to them about the camps is something that has not

been possible,'' said David Straub, a senior official in the

State Department's office of Korean affairs during the Bush

and Clinton years. There have been no such meetings since

President Obama took office.

``They go nuts when you talk about it,'' said Straub, who

is now associate director of Korean studies at Stanford

University.

Nor have the camps become much of an issue for the American

public, even though annotated images of them can be quickly

called up on Google Earth and even though they have existed

for half a century, 12 times as long as the Nazi

concentration camps and twice as long as the Soviet Gulag.

Although precise numbers are impossible to obtain, Western

governments and human groups estimate that hundreds of

thousands of people have died in the North Korean camps.

North Korea officially says the camps do not exist. It

restricts movements of the few foreigners it allows into the

country and severely punishes those who sneak in. U.S.

reporters Laura Ling and Euna Lee were sentenced last month

to 12 years of hard labor, after being convicted in a closed

trial on charges of entering the country illegally.

North Korea's gulag also lacks the bright light of

celebrity attention. No high-profile, internationally

recognized figure has emerged to coax Americans into

understanding or investing emotionally in the issue, said

Suzanne Scholte, a Washington-based activist who brings camp

survivors to the United States for speeches and marches.

``Tibetans have the Dalai Lama and Richard Gere, Burmese

have Aung San Suu Kyi, Darfurians have Mia Farrow and George

Clooney,'' she said. ``North Koreans have no one like that.''

Executions as Lessons

Before guards shoot prisoners who have tried to escape,

they turn each execution into a teachable moment, according

to interviews with five North Koreans who said they have

witnessed such killings.

Prisoners older than 16 are required to attend, and they

are forced to stand as close as 15 feet to the condemned,

according to the interviews. A prison official usually gives

a lecture, explaining how the Dear Leader, as Kim Jong Il is

known, had offered a ``chance at redemption'' through hard

labor.

The condemned are hooded, and their mouths are stuffed with

pebbles. Three guards fire three times each, as onlookers see

blood spray and bodies crumple, those interviewed said.

``We almost experience the executions ourselves,'' said

Jung Gwang Il, 47, adding that he witnessed two executions as

an inmate at Camp 15. After three years there, Jung said, he

was allowed to leave in 2003. He fled to China and now lives

in Seoul.

Like several former prisoners, Jung said the most arduous

part of his imprisonment was his pre-camp interrogation at

the hands of the Bowibu, the National Security Agency. After

eight years in a government office that handled trade with

China, a fellow worker accused him of being a South Korean

agent.

``They wanted me to admit to being a spy,'' Jung said.

``They knocked out my front teeth with a baseball bat. They

fractured my skull a couple of times. I was not a spy, but I

admitted to being a spy after nine months of torture.''

When he was arrested, Jung said, he weighed 167 pounds.

When his interrogation was finished, he said, he weighed 80

pounds. ``When I finally got to the camp, I actually gained

weight,'' said Jung, who worked summers in cornfields and

spent winters in the mountains felling trees.

``Most people die of malnutrition, accidents at work, and

during interrogation,'' said Jung, who has become a human

rights advocate in Seoul. ``It is people with perseverance

who survive. The ones who think about food all the time go

crazy. I worked hard, so guards selected me to be a leader in

my barracks. Then I didn't have to expend so much energy, and

I could get by on corn.''

Defectors' Accounts

Human rights groups, lawyers committees and South Korean-

funded think tanks have detailed what goes on in the camps

based on in-depth interviews with survivors and former guards

who trickle out of North Korea into China and find their way

to South Korea.

The motives and credibility of North Korean defectors in

the South are not without question. They are desperate to

make a living. Many refuse to talk unless they are paid.

South Korean psychologists who debrief defectors describe

them as angry, distrustful and confused. But in hundreds of

separate interviews conducted over two decades, defectors

have told similar stories that paint a consistent portrait of

life, work, torment and death in the camps.

The number of camps has been consolidated from 14 to about

five large sites, according to former officials who worked in

the camps. Camp 22, near the Chinese border, is 31 miles long

and 25 miles wide, an area larger than the city of Los

Angeles. As many as 50,000 prisoners are held there, a former

guard said.

There is a broad consensus among researchers about how the

camps are run: Most North Koreans are sent there without any

judicial process. Many inmates die in the camps unaware of

the charges against them. Guilt by association is legal under

North Korean law, and up to three generations of a

wrongdoer's family are sometimes imprisoned, following a rule

from North Korea's founding dictator, Kim Il Sung: ``Enemies

of class, whoever they are, their seed must be eliminated

through three generations.''

Crimes that warrant punishment in political prison camps

include real or suspected opposition to the government. ``The

camp system in its entirety can be perceived as a massive and

elaborate system of persecution on political grounds,''

writes human rights investigator David Hawk, who has studied

the camps extensively. Common criminals serve time elsewhere.

Prisoners are denied any contact with the outside world,

according to the Korean Bar Association's 2008 white paper on

human rights in North Korea. The report also found that

suicide is punished with longer prison terms for surviving

relatives; guards can beat, rape and kill prisoners with

impunity; when female prisoners become pregnant without

permission, their babies are killed.

Most of the political camps are ``complete control

districts,'' which means that inmates work there until death.

There is, however, a ``revolutionizing district'' at Camp

15, where prisoners can receive remedial indoctrination in

socialism. After several years, if they memorize the writings

of Kim Jong Il, they are released but remain monitored by

security officials.

South's Changing Response

Since it offers a safe haven to defectors, South Korea is

home to scores of camp survivors. All of them have been

debriefed by the South Korean intelligence service, which

presumably knows more about the camps than any agency outside

of Pyongyang.

But for nearly a decade, despite revelations in scholarly

reports, TV documentaries and memoirs, South Korea avoided

public criticism of the North's gulag. It abstained from

voting on U.N. resolutions that criticized North Korea's

record on human rights and did not mention the camps during

leadership summits in 2000 or 2007. Meanwhile, under a

``sunshine policy'' of peaceful engagement, South Korea made

major economic investments in the North and gave huge,

unconditional annual gifts of food and fertilizer.

The public, too, has been largely silent. ``South Koreans,

who publicly cherish the virtue of brotherly love, have been

inexplicably stuck in a deep quagmire of indifference,''

according to the Korean Bar Association, which says it

publishes reports on human rights in North Korea to ``break

the stalemate.''

Government policy changed last year under President Lee

Myung-bak, who has halted unconditional aid, backed U.N.

resolutions that criticize the North and tried to put human

rights on the table in dealing with Pyongyang. In response,

North Korea has called Lee a ``traitor,'' squeezed inter-

Korean trade and threatened war.

An Enforcer's View

An Myeong Chul was allowed to work as a guard and driver in

political prison camps because, he said, he came from a

trustworthy family. His father was a North Korean

intelligence agent, as were the parents of many of his fellow

guards.

In his training to work in the camps, An said, he was

ordered, under penalty of becoming a prisoner himself, never

to show pity. It was permissible, he said, for bored guards

to beat or kill prisoners.

``We were taught to look at inmates as pigs,'' said An, 41,

adding that he worked in the camps for seven years before

escaping to China in 1994. He now works in a bank in Seoul.

The rules he enforced were simple. ``If you do not meet

your work quota, you do not eat much,'' he said. ``You are

not allowed to sleep until you finish your work. If you still

do not finish your work, you are sent to a little prison

inside the camp. After three months, you leave that prison

dead.''

An said the camps play a crucial role in the maintenance of

totalitarian rule. ``All high-ranking officials underneath

Kim Jong Il know that one misstep means you go to the camps,

along with your family,'' he said.

Partly to assuage his guilt, An has become an activist and

has been talking about the camps for more than a decade. He

was among the first to help investigators identify camp

buildings using satellite images. Still, he said, nothing

will change in camp operations without sustained diplomatic

pressure, especially from the United States.

Inconsistent U.S. Approach

The U.S. government has been a fickle advocate.

In the Clinton years, high-level diplomatic contacts

between Washington and Pyongyang focused almost exclusively

on preventing the North from developing nuclear weapons and

expanding its ballistic missile capability.

President George W. Bush's administration took a radically

different approach. It famously labeled North Korea as part

of an ``axis of evil,'' along with Iran and Iraq. Bush met

with camp survivors. For five years, U.S. diplomats refused

to have direct negotiations with North Korea.

After North Korea detonated a nuclear device in 2006, the

Bush administration decided

to talk. The negotiations, however, focused exclusively on

dismantling Pyongyang's expanded nuclear program.

In recent months, North Korea has reneged on its promise to

abandon nuclear weapons, kicked out U.N. weapons inspectors,

exploded a second nuclear device and created a major security

crisis in Northeast Asia.

Containing that crisis has monopolized the Obama

administration's dealings with North Korea. The camps, for

the time being, are a non-issue. ``Unfortunately, until we

get a handle on the security threat, we can't afford to deal

with human rights,'' said Peter Beck, a former executive

director of the U.S. Committee for Human Rights in North

Korea.

A Family's Tribulations

Kim Young Soon, once a dancer in Pyongyang, said she spent

eight years in Camp 15 during the 1970s. Under the guilt-by-

association rule, she said, her four children and her parents

were also sentenced to hard labor there.

At the camp, she said, her parents starved to death and her

eldest son drowned. Around the time of her arrest, her

husband was shot for trying to flee the country, as was her

youngest son after his release from the camp.

It was not until 1989, more than a decade after her

release, that she found out why she had been imprisoned. A

security official told her then that she was punished because

she had been a friend of Kim Jong Il's first wife and that

she would ``never be forgiven again'' if the state suspected

that she had gossiped about the Dear Leader.

She escaped to China in 2000 and now lives in Seoul. At 73,

she said she is furious that the outside world doesn't take

more interest in the camps. ``I had a friend who loved Kim

Jong Il, and for that the government killed my family,'' she

said. ``How can it be justified?''

Exhibit 2

[From the Washington Post, July 21, 2009]

Clinton: U.S. Wary of Growing Burmese, North Korean Military

Cooperation

(By Glenn Kessler)

Bangkok, July 21--The Obama administration is increasingly

concerned that nuclear-armed North Korea is building

mysterious military ties with Burma, another opaque country

with a history of oppression, Secretary of State Hillary

Rodham Clinton said Tuesday.

