Floor Statements

Mr. President, I ask unanimous consent that Vishal Patel and Samantha Harvell, two fellows in my office, be granted the privilege of the floor during the pendency of H.R. 1.

Mr. President, I call up amendment No. 63.

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

Mr. President, I send a modification of the amendment to the desk.

Mr. President, I wish to briefly describe the import of this amendment, as modified.

Express Lane enrollment seeks to address the problem that up to 6 million children in this country are eligible but are not enrolled in either Medicaid or CHIP and that the vast majority of these children are enrolled in other Federal programs at the same time.

Eligibility for other Federal programs--here I am speaking about food stamps or the National School Lunch Program or the WIC Program-- enrollment in those programs is at lower levels of income eligibility than Medicaid and CHIP, so those children identified by those other Federal programs as low income are virtually, by definition, eligible for Medicaid or for CHIP.

I have worked with Senator Baucus and my colleagues in the Finance Committee to write a provision in the bill which will provide a State option to utilize Express Lane eligibility to enroll children into the CHIP program.

This amendment provides a very simple technical clarification that parents may consent to their children's enrollment in CHIP or Medicaid through various means established by the Secretary, including orally, through electronic signatures, and otherwise. Without this clarification, a child could be determined eligible through Express Lane, but a parent might have to go to a State Medicaid agency to sign a form instead of providing an electronic signature or authorizing coverage over the phone. This is the exact kind of needless bureaucratic hurdle Express Lane is intended to prevent.

So I urge my colleagues to support this amendment, as modified.

Mr. President, I yield the floor and suggest the absence of a quorum.

Mr. President, there are about 6 million children in the country who are eligible for Medicaid or CHIP who are not enrolled. In many of these cases, these are children who are also eligible for and enrolled in other Federal programs that have similar or even more severe requirements for eligibility. To fix this problem, we put a provision in the bill--Senator Baucus and those in the Finance Committee--included a provision for so-called express lane eligibility as a way to sign up children for the CHIP program.

My amendment simply clarifies that the consent of the parent--not the determination of eligibility but the consent of the parent--for the enrollment of the child in the CHIP program or Medicaid can be accomplished through something other than a formal signed document at the Medicaid office. We give the Secretary the discretion to set that up. We believe this is a great change and will help us to register the children who ought to be registered for the CHIP program.

I urge my colleagues to support the amendment.

Madam President, I thank my colleague from Montana and congratulate him for his leadership on this very important piece of legislation.

I come to the floor to offer my strong support for the Children's Health Insurance Program reauthorization. This is legislation that has come out of the Finance Committee which Senator Baucus chairs. It will ensure that 13 million American children will either maintain health care coverage or receive that coverage for the first time.

We worked very hard in the committee to develop the best bill we could. It is a major step forward for our Nation. As many Americans face grave economic uncertainty, it is critical we move quickly to pass this legislation and send it to President Obama for his signature.

The State Children's Health Insurance Program, or CHIP, represents a partnership between the States and the Federal Government. It works by providing States with an annual allotment at an enhanced matching rate for health care coverage for low-income residents. Since CHIP was created in 1997, it has been extremely successful. In fact, despite the fact that private coverage has eroded significantly since CHIP was created, many health care experts believe this program is the primary reason the percent of low-income children in the United States without health coverage has fallen by about a third during that same period.

CHIP is particularly important to my home State of New Mexico. The people in New Mexico have a very difficult time acquiring health insurance. We remain the second most uninsured State in the Nation. Currently, more than 30,000 New Mexicans depend on CHIP for their health coverage. Under this legislation, my State would receive $196 million for CHIP this year. This represents a 277-percent increase over the State's current CHIP allotment. This represents the fourth largest percentage increase of any State in the country.

With this additional funding, tens of millions of additional low- income New

Mexico children--and adults--would have access to health care for the first time. This legislation also corrects an inequity in the Federal law that, despite our very high uninsurance rate which we have in New Mexico, this inequity has prevented New Mexico from covering many of our children through Medicaid. It has required our State to return more than $180 million to the Federal Government since 1997.

The bill also includes modest improvements to requirements that have made it very difficult for New Mexicans to prove they are in fact American citizens and, therefore, eligible for Medicaid. The State estimates that approximately 10,000 New Mexico children who are currently U.S. citizens have been denied health insurance because of these requirements. I have offered an amendment to make further improvement in this provision to ensure that U.S. citizens are not inappropriately denied the health insurance to which they are entitled.