``We know that there are also growing concerns about

military cooperation between North Korea and Burma, which we

take seriously'' Clinton told reporters after talks in the

Thai capital. ``It would be destabilizing for the region. It

would pose a direct threat to Burma's neighbors.''

U.S. officials traveling with Clinton, who is in Thailand

to attend a regional security forum, said the concerns about

Burma and North Korea extend to possible nuclear cooperation.

North Korea has a long history of illicit missile sales and

proliferation, including secretly helping to build a Syrian

nuclear reactor that was destroyed in 2007 by Israeli jets.

``This is one of the areas we'd like to know about,'' said

one official. ``We have concerns, but our information is

incomplete.''

Burma, also known as Myanmar, is regarded as one of the

world's most oppressive nations, run by generals who have

enriched themselves while much of the country remains

desperately poor. North Korea is an equally grim country,

with vast prison camps and an ailing dictator, Kim Jong Il.

The evidence of growing Burmese-North Korean cooperation

since formal ties were restored in 2007 is extensive, but the

full extent of the military relationship is unclear.

The nuclear connection is even murkier, but intelligence

agencies have tracked suspicious procurement of high-

precision equipment from Europe, as well as the arrival in

Burma of North Korean officials associated with the company

connected to the Syria reactor, according to David Albright,

director of the Institute for Science and International

Security in Washington.

``Something may be going on, but no one has any proof. It

is a mix of suspicions and concerns,'' Albright said, adding

that close examination of satellite imagery of suspected

nuclear sites has turned up no evidence. But he said that the

purchases of high-precision equipment were especially

troubling because the equipment did not make sense for use in

missiles and it was shipped to educational entities that had

connections to Burmese nuclear experts.

Japanese officials last month also arrested three people

for attempting to illegally export dual-use equipment to

Burma, via Malaysia, under the direction of a company

involved in the illicit procurement for North Korean military

programs.

Moreover, Albright said, European and U.S. intelligence

agencies have identified people associated with Namchongang

Trading Corp., a North Korean company also known as NCG, as

working in Burma. NCG reportedly provided the critical link

between Pyongyang and Damascus, acquiring key materials from

vendors in China and probably from Europe and secretly

transferring them to a desert construction site near the

Syrian town of Kibar.

The State Department last month cited NCG for being

``involved in the purchase of aluminum tubes and other

equipment specifically suitable for a uranium enrichment

program since the late 1990s.''

U.S. officials have observed other troubling connections.

The U.S. Navy last month closely tracked Kang Nam 1, a rusty

North Korean freighter, after the government in Pyongyang

tested a nuclear weapon. Although U.S. officials were never

completely certain the ship was headed to Burma, the ship

returned to North Korea after the United States, China and

other countries put pressure on Burma to respect a United

Nations resolution barring most North Korean weapons exports.

Photographs that have emerged in recent weeks also show an

extensive series of 600 to 800 tunnel complexes and other

underground facilities built in Burma with North Korean

technical assistance near its new capital, Naypyidaw. North

Korean officials can be spotted in the photos, which were

taken between 2003 and 2006 and posted on the Web site of

YaleGlobal Online by journalist Bertil Lintner, an expert on

Burma.

Burma has uranium deposits, but as a signatory to the

nuclear Non-Proliferation Treaty, it is required to allow

inspections of any nuclear facilities. Russia in 2007 agreed

to help build a 10-megawatt light-water reactor in Burma, but

little appears to have come of the project.

At the news conference, Clinton also strongly criticized

the Burmese government for its well-documented use of gang

rape as a military tactic, organized by Burmese officers,

against ethnic minorities. A new offensive against the Karen

ethnic group has sent more than 4,000 refugees fleeing across

the border into Thailand in recent weeks.

``We are deeply concerned by reports of continuing human

rights abuses within Burma, particularly by actions that are

attributed to the Burmese military concerning the

mistreatment and abuse of young girls,'' Clinton said.

The Obama administration is conducting a review of its

Burma policy, which Clinton said has been placed on hold

while Washington awaits the outcome of the trial of Nobel

Peace Prize laureate Aung San Suu Kyi.

``We have made clear we expect fair treatment of Aung San

Suu Kyi, and we have condemned the way that she has been

treated by the regime in Burma, which we consider to be

baseless and totally unacceptable,'' Clinton said.

The National League for Democracy, Suu Kyi's party, won a

landslide electoral victory in 1990, but the military

leadership refused to accept it. Since then, she has been

under house arrest for most of the time, as have hundreds of

her supporters.

In May, just days before Suu Kyi's six-year term under

house arrest was due to expire, the government put her on

trial for an incident involving a U.S. citizen who swam

across Rangoon's Lake Inya to reach Suu Kyi's lakefront

bungalow and allegedly stayed there one or two nights.

Suu Kyi was taken to Rangoon's notorious Insein Prison on

charges of violating the terms of her detention by hosting a

foreigner, which could bring a three- to five-year prison

term, according to Burmese opposition officials. Suu Kyi, 63,

is said to be in poor health and has recently been treated

for dehydration and low blood pressure.

``Our position is that we are willing to have a more

productive partnership with Burma if they take steps that are

self-evident,'' Clinton said. She called on Burmese

authorities to ``end the violence against their own people,''

including ethnic minorities, ``end the mistreatment of Aung

San Suu Kyi'' and release political prisoners.

Mr. President, I ask unanimous consent to add Senator Bennett from Utah as a cosponsor of the amendment.

I thank my colleague from Arizona. I think he understands more than anybody in this body the situation and what happens in a gulag-type situation. That has drawn me to the topic of North Korea for a couple years--the human rights abuses. Hundreds and thousands of North Koreans are fleeing to be able to simply get food, and a couple hundred thousand of them are in the gulag system. It is unbelievable that this can happen in 2009. We have Google Earth that can even show this. But we just say: OK, that is the sort of thing that happens there. It is mind-boggling to me that we wouldn't act resolutely.

I appreciate the chairman of the Foreign Relations Committee, the Senator from Massachusetts, who is a distinguished Senator and is very bright and experienced in foreign policy. I could not disagree with him more about North Korea. We have had an ongoing dialog and discussion about this. He makes the point that we should not pop this on the bill.

I have been trying for months for us to relist them as terrorists. They should not have been delisted in the first place. It was a terrible process move on the Bush administration to try to move the talks forward, saying we are going to delist you and you are going to do something for us. Pyongyang and Kim Jong Il said thank you very much, and now we are going to stick it in your face, which is what they have continued to do. I have listed the things, as the Senator from Arizona has mentioned as well.

The thought that we are acting resolutely, to me, is an insult to the people in North Korea who have lived under this oppressive regime. We are not acting resolutely toward North Korea. We are not putting any sanctions on them. We have asked for international sanctions, but why aren't we willing to put sanctions on ourselves? If we think this is such a proper course to follow, and we are willing to push it on an international body, why wouldn't we be willing to do it ourselves? Why wouldn't we be willing to list them as a terror nation, as a state sponsor of terror? I don't understand that; why, if it is good in the international arena, we wouldn't do it ourselves.

Plus, we need to have teeth into this. This is a modest--a modest-- proposal. It is a resolution, a sense of the Senate that North Korea should be relisted as a state sponsor of terrorism. We are not relisting them. That is an administration call. We are saying we, as a body, given the provocative actions that have taken place since they have been delisted clearly merits the relisting of North Korea as a state sponsor of terrorism. That is our opinion, and that is what we are saying to the administration.

Without a foundation in the law, it is clearly--as I read previously--allowed for the Secretary of State to determine that the government of that country has repeatedly provided support for acts of international terrorism. That is the actual wording of the law in the Arms Export Control Act. Clearly, they have acted to sponsor international terrorism with their relation with Burma, with the missiles, with the nuclear weapons, and with the proliferation they have done and continue to do.

He says, and is suggesting, that delisting has no practical effect. I believe it does have a practical effect, and it certainly does on the administration's stance toward North Korea

and their international posture toward North Korea. Plus, it has a practical effect on what we can provide for as far as aid from the United States to North Korea. We shouldn't be providing aid to the North Koreans. We should provide food aid, if we can monitor it. We shouldn't be giving oil to the North Koreans. That should be limited so the administration cannot do that. They would not be able to if they are listed as a state sponsor of terrorism.

Mr. President, it will hurt the people of North Korea and those who are in the North Korean gulags if we don't relist them. It recovers any vestige of hope they might have that at some point in time somebody of enough stature, such as the United States Government, is going to take enough notice that they are going to put pressure on the North Korean regime. I have talked with some people who were refuseniks in the Soviet Union, in a Soviet gulag during an era where we had far less communication capacity than we do today, and yet they were able to get messages at that point in time into the Soviet gulag that the Americans were putting pressure on the Soviet Union and the lack of human rights in the Soviet Union, and it gave them hope. It gave them hope in the Soviet gulag.

If we can pass this, it can give people in the gulags in North Korea hope that somebody is at least paying enough attention to put pressure on this, and maybe they may be able to live longer, or actually live at all. It can give them hope, instead of ``abandon hope all ye who enter here,'' as it says at the entrance to Inferno and as it is in the gulag system in North Korea.

So it is a modest resolution, and I would hope my colleagues would vote overwhelmingly for this resolution to relist North Korea as a state sponsor of terrorism.

I yield the floor.

I ask unanimous consent to speak as in morning business.

Mr. President, I listened carefully to the Senator from Michigan. Republicans and I believe most Democrats want health care reform this year. The President said he wants health care reform this year. Republicans want health care reform this year. We want to make sure it is done right. Let me put it this way: If we were in an operating room and a seriously ill patient came in and we knew we had only one chance to save that patient's life and to make that patient healthy, our goal would not be to see if we could do it in the next week, it would be to see if we could get it right.

So far, the proposals we have seen coming out of the committees have not gotten it right. One might say: Well, that is a Republican view of Democratic proposals. Perhaps it is. But the proposals we have seen coming out of the Senate HELP Committee and out of the House of Representatives flunk the most important test, which is cost. The most important test is whether Americans can afford their health care and, after we get through fixing it, whether they can afford their government. According to virtually everyone we have heard from, the legislation we have seen simply does not meet that test.

In my opinion, what we should do instead is start with the framework of the bill sponsored by Democratic Senator Wyden and Republican Senator Bennett which has 14 cosponsors--8 Democrats, 6 Republicans. This is a different sort of framework that offers virtually every American coverage, does so without any Washington takeover or government-run programs without raising the debt one penny, according to the Congressional Budget Office. Remember, I said that is a framework. I do not agree with every single part of that bill, although I am a cosponsor, but it may be a much better place to start than what we have seen so far.

That is not just my opinion. Lately, we have heard a lot about the Mayo Clinic in Rochester, MN. President Obama has talked a lot about the Mayo Clinic. The point is, at the Mayo Clinic and a few other clinics around the country, there have been significantly better outcomes. In other words, if you go there and come out, you are more likely to be well, and at a lower cost. And the question is, Why?

The President has repeatedly pointed to the Mayo Clinic, Democratic Senators point to the Mayo Clinic, and Republican Senators point to the Mayo Clinic. Here is what the Mayo Clinic had to say on Friday about the legislation that is being considered in the House of Representatives:

Although there are some positives in the current House Tri-

committee bill, including insurance for all and payment

reform demonstration projects--the proposed legislation

misses the opportunity to help create higher quality, more

affordable health care for patients. In fact, it will do the

opposite.

That is the Mayo Clinic talking.

In general, the proposals under discussion are not patient

focused or results oriented. Lawmakers have failed to use a

fundamental lever--a change in Medicare payment policy--to

help drive necessary improvements in American health care.

Unless legislators create payment systems that pay for good

patient results at reasonable costs, the promise of

transformation in American health care will wither. The real

losers will be the citizens of the United States of America.

That is the Mayo Clinic talking about the bill we are beginning to see in the House of Representatives.

I think the prudent thing to do is to try to make that bill better or start over and certainly not try to pass a 1,000-page or 2,000-page bill in 1 week or 10 days without knowing what is in it, as we did with the stimulus bill earlier this year.

That is not just the opinion of the Mayo Clinic. Here is a letter to House Members on July 16, a few days ago, from a number of clinics, including the Mayo Clinic. These are the Intermountain Healthcare, Gundersen Lutheran Health System, the Iowa Clinic, the Marshfield Clinic, the Rural Wisconsin Health Cooperative, ThedaCare, and Wisconsin Hospital Association.

I ask unanimous consent to have this letter printed in the Record following my remarks.

It goes on to say:

On behalf of some of the nation's leaders in health care

delivery--

These are the people whose hospitals we go to, whose clinics we go to when we are sick or when we hope to stay well--

we write to you to comment on the House bill.

They say:

We applaud the Congress for working on this. However, we

have got significant concerns.

They go on to say there are three of them.

The first is about the Medicare-like public plan, as they call it, a public plan with rates based on Medicare. They say it will have a severe negative effect on their facilities, that they lose a lot of money every year, hundreds of millions of dollars. Because what happens is that Medicare, a government-run plan, pays its doctors and its clinics and its hospitals about 80 percent of what private insurance companies are paying. So roughly 177 million of us have private insurance of one kind or another. If a doctor sees you, he gets paid 100 percent. But if you go to one of these clinics and hospitals, they are paid according to the government rate, which is roughly 80 percent of the private rate. These clinics say that is not sustainable for them, and that if that continues, some of those providers, such as the Mayo Clinic, will eventually be driven out of the market. What market? The market for Medicare patients. Those are the 45 million senior Americans who absolutely depend on Medicare for their service because for most of them, that is their only option. If that is the case, what that means is they will not be able to go to the Mayo Clinic or to the MeritCare Health System or to the Iowa Clinic or to the doctor they choose because that doctor will not be a part of the Medicare system because of low reimbursement.

So that is the first objection these clinics make to the bill they see coming because the bill they see coming proposes to create another government-run plan with government-set rates.

The second objection they have is geographic payment disparities. They say that we are a big country and there ought to be differences in the pay among different geographies.

Third, and maybe this is the most important of all, that the President has said and many of us in the Senate have said we need to change the way we pay for medical care, and we ought to pay more for value, for quality, for results, and less for volume--in plain English, not how many patients a doctor can see but how many of his or her patients stay well or get well.

We have talked about that for weeks here in our hearings. But what these respected voices in medicine are saying is that the legislation we see today--and understand, this is not even in a bill that has presented to us in the Senate yet in a way upon which we can act--does not meet the test for that. The legislation we have seen so far is running into a lot of trouble.

David Broder, the respected columnist from the Washington Post, said that the plans which have been passed in a partisan way are ``badly flawed'' and ``overly expensive.'' I mean, the Democratic plans; we have Republican plans that we would like to be considered. I mentioned that the Wyden-Bennett plan, which is the only really bipartisan plan here, has not been given one bit of consideration so far in the Senate. And then Senator Burr and Senator Coburn have a plan, Senator Gregg has a plan, and Senator Hatch has a plan. We all have different ideas. As I said, we would like for them to be considered, today I'm talking about the Democratic plans that are now being considered.

The Congressional Budget Office, of course, is the nonpartisan office in this Congress that we count on as an umpire to tell us what we are really doing. It is not supposed to have any political rhetoric. Last Thursday, the head of the Congressional Budget Office, Douglas Elmendorf was asked at a Senate Budget Committee hearing what he thought about the bills which had begun to emerge.

He said:

The legislation significantly expands the Federal

responsibility for health care costs.

In other words, here we go, at a time when we are in a recession and where the President's proposals for other programs will add more to the debt in the next 10 years, three times as much as we spent in World War II, and we are talking about legislation that would add another $2 trillion. We haven't dealt with cost which is where we ought to start. Look at the 250 million who have health care and ask the question: Can you afford it? Then after we get through fixing it, can you afford your government? And what the head of the CBO is saying, as far as the government goes, the answer is no.

Then the Lewin Group, a well-respected private agency, was asked what would happen if we had a government-run program which many of us believe will lead to another Washington takeover. We are getting accustomed to this, Washington takeovers of banks, of insurance companies, of student loans, of car companies, now maybe of health care. The Lewin Group said 88 million people will lose their private employer-sponsored insurance. How could that happen? It could happen because a small employer or a big employer would see one of these plans that is beginning to come out take place. To be specific, the Senate HELP Committee plan says you either have to provide everybody who works for you insurance or pay $750. There are a lot of employers who cannot afford to provide everybody the kind of insurance that is envisioned. So they will say: OK, we will pay the $750 fine to the government. What happens? All those employees lose their health insurance. Where do they go? Into the Government plan. That is their option. Some of them may have a choice of other plans, but if they do have a choice and one of the choices is a government-run plan, it may have the same future the Mayo Clinic and others were saying Medicare was causing to them.

The government will set a low price for the doctors and a low price for the clinics. So all these employees who now have insurance that they like will lose that insurance because of the passage of this bill. The government will set the provider rates and physician rates low, and so they will be part of a government plan for which many doctors and many hospitals and many clinics will not offer services. It is similar to giving somebody a bus ticket to a bus station with no busses.

Then there are the Medicare cuts. According to the Washington Post last week, Medicare cuts will pay for one-half the cost of health care for the uninsured in one of the bills being proposed.

If we are to find savings in Medicare and take from the 45 million elderly people who depend on Medicare, every bit of those savings ought to be put back into Medicare and not spent on some new program. I don't think legislation that is paid for half by Medicare cuts is going to go very far in this Chamber.

Then there are the employer taxes. According to the National Federation of Independent Businesses, the House version has an 8- percent Federal payroll tax. I mentioned the Senate

version, a $750 annual fine per employee, if the employer doesn't offer insurance. The NFIB, small businesses, estimates that will lose about 1.6 million jobs.

How could that be? Well, if a small employer or even a large one has government-mandated costs added and they have less money, they will hire less employees. That is one of the options they have.

Then there is the income surtax. There is a whole string of trouble for these bills. USA Today on Monday said: It is the highest tax rate in a quarter of a century that is proposed: A 45-percent top tax rate with all taxes included.

Then rationing, there are provisions in this bill which would have the government make decisions about which treatment you will have and how long you will have to wait to see a doctor.

Finally--I say ``finally'' because this is the subject I want to spend a moment on--there is the Medicaid State taxes. Sometimes this gets confusing. Mr. President, 177 million Americans have private insurance, but a lot of people have government insurance now. Veterans do. Military people have TRICARE insurance. About 45 million older people have Medicare. But then there is a program called Medicaid, which is the largest government-run program. About 60 million people are in it now. The Federal Government pays about 57 percent of it, and the States pay 43 percent. Every Governor I know--and I was once one-- has struggled with the Medicaid Program. I once came up here in the early 1980s and asked President Reagan to take it all, let the Federal Government run it and give us Governors all of kindergarten through the 12th grade. I thought that would be a good swap.

I saw a couple of Democratic Governors earlier today, and we talked about the story every Governor faces. If you have an extra dollar and you want to put it in higher education so you can improve the quality of the University of Colorado or Tennessee or keep tuition from going up, what happens to it? That dollar is stolen because it has to go in the increasing Medicaid cost. It is an inefficiently managed program. The Federal Government keeps changing the rules. The Governors have to get permission from Washington whenever they make minor changes. It is demolishing State governments right and left.

If our real goal is to help people, then why under these new plans do we say to low-income people--defined as, say, a family of four who makes less than $32,000--your only option is going to be to go in the Medicaid Program under this plan. It is estimated by the Congressional Budget Office and others that 15 or 20 million Americans will be added to the 60 million in the Medicaid Program. What will they find when they get there? They will find that 40 percent of the doctors don't see Medicaid patients. When we add another 15 or 20 million people to it, it may be a larger number. Why don't they do see Medicaid patients? For the same reason the Mayo Clinic warned about this government plan in its letter. It is because Medicaid only pays its doctors and its hospitals about 72 percent of what Medicare pays.

If you are confused by that, it works out pretty simply. Medicare pays 80 percent of what the private insurers pay, and Medicaid pays about 72 percent of what Medicare pays. If you are a doctor or a clinic or a hospital, you get paid about 60 percent, if you are helping a Medicaid patient, of what you would if you were helping one of us who has his or her own private health care. You can see that will be a pernicious trend. If we continue to dump low-income people into a government-run Medicaid Program, that is what will happen.