I am glad to report that the legislation also includes a provision I have championed for many years that will allow States to automatically enroll children in CHIP if they have already been deemed eligible for another public program with comparable income standards, such as the National School Lunch Program or the Food Stamp Program. This provision is often referred to as ``express lane,'' and it would help States use technology to cut through the bureaucracy that all too often prevents Americans from receiving health benefits. Health experts tell us that express lane is one of the most important ways we have to reduce the number of uninsured Americans.

I also offered an amendment to clarify several of the express lane provisions in the bill. It is my hope that can be accepted as well.

The bill contains many other provisions that are important to me, such as a mandate to provide dental coverage for children receiving CHIP benefits, as well as a wrap provision, which I proposed during the committee markup, to allow children with private coverage who do not receive dental benefits to receive such benefits through CHIP.

The legislation also includes very significant improvements in the ability of States to perform outreach enrollment to Native American populations, as well as providing outreach funding to Promotoras and other community health workers. These people play a critical role in my State and throughout the country in reaching some of the most isolated populations.

Finally, the bill also protects the provision of mental health services to children.

As I mentioned earlier, I have worked hard on this bill, as have many of my colleagues. It is critical we move swiftly to get this to the President for his signature. Given the urgency we face, I am surprised by some of the opposition that has been expressed by my colleagues on the other side of the aisle. As I read this legislation, it is very similar to the bills that were strongly supported by both Democrats and Republicans in the 110th Congress. These bills passed with a filibuster-proof majority here in the Senate. Provisions in the bill before us today regarding income eligibility, regarding adult coverage, and the other issues being raised, remain more or less the same as in the bills that were strongly supported by Republicans in the last Congress. In fact, the most significant difference between the bill we are now considering and the bill we passed last year is the addition of a State option to remove the current 5-year ban for health care coverage for legal immigrant children and pregnant women. I hope the optional coverage for legal immigrants is not so objectionable to some of my colleagues that they would walk away from the millions upon millions of American children who receive care through this program.

Americans are struggling and our economy is in a very serious situation. The bill before us is urgently needed by many in this country. I hope my colleagues will support this important bill.

I yield the floor.

Mr. President, the legislation I am introducing today, entitled the Community Health Workers Act of 2009, will help improve access to health education and outreach services to women and children in medically underserved areas, including the U.S. border region along New Mexico.

Lack of access to adequate health care and health education is a significant problem on the southern New Mexico border. While the problem of access is in part due to a lack of insurance, it is also attributable to non-financial barriers such as a shortage of physicians, hospitals, and other health professionals; inadequate transportation; a lack of bilingual health information and health providers; and a culturally insensitive system of care.

This legislation would help overcome these impediments by providing $15 million in grants annually for a 3 year period to State, local, and tribal organizations, including community health centers and public health departments, for the purpose of hiring community health workers to provide health education, outreach, and referrals to women and families who otherwise would have little or no contact with health care services.

Factors such as poverty, language, and cultural differences impede access to health care in medically underserved populations; hence, community health workers are in a unique position to improve health outcomes and quality of care for groups that have traditionally lacked access to adequate services. They often serve as ``community specialists'' and are members of the communities in which they work. As such they can effectively serve hard-to-reach populations.

In a shining example of how community health workers serve their communities, a group of so-called ``Promotoras'', community health workers, in Dona Ana County were quickly mobilized during a recent flood emergency in rural New Mexico. These community health workers assisted in the disaster recovery efforts by partnering with the Federal Emergency Management Agency, FEMA, to find, inform and register flood victims for Federal disaster assistance. Their personal networks and knowledge of the local culture, language, needs, assets, and barriers greatly enhanced FEMA's community outreach efforts. The Promotoras of Dona Ana County demonstrate the important role community health workers could play in communities across the Nation, including increasing the effectiveness of new initiatives in homeland security and emergency preparedness, and in implementing risk communication strategies.