There is another thing that happens with Medicaid. Many members of the committees working on this bill said: We can't let that happen. We can't be inhumane and just say we are out here to help people who are uninsured, and we are going to dump 20 million of them into a government-run program that doesn't have enough doctors and hospitals and clinics. We will have to raise what we pay to doctors and clinics. That sounds good, but that is very expensive, particularly for a program such as Medicaid that, according to the Government Accountability Office, $1 out of every $10 is fraudulent, is wasted. That is $32 billion a year. That is the program we are going to expand? That is the program we are going to say to low-income people: Congratulations, go into this program where you are not likely to find a doctor every time you want one, and there are a lot of hospitals and clinics that will not take you because we will not pay them for that.

Because Senators and Congressmen hear that, they say: We will raise the rates. Here is the proposal: The proposal is, we are going to increase the number of people who are eligible for Medicaid by 133 to 150 percent of the Federal poverty level. That is a substantial increase. Then, if we are going to do that and put many more people into the program, we are going to have to order an increase in what we pay the doctors and the clinics to serve them, maybe up to 83 or 85 percent of the Medicare level.

Let me talk about what that would do in one State. We called the State Medicaid director in Tennessee. Our program is called TennCare. We said: What would it cost Tennessee if we increase coverage of Medicaid up to 150 percent of the Federal poverty level? The answer came back, nearly $600 million a year. That is the State's share of the cost which is a little more than a third. The Federal Government's share is twice that. So the Federal Government is saying: That is all right. We know Tennessee doesn't have the money to do that, so we will pay it all for the first 5 years. Then, after 5 years, so the talk goes--and we were told, when we were working on this bill, this is an assumption--we will shift these costs back to Colorado, back to Tennessee. Back comes what in today's dollars is about $600 million to the State of Tennessee.

Remember what I said. This is a program doctors don't want to go to because they don't get paid very well. So we will have to increase the amount of money we pay doctors. So if States are required to pay doctors and providers under the Medicaid system 110 percent of what Medicare is paid, that still isn't what doctors and hospitals get, if they see somebody with private health insurance. That is about the same amount of money, about $600 million added just for the State cost, which brings the total new state cost for paying physicians and hospitals more and for all the new people in the Medicaid Program to $1.2 billion. That is a huge amount of money.

We throw around dollars up here and figures that make any amount of money seem unimaginable. What is $1 trillion, what is $10 trillion, what is $40 billion. We former Governors can imagine it. I figured it out. If in 5 years you shifted back to the State of Tennessee just its share of those costs from the expansion of Medicaid and paying the doctors and hospitals more, the bill for the State of Tennessee to pay the increased Medicaid costs would be an amount of money that equals a new 10-percent State income tax.

The truth is, for our State--and I believe for almost every State--it is an amount of money that nobody has enough taxes to pay. You can run politicians in and out and defeat them for raising taxes all day long, and they still couldn't come up with ways to pay for it. In other words, these bills are based on a premise and assumption that will either bankrupt the States or, if the Federal Government says we will pay for it all, it will add $5, $6, $700 billion more over 10 years to the legislation we are considering.

We need to think that through. Is that the best way to help people who are low income? I don't think so. I think there are much better ways. The Wyden-Bennett framework is a better way. It rearranges the tax deductions we have for people who have health insurance from their employers and it says: Let's take the available money and give the money to low-income people who then buy private health insurance. It may be a very basic plan. But at least they would have health insurance, and they wouldn't be stuffed in a government program 40 percent of the doctors wouldn't see and that many of the best clinics and hospitals wouldn't allow them to come in.

We have been told already by the Congressional Budget Office that proposal would not add a penny to the debt. Not only does it not create a new government program, it actually makes the Medicaid Program, except

for Americans with Disabilities, history. In other words, if you are poor, you are not stuffed into a program that nobody else would want to join anyway. You have a chance to buy your own insurance, and you are not consigned to the worst run government program we have today.

So there are some real possibilities with health care, and there are some plans on the table that will lead us in the right direction. We have advice from distinguished Americans with a stake in this--which is every single one of us--but the most distinguished are those who deal with it every day. The Mayo Clinic is saying the proposed legislation misses the opportunity to help create higher quality, more affordable health care for patients. In fact, it will do the opposite.

Shouldn't we slow down and get it right? Shouldn't we get it right? This is the only chance we have to do this. If we do it wrong, we will not be able to undo it. This is 16, 18 percent of the American economy we are talking about. People have tried to do it for 60 years, and they failed.

The only way we will do it is if we do it together. The Democrats have big majorities over on that side. They do in the House. But that is not the way things usually happen around here. The President has said--and I take him at his word--and many of the leaders have said-- and I take them at their word--that we would like to get 70, 80 votes for the health care result. We would too.

But in order to do that, we are going to have to do it the way we usually do when we have bipartisan events around here. We get some Democrats and some Republicans and they sit down with the President and they share ideas and they agree on some things. They don't just say: OK, here it is, and we are going to vote down almost every significant idea you have on the way through.

I respect the fact that Senator Baucus is trying to do that in the Finance Committee, and perhaps he will succeed, working with Senator Grassley and others. But this is going to take some time. It cannot be done overnight. There are many sections to this bill. Each of them might be 500 pages long. They have enormous consequences to individuals. That is why we have all these clinics writing and saying: If you do it the way it looks like you are going to do it, you may drive us out of the business of helping Medicare patients.

Do we really want to do that? Do we really want to say to 45 million Americans who depend on Medicare: We are going to pass a bill that will accelerate the process whereby respected clinics and the doctor you might choose will not see you anymore because they cannot afford to because the government will not pay them under the system we have?

So I would suggest we start over, literally, conceptually; start over and listen to these clinics and doctors and focus on the delivery system and focus, first, on those 250 million Americans who already have health insurance and ask the question: Can they afford it? And, what could we do to make it possible for those Americans to afford it? And can we do it in a way that permits us to be able to honestly say when we are through that those same 250 million Americans can afford their government when we are through without adding to the debt?

Then let's look at the 46 million people who are uninsured. Of course, we need for them to be insured. But the fact is, 11 million of the uninsured are already eligible for programs we already have; 10 million or so are noncitizens--half of them legally here, half of them not; a large number of them are making $75,000 a year and could afford it but just do not buy it; and another significant number are college students.

So we are going to have to go step by step by step and see in what low-cost way we can include a large number of these 46 million Americans, who are not part of the system, in the system. But that is the wrong place to start. That is the place to end.

So, Mr. President, all I am saying is, on the Republican side of the aisle we can tell you what we are for. Some of us are for the Wyden- Bennett bill with our Democratic colleagues. That is the only bipartisan bill before us today. It has not even been seriously considered by this body, but it is there, and it has significant support in the House. We have two doctors over here: Dr. Barrasso, who has been an orthopedic surgeon for 25 years, and Dr. Coburn from Oklahoma, an OB/GYN doctor. They would like to be involved in the process. So far their ideas are not really being adopted in the result we might have. We have Senator Gregg from New Hampshire, one of the most respected Senators, who has been a part of many bipartisan efforts, and he has his own bill. He would like to be more a part of it, but his ideas do not fit the way things are going. But the way things are going are too expensive for the Congressional Budget Office and take us in the wrong direction, according to the Mayo Clinic.

So maybe we ought to step back and say: Well, let's listen to these other ideas. Let's go very carefully. Let's work with the President. Let's see if we can get a result. Let's keep a four-letter word out there that is a good word; and that is ``cost,'' and make sure we focus first on the 250 million Americans who have health insurance and make sure they can afford it; and, second, make sure when we finish fixing health care that those same Americans can afford their government.

I thank the Presiding Officer, and I yield the floor.

Exhibit 1

July 16, 2009.

Hon. Ron Kind,

Longworth House Office Building,

Washington, DC.

Dear Congressman Kind: On behalf of some of the nation's

leaders in health care delivery, we write to you today to

comment on the House health care reform bill introduced

earlier this week. We would like to thank you for the

opportunity to comment on this legislation. We applaud the

Congress for its commitment to passing comprehensive health

care delivery system reform this year. However, we have

significant concerns about the current language of the bill

and we ask that these concerns, set forth below, be addressed

before the committee action is concluded.

Medicare-like Public Plan

First, we are concerned that a public plan option with

rates based on Medicare rates will have a severe negative

impact on our facilities. Today, many providers suffer great

financial losses associated with treating Medicare patients.

For example, several of the systems that have signed onto

this letter lost hundreds of millions of dollars under

Medicare last year. These rates are making it increasingly

difficult for us to continue to treat Medicare patients. The

implementation of a public plan with similar rates will

create a financial result that will be unsustainable for even

the nation's most efficient, high quality providers,

eventually driving them out of the market. In addition,

should a public plan with inadequate rates be enacted, we

will be forced to shift additional costs to private payers,

which will ultimately lead to increased costs for employers

who maintain insurance for their employees. We believe all

Americans must have guaranteed portable health insurance, but

it is critical that we not lose sight of the need to ensure

adequate and equitable reimbursement.

Geographic Payment Disparities

Second, our health care systems are among the most cost-

efficient in the country in caring for Medicare patients.

However, many of us operate in states with some of the lowest

Medicare reimbursement rates in the nation. Current physician

payments due to geographic disparities are actually greater

under Medicare than under commercial insurance. This may be

difficult to believe, given the government's rate-setting

power, but flows from the fundamentally flawed payment

methodology. To date, health care reform proposals simply

continue the current payment methodology, despite the fact

that formula changes have been identified to address this

problem. We support payment changes that work to reduce

geographic disparities, rather than perpetuating the flaws in

the current payment system. While we believe that the

Institute of Medicine study is a good first step, we

encourage Congress to take this further and enact payment

reforms that will address the existing disparities.

Value Index Proposal

Third, consistent with statements from President Obama, we

believe that focusing on, defining, measuring, and paying for

value is essential for controlling cost within the U.S.

health care system. The system must be reformed to compensate

for value instead of volume. We believe inserting a value

index into various aspects of the Medicare payment system

(e.g., physician fee schedule, hospital rates) is the means

to accomplish this end goal of compensating for quality

rather than quantity.

We appreciate the opportunity to comment on this

legislation. We urge you to address the above-stated

concerns, which will demonstrate that Congress is serious

about preserving the best parts of the existing health

care delivery system. If we can be of assistance to you

moving forward, please do not hesitate to contact us.

Sincerely,

Everett Clinic, Gundersen Lutheran Health System,

HealthPartners, Intermountain Healthcare, Iowa Clinic,

Marshfield Clinic, Mayo Clinic.

MeritCare Health System, Park Nicollet Health System,

Rural Wisconsin Health Cooperative, ThedaCare,

Wisconsin Hospital Association, Wisconsin Medical

Society.

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

I ask unanimous consent to speak as in morning business.

Mr. President, as we meet here today we are discussing the Defense authorization bill. We debate it each year. It is basically an authorization for the expenditure of funds in defense of America. It is a significant bill with a lot of different parts. I commend the Senators who have brought this to the floor, Senator Carl Levin, the chairman of the Armed Services Committee, and his Republican counterpart, Senator John McCain.

I know this bill is important and I know we will be returning to substantive amendments on this bill very shortly. But while we have this break in the action, I want to address another issue which is being debated in almost every corridor on Capitol Hill, and that is the issue of health care reform. It is an interesting issue and an amazing challenge to this Congress, to try to grapple with the health care system in the most prosperous Nation on Earth.

Despite our prosperity, we know there is something fundamentally flawed with our health care system. We spend more than twice as much per person in America on health care as any other country, and the results do not show that money is being well spent. Many other countries, spending a fraction of what the United States spends, end up with very different and much better results in terms of survival from certain diseases and illness, and mortality rates. There is something to be learned here about how we can be more effective in providing health care for our citizens and not break the bank.

Most Americans know what I am talking about when I talk about cost, because they are facing cost issues every day. They know health insurance premiums in America in the last several years have gone up three times faster than the incomes and wages of Americans. We have learned it is not unusual for one-fourth of Americans to spend 1 out of every $10 in income for health insurance. Some, a smaller group but a significant group, spend up to $1 out of every $4 in income on health insurance. The number keeps going through the roof with no end in sight. It worries us, not just as individuals and members of families, but businesses that are trying to do the right thing for their employees and be competitive.

It worries units of government because, whether it is your State government providing assistance for Medicaid or whether it is the Federal Government concerned about Medicare and Medicaid, the costs of health care are growing so quickly that they could easily put us into a perpetual debt situation, something we do not want to see, something we cannot leave to our children.

Now we are debating in the House and in the Senate, in a variety of different committees, how to change this health care system. Needless to say, it is a contentious debate. There are a lot of different points of view. There are some people and companies in America that want no change in our health care system. Most people do. Some don't. Many of those who are resisting change, who are unwilling to support the President's efforts to move us in this direction, are the very same companies and people who are profiting from the current system.

Make no mistake, when you spend billions of dollars on a system, much more than any other country, you are going to end up in a situation where many people are profiting handsomely from the current system. When you talk about reform--reducing the cost, reducing the payments, being more cost effective--these people see money going out the window, and they are going to fight it.

That is what the battle is all about. We have been through it before, and now we have returned to it. But in addition to cost, there is also the issue of the availability of health insurance. This morning's Chicago Tribune, on the front page, told the story of a man who sadly is one of the victims of this situation. He lives in a suburb of Chicago, and he works as a doorman at one of the buildings. He had a bad back. He finally was told--he tried a lot of conservative treatment; it just did not work--you are going to have to have back surgery.

So he did what he was supposed to do. He went to his insurance company and said: The doctor is recommending a surgery, and I want to know if it will be covered by my health insurance. Well, the health insurance company sent back to him written confirmation that the costs of the surgery would be covered by his health insurance. So he went through with the surgery and ended up incurring $148,000 in medical bills.

I think you know how this story ends. They turned in the bills to the insurance company, and they denied them. They said: We did not really approve this surgery. You should have taken a more conservative approach to it.

Well, he thought he had done everything he was supposed to. What followed was a battle with this insurance company, day after day, month after month, while people were saying: Send us the $148,000. This man of limited means was fighting to finally get this health insurance company to pay what they promised to pay. It took him months.

When it was all over, Mr. Napientek, Michael Napientek, ended up with coverage. Had he failed to get the coverage for that surgery, it would have wiped out his entire life's savings. That is the reality of health care. That is the situation too many people find themselves in, so vulnerable in a situation where one medical bill denied by an insurance company bureaucrat can literally wipe out their life's savings.

We can do better. We have to do better. That is what this debate is all about. First, we have to reduce the cost of health care for families and businesses and governments across America. There are ways to do that. We can lower costs to make sure every American has access to insurance. We can make it clear that no one can be turned down for insurance coverage because of a preexisting condition. We can make certain there is no discrimination in the premiums that are charged individual Americans because one is a male and another female; one is a certain age and another not. We can make certain there is more fairness in the way people are treated by these health insurance companies.

This idea of denying coverage for preexisting conditions, imagine how frustrating that must be to realize that if you turned in a claim this year on your health insurance because you had a bad back, and you went to the doctor next year, when it came time for surgery they would not cover it.

This happened to a friend of mine, a fellow I grew up with in East St. Louis, IL, in the trucking business. He not only owned the business, he drove the trucks. When he reached 60 years of age, his back was killing him. Well, at that point his company had lost its health insurance. Why? Because the wife of one of the employees had a sick baby. Her sick baby incurred a lot of medical bills, and the cost of health insurance went through the roof. They

had to cancel the company's health insurance, give the employees some money, and say: Fend for yourself.

He was in the same boat. He went out to get private health insurance, complained about a bad back. The following year when the doctor said he needed back surgery, he turned in a claim to his health insurance company, and they said: No, it is a preexisting condition. We will not cover your back surgery.

Do you know what he had to do? He ended up filing a worker's compensation claim claiming that his back injuries had to do with bouncing around in a truck for 30 or 40 years, not an unreasonable conclusion. Do you know who he sued? He sued himself. He sued as an employee of the company. He sued himself as owner of the company.

Is that crazy to reach that point? And he won, incidentally. They said it is subject to worker's compensation. We will pay for the surgery.

He had done everything right, providing health insurance for his employees until he could not afford it, trying to get private insurance for himself at the age of 60, then turning in a claim and being turned down. He could have been wiped out by that surgery, just as the man on the front page of the Chicago Tribune.

We are all in this vulnerable situation because the health insurance companies have so much power over our lives. I listen to those on the other side of the aisle who come--not all of them but many--every single day and say we do not need to change this system. Who are they talking to? Who are they listening to? They are not listening to people like these who find out every day that they do not have coverage, that the cost of insurance is too high, that their doctor is in a debate with a clerk at an insurance company over whether they are going to get the necessary and proper treatment for a medical condition. That is the reality.

There are many ways to address this, and we should. We have to address it by making sure everyone has access to health insurance regardless of preexisting conditions, health status for a medical condition. We have to get rid of the so-called lifetime caps.

Imagine that a diagnosis tomorrow that you or someone you love in your family has a chronic condition that is going to call for medical treatment for a long period of time, and then you realize there will come a moment when that health insurance company would say: We are out of here. You just broke the bank. You hit the cap on your policy.

We have to put an end to that. We also have to limit the out-of- pocket expenses individuals have to pay. There comes a point where people cannot afford this expense. We have to require equal treatment for men and women--Black, White, and brown, young and old, whether they live in a rural area or in a city.

We have to make sure if a health insurance policy in America is offered, it is a good policy that covers the basic needs. There are policies that do not. They sell health insurance you can afford, and guess what. It is worthless. That is not good for America and it is not good for our families.

There are ways to lower costs. We ought to be pushing for prevention. We ought to be trying to find ways to keep people well, incentives for the right conduct and healthy outcomes. Right now there is not much of a reward or an incentive for wellness. We also have to give support to small businesses. When we look at the insured in America, most of them are small business employees and their children. The poorest people in America are covered by Medicaid, the government health insurance, as they should be.

Folks are fortunate, like myself, under the Federal Employees Health Benefits Program, and most others who have health insurance policies, to have coverage. But the folks in the middle who get up and go to work every day for the small businesses of America--and their kids--are the ones who do not have coverage. We can do better.

One of the proposals before us in Congress is to make sure small businesses can start getting into pools where they can use that pooling power to reach out and have health insurance coverage that is affordable. That is within our reach.

Senator Reed is on the Senate floor today. He and I were fortunate enough to be at lunch today when our colleague from Connecticut, Chris Dodd, got up and spoke about what had happened in the HELP Committee, the Health, Education, Labor and Pensions Committee, in preparing a bill on health care reform. There were 800 amendments filed. They met for 61 days. Some 400 amendments were considered and voted on. Over 100 of those were from the Republican side of the aisle. They were trying their best to create a bipartisan compromise to get through the bill.

But Senator Dodd came up and talked about this, not in terms of a specific bill and its provisions; he talked about the historic opportunity we have. He said for many of us, for most of us now serving in the Senate, this may be the only time in our political careers when we can change the health care system for the better; when we can make sure that people in America have a better chance to be able to afford the cost of health care.

He certainly inspired us when he pulled out this magazine and showed us a picture of our colleague, Senator Teddy Kennedy, on the cover of Newsweek, and the quote from Ted Kennedy that says: ``We're almost there.''

There is a long essay in here about Ted Kennedy's terrific public career and how much of it has been spent on this issue of health care; what it meant to him personally when his son was diagnosed with bone cancer and had to have his leg amputated; what he went through in a plane crash; when he has seen others and what they have gone through.

Teddy Kennedy reminds us that these opportunities do not come around very often. There is lots we can debate and argue about, but at the end of the day the American people want to see the debate end. They want to see us acting together responsibly for health care that is centered on patients; to make sure they have a health insurance policy they like, that they can keep; to make certain they have a good strong confidential relationship with their doctors for themselves and their families; to make sure, as well, they are not excluded from coverage for preexisting conditions; to make sure that health insurance is going to be affordable; and to make sure it covers all Americans.

We can do it. We are a great and prosperous nation. We have a President who is committed to it. And working with him on a bipartisan basis we can get this done. We can work with the health care professionals--the doctors, the nurses, those leading hospitals--who can show us the way to reduce the cost of care without reducing its quality.

This is our chance. For those who are saying no, that they want the status quo, they do not want to change it, only a small percentage of Americans agree with them. Most Americans agree what I have talked about today needs to be done. We have to overcome those voices of negativity and doubt who continue to come to the Senate floor, those who create fear of change.

Let me tell you, this is a great, strong country that tackles big problems. We have never been assigned a bigger assignment than this one, health care for America. It touches all 300 million of us. We have to make sure it is done fairly, done effectively, and done quickly. If we let this drag out for months beyond this year, it is going to be harder and harder for us to reach our goal.

I encourage my colleagues on both sides of the aisle to work toward that goal, make certain that President Obama's leadership is rewarded with health care reform that does make a difference.

I yield the floor.

I announce that the Senator from West Virginia (Mr. Byrd), the Senator from Massachusetts (Mr. Kennedy), the Senator from Maryland (Ms. Mikulski), the Senator from Pennsylvania (Mr. Specter), and the Senator from Virginia (Mr. Webb) are necessarily absent.

Mr. President, the National Defense Authorization Act for Fiscal Year 2010 authorizes almost $680 billion for the Department of Defense and the national security programs of the Department of Energy.

The bill provides pay and health care to servicemembers and their families; funds troops with the equipment and resources they need to fight and provide security; strengthens our ability to train foreign militaries and protect against IEDs and rogue nuclear threats; and terminates questionable weapons programs.

It also includes legislation to complete the James A. Lovell Federal Health Care Center in Illinois.

It gives the VA and the Navy the authority they need to finalize a model partnership between the North Chicago VA Medical Center and the Naval Health Clinic Great Lakes.

This is a model that the Departments hope can be replicated around the country.

Combining separate Federal hospitals will provide better care for our servicemembers and veterans while saving valuable taxpayer dollars.

Given the conflicts we face abroad, this bill provides the right amount to spend in support of our troops. Today, the United States is the world's leader in defense spending. Last year, U.S. military spending accounted for almost half of the world's total military spending. We spend more than the next 46 countries combined. U.S. military spending, combined with that of our close allies, makes up 72 percent of all military spending in the world. Our defense budget is six times larger than China's and 100 times larger than Iran's.

These funds make good on a promise to our men and women in our military. Our troops continue to do everything we ask of them in the wars in Iraq and Afghanistan. These conflicts have taken an extraordinary toll on servicemembers and their families that we cannot forget.

The Armed Forces, particularly the Army and the Marine Corps, will continue to be heavily stressed, even as we start to redeploy our forces from Iraq. Servicemembers still do not have enough dwell time between deployments and the Army has seen a troubling rise in the number of suicides. These are indications of the strain that multiple and continued deployments are taking on the force. The President requested increasing the size of the Army to 547,400 soldiers and increasing the Marine Corps to 202,100 Marines, while preventing cuts in Navy and Air Force personnel. This bill supports the President's request. It also authorizes an additional 30,000 soldiers in 2011 and 2012, should the Secretary of Defense believe such troops are necessary. Additional soldiers and marines will help ease the burdens caused by multiple deployments.

More personnel will give each service more breathing room to care for its wounded warriors. Others can continue the fight while injured and ill servicemembers can recover in wounded transition units.

This legislation creates a task force to assess the policies and programs that support the care and transition of recovering wounded and seriously ill members of the Armed Forces. The task force will consider whether servicemembers have sufficient access to care for posttraumatic stress disorder and traumatic brain injury, the signature injury of the wars. It will look at how well we help injured warriors transition from the Department of Defense to the Department of Veterans Affairs.

The task force will also review the support available to family caregivers as they care for recovering injured and seriously ill members of the Armed Forces. For every servicemember successfully recovering from a serious injury or illness, there is often a family member who has put the brakes on his or her life to care for that person.

Last week, my office received a call from the family of Jordan Hoyt, a soldier from Barry, IL. He was seriously injured in Afghanistan and is receiving care at Walter Reed Army Medical Center here in Washington. His wife Haley has moved to Washington to be near Jordan while he goes through months of surgery and rehabilitation. She has brought with her their infant child, who was born while Jordan was away serving his country. Haley is from Quincy. She has left her family behind to help Jordan recover from his injury. She has also delayed her educational plans to study criminal justice. Haley is 19 years old. After Jordan leaves Walter Reed, the couple will return to Quincy to live with her mother, who has already provided them with incredible support. While taking care of wounded servicemembers is our basic responsibility, we also need to support the families whose lives have been up-ended by the wars. I commend the committee for including this task force to look at the needs of family caregivers.

This President inherited many challenges at home and abroad, including two wars and a challenging situation in

Pakistan. This bill supports President Obama's new direction in addressing these priorities. In June, our military redeployed from Iraq's cities under the Status of Forces Agreement concluded by the government of Iraq and the previous administration. The Iraqis must continue to take responsibility for their own future.

I commend the President's increased focus on defense and development in Afghanistan; preventing the reemergence of the Taliban and al-Qaida; and strengthening economic, agricultural, educational, and democratic development. These goals are important to development in Afghanistan, but they are essential to our military's strategy. I support the National Defense Authorization Act and commend Chairman Levin and Senator McCain for their leadership.

Almost 3,000 soldiers from the Illinois Army National Guard are currently deployed to Afghanistan. Members of the Illinois Guard's 33rd Infantry Brigade Combat Team are helping train the Afghan National Police and providing force protection at military bases. It has been a difficult deployment, with many casualties. Gen William Enyart, the Adjutant General of Illinois, has had to attend the funerals of too many of his soldiers. He sent me an article he had written this spring. Why do the young soldiers serve, he asked? This is what he wrote. They serve because:

They are our kids, they are our protectors. They are what

stand between us and chaos. They don't have to be asked to

serve. They don't have to be asked to go into danger. They do

it, not out of hate, not out of vengeance, but out of love.

Love of family, love of community, love of fellow soldier.

I think he is right. Members of the Armed Forces and their families make these sacrifices to keep our country safe. We owe them much in return. This bill takes one step by providing them the resources they need. I ask my colleagues to support this legislation and to send it to the President for his signature.

Mr. President, thank you very much. I thank the floor manager on the majority side for this unanimous consent which allows me to proceed now under morning business.

I wish to say a word or two about the Defense authorization bill which is before us, and then I want to pivot. I will talk about the health of our Nation's defense, but also about the health care of our people.

Let me start off by extending my thanks to the leaders of the Armed Services Committee, Senator Levin and Senator McCain, and their staffs for the good work they have done. I wish to thank Senator Reed of Rhode Island for his contributions as well. Standing here on the floor, I am looking at Senator Reed, a graduate of the

Military Academy at West Point, and right across the aisle, at Senator McCain, a graduate of the Naval Academy. It is great to have that kind of experience here in the Senate. They are sitting on opposite sides of the aisle, coming from schools that are sometimes thought to be rivals, but they are able to work together when we need them to.

I wish to express my thanks to the President and to the Secretary of Defense Bob Gates. We have learned that in the last 7 years, cost overruns from major weapons systems in this country grew from about $45 million in 2001 to last year almost $300 billion, a growth over 7 years in cost overruns for major weapons systems in 2001 of $45 million and last year almost $300 billion. What we need is for the administration as well as the Secretary of Defense and the Joint Chiefs to say to the folks on the Armed Services Committee, but also to say to us in the Senate and in the House: These are the weapons systems we need, these are the threats we believe we face as a nation, and to give us some sense of priorities of the weapons systems we should support and fund, the troop levels we need and, frankly, the weapons systems we don't need and the troop levels we don't need.

I was privileged to follow on the heels of the Presiding Officer, Senator Kaufman, about a month and a half ago to Afghanistan and Pakistan. He and Senator Reed, I think, led that CODEL and shared with us our needs in that part of the world. We need a military strategy and we also need a civilian strategy in Afghanistan, and I think this administration has given us a good two-pronged approach. We have good new leadership there on the military side. Basically, though, they said our job here is counterinsurgency. We need more troops, more trainers to train the Afghans and to train the military side, and then the civilian side. We also need mobility in terms of a lot of additional helicopters, about 150 new helicopters or additional ones coming in to provide the mobility to move our men and women all over the southern part of Afghanistan, and to meet the Taliban threat.

The kind of weapon we don't use there or don't need there, I will be very blunt, is the F-22 which we discussed and debated here for the last several days, a fighter aircraft that has been around for a dozen or so years. We are still building more of them, but they have never flown a flight mission in Iraq and never flown a flight mission in Afghanistan either. The F-22 is limited in what it can do. It basically is a fighter, air-to-air combat. The Afghans, the Taliban, don't have fighter aircraft. In Iraq, the folks we are fighting there don't have aircraft. Meanwhile, we have F-15s, F-16s, F-18s. We are going to build 2,500 F-35s, for less than half the price of the F-22, which not only do dog fights but can also do ground-to-air support and a variety of different functions that the F-22 cannot for a lot less money. The administration, I think wisely, said as hard as it is sometimes to stop the production line on aircraft, in this case the F-22, in terms of what is cost effective, we need to refocus on the F-35 and on counterinsurgency, preparing for those kinds of challenges we face. We voted to do that, a 58-to-40 vote. I was very pleased with the vote and I commend everyone who voted as they did, and, frankly, the people who took the opposite view. There were some tough issues to deal with, I know particularly from folks in whose States the aircraft are being produced and systems for those aircraft are being produced. I know it is difficult to accept. But I am encouraged by that vote.

My hope is we will pay heed to some of the priorities sent to us by the Secretary of Defense, which are designed to make sure we spend money on weapons systems that we are likely to need in the 21st century--certainly in the next decade or two or three--and I think with today's vote, we are on a better path to do that.

Health Care Reform

Sort of pivoting, if I can, after having said a word about the health of our Nation's defense, let me talk about the health of the people in our country. Some of my colleagues are probably getting tired of hearing me say this, but when talking about health care, I mention four things: No. 1, we spend more money for health care than any other nation on Earth. No. 2, we don't get better results. No. 3, we have 14,000 people in this country today losing their health care. No. 4, some 47 million Americans today don't have health insurance, don't have health care. We have to do better than this. We have to do better than this. I believe we can.

There has been a big focus, as there should be, on extending health care coverage to 47 million folks who don't have it, and we need to address that, obviously. Having said that, the other concern we need to address is reining in the growth of health care costs. We are getting clobbered as a nation in terms of being able to compete with the rest of the world where we pay so much more money for health care than any other nation, and employers pay, and we are getting clobbered as a Federal Government with the cost of Medicare and Medicaid, and State governments trying to bear their share of the cost of Medicaid. They see enormous pressures on their State budgets.

Over lunch today, I said to my colleagues in our caucus meeting that wouldn't it be great if somehow we could have our cake and eat it too. I said that with a piece of chocolate cake staring me right in the face. But as it turned out, there are delivery systems, if you will, of health care in this country where they are not necessarily having their cake and eating it too, but where they are able to provide better health care, better outcomes, at a lower price. Think about that: better health care, better outcomes, better quality of health care at a lower price.

The names are beginning to become familiar to us. Some are already familiar: Mayo in Minnesota, and now they have an operation down in Florida too to see if that model will work in Florida, and it has; Kaiser Permanente in northern California, an outfit called Intermountain Health--all of these are nonprofits--Cleveland Clinic in Cleveland, OH, an outfit called Geisinger in Hershey, PA; there is what is called a health care cooperative in the State of Washington, I believe it is around Puget Sound, called Puget Sound Cooperative where they have been able to emulate this interesting result of better quality outcomes, better health care, lower prices.

What we need to do is to attempt not only to extend health care coverage to folks who don't have it--47 million--but to rein in the growth of health care costs. The idea that health care costs grow at 2 or 3 or 4 percent over the consumer price index, to continue to do that is going to cripple us economically and competitively as a nation. It is going to cripple our ability to rein in our large and growing deficits.

In the last 8 years in this Nation we ran up as much new debt as we did in the first 208 years of our Nation's history. Think about that: In the last 8 years, we ran up as much new debt in this country as we did in our first 208 years as a nation. This year we are on track to have the biggest single-year deficit we have ever had. We are also in the worst economic downturn since the Great Depression, and we are trying to stimulate the economy and get it moving. I am encouraged that it is starting to move, but that is a huge deficit, coming on the heels of, frankly, 8 years where we spent like drunken sailors, and I know how drunken sailors spend. It is not a pretty sight, and this is, frankly, not a pretty sight either.

We need to go to school on the Mayos, the Geisingers, the Cleveland Clinics, the Kaiser Permanentes, the Puget Sounds, the Intermountain Healths, and see what we can learn from them. What is their secret? How are they able to do this, better outcomes, less price?

As it turns out, there are a number of things they do in common. I wish to mention a few of them today. Among the things they do, they have literally brought on to their staff the doctors at Cleveland Clinic, for example, who provide health care. They are on staff at the Cleveland Clinic. The same is true at Mayo and these other nonprofits.

I saw an interesting special on CNN a couple of weekends ago. They were interviewing a number of people who worked at the Cleveland Clinic. They interviewed a fellow who is a doctor, a cardiologist, as I recall. He used to be in private practice. He said, in the old days when I was on my own in private practice or group practice, I got paid, compensated, for the number of hearts I operated on. If somebody came to me

and they had a heart problem and it could be addressed by diet or exercise or medicine, he said, usually I didn't prescribe those things. I didn't get paid for doing that. If they needed to have a heart operation and we could address their problem with an operation, he said, I got paid for that. As a result, I was more inclined to operate on people's hearts than to use some approaches that were arguably more cost effective. He went on to say, now I work for the Cleveland Clinic. I am a staff doc here. I don't have to operate on people's hearts to be compensated. I can provide good advice, help people with their diet problems, their exercise problems, their weight problems. I can help people better understand what their opportunities are with medicine. I still get paid. Bingo.

So a light went off for me. Some of us are hearing quite a bit the need to get away from these fee-for-service deals where we basically incentivize doctors, hospitals, and nurses to ask for and order more visits, more procedures, more MRIs, more lab tests, for imaging, more x-rays, because they get paid for it, because they know that by doing more of everything, they reduce the likelihood that they are going to be sued. That sort of gets us in this conundrum where we overuse health care. If we are going to have real success in drawing down the costs of health care, part of it will be addressing the issue of fee for service, get away from that practice, and get away from the overutilization of the health care we have.

Let me mention some of the things they are doing at these five or six entities I mentioned, these nonprofits. Among the things they do is coordinate care. I use my mom as an example. My mom is now deceased. She lived in Florida for roughly the last 30 or so years of her life. She had dementia; she had congestive heart failure; she had arthritis. She had five doctors. The last years of her life that she was down there, my sister and I would go down to visit my mom about every other month or so. We would take turns, and we would go with our mom to visit her doctors. These five doctors my mom had never talked to each other. In fact, I don't think they knew that the other doctors existed. They were all in the aggregate prescribing something like 15 different kinds of prescription medicines. We kept them at her home in what looked like my dad's old fishing tackle box. It was compartmentalized with medicines to take before breakfast, during breakfast, after breakfast; before lunch, during lunch, and throughout the day. Some of those medicines my mom was prescribed, she didn't need to take. Somebody needed to know what she was taking and say, You shouldn't be taking these two medicines in combination; they are hurting you. We didn't have good coordination of care of my mom.

One of the things these nonprofits do is coordinate the care that is provided to my mom or anybody's mom or dad. Another thing that would have been very helpful for my mom or other people in that situation is to have electronic health records. If my mom had an electronic health record such as we have in the VA and like we are developing in Delaware and some other States, when my mom went from doctor's office to doctor's office they would know in each office who else she was seeing and the medicines she was being prescribed, the lab tests and everything. They would have it right there for her when she came for her regular visit.

We have a great ability to harness information technology or electronic health care records, which are a big part of that. Our nonprofits I have talked about--the half dozen or so--have that in common. On wellness and prevention, we know it is not just from nonprofits but out in California is Safeway, and these people have supermarkets all over America and several hundred thousand employees. Their health care costs from 2004 to 2008 have been level and flat. They have incentivized employees to do the right thing for themselves, in terms of holding down their weight, helping them get off tobacco, to fight obesity and lethargy, to get off the sofa, and to eat what is right; and there are antismoking campaigns and all kinds of stuff. So we have a good model there to perform.

It is not just the nonprofits but a lot of employers are starting to get into this as well.

There are another one or two points I will mention on the nonprofits. On chronic disease management, such as heart disease and diabetes, I am told that about 80 percent of the cost of these chronic diseases can be controlled by four factors: diet, exercise, overweight/obesity, and smoking. Those four factors control about 80 percent of the cost of our expenditures on chronic care. If we work with those four items, we will help reduce the costs and provide better outcomes for people. We will also hold down our costs. There are a couple lessons from the nonprofits and others. Part of it is pharmacy--making sure people who need pharmaceutical medicines, small and large molecules, are taking those, and somebody is checking to make sure they are taking what they need.

Focusing on primary care, many of those people coming out of medical schools want to be specialists. They are not interested in being primary care doctors. We need more primary care doctors. We need to change the incentives to get more primary care doctors, which is what we need. Another idea is for us to pool insurance costs. As my colleagues know, we have the Federal Employee Health Benefit Plan. We have an insurance pool where we pool all the Federal employees and their dependents and the retirees and their dependents into one large pool to purchase health insurance. They get it at a not cheap price but a pretty good price. One of the reasons why is, when you have a lot of people in the purchasing pool, you get a good variety and much better costs. If you think about the administrative costs for health insurance, as a percentage of premiums, I am told, in the Federal Employee Health Benefit Program, it is about 10 percent. When it comes to people buying individual policies and small businesses, their administrative costs as a percentage of premiums are about 30 percent. So the idea of creating large purchasing pools makes a whole lot of sense.

I will close here. The idea that we would pass health care legislation and stop extending coverage for people who don't have it-- if that is all we do, we have failed the American people. We have to do at least two things. One is extend coverage but also make sure the coverage we extend provides better coverage, better quality outcomes and better health care and that we do so at a price that is diminished and does not continue to expand by several times the rate of inflation. We can do that going forward. That is what we need to do.

My friends have been generous in allowing me to proceed. I see several Senators are anxious to get back into the debate.

I yield the floor.

Mr. President, I thank the Chair and I thank my friend from Arizona, Senator Kyl, for his very strong statement. I rise to speak in support of this bipartisan amendment which I have cosponsored along with Senator Kyl, Senator Bayh, and Senator McCain.

As you know, President Obama has made a historic offer to Iran's leaders, inviting them to engage in direct diplomacy to resolve the outstanding differences between our two countries. As the President has repeatedly said, the door is open for the Iranians to come in out of the cold, if they choose to do so. It is by suspending their illicit nuclear activities and ending their support for terrorism that the Iranians have a clear path to ending their international isolation and taking their rightful place in the community of nations.

Unfortunately, as Senator Kyl said, it has now been more than 3\1/2\ months since the formal offer of engagement was made by President Obama, and there has been no reply from the Iranians. Meanwhile, Iran's illicit nuclear activities have continued to speed forward, in violation of multiple U.N. Security Council resolutions. Thousands of additional centrifuges are being installed, and more and more fissile material is being stockpiled.

At the same time, Iran's support for terrorist proxies in Iraq, in Lebanon, and in the Palestinian Authority areas has continued. And, of course, over the past month we and the rest of the world have watched with horror as the Iranian regime has engaged in a brutal crackdown against its own people, who have sought no more than basic human rights.

President Obama, together with our international allies, has been very clear that we will not wait indefinitely for the Iranians to respond to our offer of talks, nor will we enter into negotiations--if that is the willingness of the Iranians--that go on without end. Two weeks ago, at the annual G8 summit in Italy, the President joined with other world leaders to make clear to the Iranians that they have until the G20 summit in Pittsburgh, at the end of September, to return to the negotiating table or face the consequences.

The amendment Senators Kyl, Bayh, McCain, and I have put forward would place the full weight of the U.S. Senate behind the time frame that the President and the G8 have articulated. Our amendment expresses our strong hope that Iran seizes this historic opportunity for direct dialogue.

We also make clear that if the Iranians have failed to engage with us diplomatically by the time of that G20 summit 2 months from now, it is our preference that multilateral sanctions be imposed through the United Nations Security Council. However, the Iranian Government--the regime that controls the people of Iran--must also understand that the United States is itself prepared to put in place what Secretary of State Clinton a while ago referred to as crippling sanctions in the event that they in Tehran continue to flaunt the will of the international community.

Specifically, our amendment asks the President to impose sanctions on the Central Bank of Iran and other banks involved in proliferation and terrorist activities, in the event that the Iranians haven't entered into negotiations that are serious by the time of the Pittsburgh summit or if they haven't suspended enrichment and reprocessing activities within 60 days of that summit.

The Central Bank of Iran is the financial lifeline of that regime. It is an entity that our own Treasury Department says has engaged in deceptive financial practices and facilitated the efforts of other Iranian banks that are involved in bankrolling proliferation and terrorist activities to avoid international sanctions, and that have themselves been sanctioned by the U.N. and our Treasury Department as a result.

I will say this. The idea of imposing sanctions on the Iranian Central Bank is not new. It has already been endorsed by a bipartisan majority in this Chamber. Last year, the Senate Banking Committee, under Chairman Dodd, adopted bipartisan legislation by a vote of 19 to 2 to urge the President to immediately impose sanctions against the Central Bank. Also last year, the House of Representatives passed such legislation that urged immediate sanctions.

More recently, the legislation that Senators Bayh, Kyl, and I introduced this spring--the Iran Refined Petroleum Sanctions Act, S. 908--in addition to the other steps it takes--also expresses the sense of the Senate that the President should impose sanctions against the Central Bank of Iran.

I am very grateful to report that S. 908, the Iran Refined Petroleum Sanctions Act, now has 67 Members of the Senate, a strong bipartisan group of 67, or two-thirds, as cosponsors of that legislation. These cosponsors range all across the ideological spectrum of Members of the Senate, and clearly make the point to Iran and to the rest of the world that whatever other differences we have, we stand together here as a strong majority and beyond the Senate in our concern about the nuclear proliferation and terror-sponsoring activities of the Iranian Government.

You might say, if you are one of the 67 cosponsors of S. 908--which does more than this amendment does but includes it--you have already spoken in favor of this amendment.

This amendment, I want to point out and make clear, in no way ties the President's hand in his diplomacy with Iran. That is not our intent. The amendment is about empowering the President, giving him additional leverage in his diplomacy, by endorsing the same timetable that came out of the G8 summit a short while ago. The effect is this, and I will repeat: The Iranians must appreciate that there will be consequences if they fail to respond to the international community's diplomatic initiatives; in other words, if they continue to speed their nuclear program forward.

I think this amendment will send an unmistakable message to the fanatical regime in Tehran, in support of the G8, in support of President Obama: Either you can engage with the United States and the world community and take steps to suspend your nuclear activities or you can continue on your current course, in which case you will face the crippling sanctions this sense-of-the-Senate resolution calls for.

I thank the Chair, and I yield the floor.

I thank my friend from Arizona. I am encouraged by that. And in talking to the other cosponsors, we would be happy to have a voice vote. It would send a message.

Mr. President, I ask unanimous consent that the pending amendment be set aside and that amendment No. 1528 be called up.

Mr. President, I ask unanimous consent that further reading of the amendment be dispensed with.

Mr. President, I am pleased and proud to introduce this amendment with a bipartisan group of cosponsors. To state it briefly, it extends the authorized end strength of the U.S. Army by 30,000 over the next 3 years, effective with the commencement of fiscal year 2010. It doesn't mandate this increase, but it expands the authority of the Secretary of Defense, obviously, with the support and authorization of the President of the United States, the Commander in Chief, to extend the end strength of the U.S. Army. End strength means how many soldiers can the U.S. Army have. Of course, it does this to reduce the tremendous stress on the U.S. Army, which is carrying the burden of combat in two wars, in Iraq and Afghanistan today, and over the next year or 18 months will be in this unique position.

Progress has been made, thank God, in Iraq, and the Iraq Security Forces are progressively taking over responsibility for keeping the security in their country. The drawdown of American soldiers is happening in a methodical and responsible way, and I again express my appreciation to President Obama that it is happening in that way. At the same time, we are increasing our troop presence in Afghanistan. Bottom line: The demand for members of the U.S. Army on the battlefield over the next year, 18 months, at the outside 2 years, is going up. If the supply remains constant, that means the stress on every soldier in the U.S. Army and his or her family will not be reduced. As a matter of fact, it will go up. The term for this--which I will get to in a minute--in the Army is ``dwell time.''

This is an amendment that began with members of the Senate Armed Services Committee, and a comparable amendment in the House Armed Services Committee, recognizing, as we all do, the tremendous stress that our Army is under, the extraordinary job they are doing in Iraq and Afghanistan.

This is really the next great generation of the American military. But we see in it some tough statistics: the increase in mental health problems, the increase in divorces of members of the service, and, worse, of course, the increase in suicides.

There are many things we have supported in this Senate and the Congress--and the administration has--to respond to each one of those problems. But in a way, the most direct thing we can do is to increase the size of the U.S. Army so there is less pressure on every soldier in the Army, in this sense. Every time we add another soldier to the U.S. Army--and we are talking about authorization to add 30,000 more--it means that much more time every other member of the U.S. Army can spend back at base retraining, preparing and, most important of all, spending time with their families.

As I know the Presiding Officer knows--and I know the President of the United States knows it too--the good news is that the Secretary of Defense, Bob Gates, who has done and is doing an extraordinary job for our country with, of course, the support and authorization of President Obama, yesterday announced that he would be temporarily increasing the Active-Duty end strength of the U.S. Army by 22,000 soldiers over the course of the next 3 years.

I cannot sufficiently express my words of appreciation for Secretary Gates's decision. He acted by employing the emergency authority he has in an authorization of the use of force and a built-in statutory waiver he has up to 3 percent of existing end strength to expand the size of the Army. This amendment, which had been planned,

and was in the committee before this great action by Secretary Gates yesterday, is now before us, and I am honored to offer this amendment with a bipartisan group of cosponsors who are listed on this amendment as a way to do two things: The first is that it literally increases from 547,000 to 577,000-plus the authorized end strength of the U.S. Army, and to leave that authority there in case there is a need that Secretary Gates and the President see in the coming 3 years to raise the number.

I will be happy to yield.

Two reasons. The first is that it is a bit beyond what Secretary Gates did. He authorized using the extraordinary powers he possesses as Secretary in this time of conflict up to 22,000 for the next 3 years. The amendment authorizes--doesn't mandate, doesn't appropriate--30,000 for the next 3 years. So it gives some latitude, depending on how conditions go in Iraq and Afghanistan, to go a bit further--8,000 more, if necessary, over the next 3 years.

Second, I say to my friend from Arizona, when this amendment started, we didn't know Secretary Gates was going to do this. I am grateful he did, but this amendment now--frankly, as Secretary Gates himself said to me yesterday, and I appreciate it and I don't think he would mind if I repeated it on the Senate floor--gives the Senate and Congress the opportunity to essentially vindicate and support the step that the Secretary has made and, as he put it, send a message from the Senate to the members of the U.S. Army that help is on the way.

My friend from Arizona is absolutely right. There is no doubt, based on the demand, certainly temporarily, over the next 18 months, perhaps 2 years, as we are drawing down in Iraq, but not as rapidly as we are adding forces in Afghanistan, that there is at least a temporary need for more than the authorized 547,000 members of the U.S. Army.

Absolutely. As a matter of fact, one of the reasons Secretary Gates gave yesterday I will read:

The decision to eliminate the routine use of ``stop loss''

authority in the Army requires a larger personnel flow for

each deploying unit to compensate for those whose contract

expires during the period of deployment.

So, yes, this makes it possible to end the use of stop loss, which is essentially, in layman's terms, a way to require people to stay actively deployed longer than they originally were going to be deployed.

I thank my friend from Arizona. We have illuminated most of the reasons in our exchange why this amendment is important. I will simply add a few more things Secretary Gates said yesterday, which is:

The army has reached a point of diminishing returns in

their multiyear program to reduce the size of its training

and support ``tail.''

That is the training and support which supports the Active-Duty Army.

The cumulative effect of these factors is that the Army

faces a period where its ability to continue to deploy combat

units at acceptable fill rates is at serious risk.

Here is the point I just made in response to Senator McCain's question.

Based on current deployment estimates, this is a temporary

challenge--

A temporary point of stress. We hope and pray that is true. It certainly looks like it is--

which will peak in the coming year and abate over the course

of the next 3 years.

Mr. President, in addition to the Secretary of Defense, we heard from the Army's Chief of Staff, GEN George Casey, and Secretary of the Army Pete Geren, who have been advocates within the Pentagon for this increase in end strength, and I thank them for that. Admiral Mullen, Chairman of the Joint Chiefs, told our Armed Services Committee earlier this year that the light at the end of the tunnel, as he put it, is still more than 2 years away, and that is only if everything goes according to plan, which in combat, obviously, often does not.

Again, I say this is an authorization; it is not a mandate. I will add that Secretary Gates announced yesterday that he will find a way to fund the additional troops in this year and fiscal year 2010--the one that begins October 1--by reprogramming other funds appropriated to the Pentagon for fiscal year 2011, which is the budget that will be presented to us next year, if it is probable that the Department of Defense will require funding as part of its normal operations, and more likely as part of the OCO fund--the overseas contingency operation fund--which supports our presence in Iraq and Afghanistan.

I cannot say enough, I know all of us in the Senate believe we cannot say enough, in gratitude to the members of the U.S. Army who are leading the battle for us against the Islamic extremists and terrorists who attacked us on 9/11/01. We owe them a debt we can never fully repay.

One thing we can do, that Secretary Gates did yesterday and the Senate can do in this amendment, is to send a message to our troops in the field that help is on the way in the most consequential way, which is additional members of the Army.

I ask that when the vote be taken, it be taken by the yeas and nays.

Again I say to my colleagues I am doing that, although I expect there will be very strong support for this, because I believe it is the most visible way for this Senate to send the message to the U.S. Army of appreciation and gratitude, to them and their families, that help is on the way.

I yield the floor.

Mr. President, briefly I thank Senator Levin, the chairman of the Armed Services Committee, not just for his strong statement of support now but for the support he has given during our committee's deliberations to the goal of achieving an increase in Army end strength.

I yield the floor.