The positive benefits of the community health worker model also have been documented in research studies. Research has shown that community health workers have been effective in increasing the utilization of health preventive services such as cancer screenings and medical follow up for elevated blood pressure and improving enrollment in publicly funded health insurance programs. In the case of uninsured children, a study by Dr. Glenn Flores, ``Community-Based Case Management in Insuring Uninsured Latino Children,'' published in the December 2005 issue of Pediatrics found that uninsured children who received community-based case management were eight times more likely to obtain health insurance coverage than other children involved in the study because case workers were employed to address typical barriers to access, including insufficient knowledge about application processes and eligibility criteria, language barriers and family mobility issues, among others. This study confirms that community health workers could be highly effective in reducing the numbers of uninsured children, especially those who are at greatest risk for being uninsured. Preliminary investigation of a community health workers project in New Mexico similarly suggests that community health workers could be useful in improving enrollment in Medicaid and the State Children's Health Insurance Program.

According to a 2003 Institute of Medicine, IOM, report entitled, ``Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,'' community health workers offer promise as a community- based resource to increase racial and ethnic minorities' access to health care and to serve as a liaison between healthcare providers and the communities they serve.

Although the community health worker model is valued in the New Mexico border region as well as other parts of the country that encounter challenges of meeting the health care needs of medically underserved populations, these programs often have difficulty securing adequate financial resources to maintain and expand upon their services. As a result, many of these programs are significantly limited in their ability to meet the ongoing and emerging health demands of their communities.

The IOM report also noted that ``programs to support the use of community health workers . . . especially among medically underserved and racial and ethnic minority populations, should be expanded, evaluated, and replicated.''

I am introducing this legislation to increase resources for a model that has shown significant promise for increasing access to quality health care and health education for families in medically underserved communities.

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

Mr. President, the legislation I am introducing today, entitled the Community Health Workers Act of 2009, will help improve access to health education and outreach services to women and children in medically underserved areas, including the U.S. border region along New Mexico.

Lack of access to adequate health care and health education is a significant problem on the southern New Mexico border. While the problem of access is in part due to a lack of insurance, it is also attributable to non-financial barriers such as a shortage of physicians, hospitals, and other health professionals; inadequate transportation; a lack of bilingual health information and health providers; and a culturally insensitive system of care.

This legislation would help overcome these impediments by providing $15 million in grants annually for a 3 year period to State, local, and tribal organizations, including community health centers and public health departments, for the purpose of hiring community health workers to provide health education, outreach, and referrals to women and families who otherwise would have little or no contact with health care services.

Factors such as poverty, language, and cultural differences impede access to health care in medically underserved populations; hence, community health workers are in a unique position to improve health outcomes and quality of care for groups that have traditionally lacked access to adequate services. They often serve as ``community specialists'' and are members of the communities in which they work. As such they can effectively serve hard-to-reach populations.

In a shining example of how community health workers serve their communities, a group of so-called ``Promotoras'', community health workers, in Dona Ana County were quickly mobilized during a recent flood emergency in rural New Mexico. These community health workers assisted in the disaster recovery efforts by partnering with the Federal Emergency Management Agency, FEMA, to find, inform and register flood victims for Federal disaster assistance. Their personal networks and knowledge of the local culture, language, needs, assets, and barriers greatly enhanced FEMA's community outreach efforts. The Promotoras of Dona Ana County demonstrate the important role community health workers could play in communities across the Nation, including increasing the effectiveness of new initiatives in homeland security and emergency preparedness, and in implementing risk communication strategies.

The positive benefits of the community health worker model also have been documented in research studies. Research has shown that community health workers have been effective in increasing the utilization of health preventive services such as cancer screenings and medical follow up for elevated blood pressure and improving enrollment in publicly funded health insurance programs. In the case of uninsured children, a study by Dr. Glenn Flores, ``Community-Based Case Management in Insuring Uninsured Latino Children,'' published in the December 2005 issue of Pediatrics found that uninsured children who received community-based case management were eight times more likely to obtain health insurance coverage than other children involved in the study because case workers were employed to address typical barriers to access, including insufficient knowledge about application processes and eligibility criteria, language barriers and family mobility issues, among others. This study confirms that community health workers could be highly effective in reducing the numbers of uninsured children, especially those who are at greatest risk for being uninsured. Preliminary investigation of a community health workers project in New Mexico similarly suggests that community health workers could be useful in improving enrollment in Medicaid and the State Children's Health Insurance Program.

According to a 2003 Institute of Medicine, IOM, report entitled, ``Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,'' community health workers offer promise as a community- based resource to increase racial and ethnic minorities' access to health care and to serve as a liaison between healthcare providers and the communities they serve.

Although the community health worker model is valued in the New Mexico border region as well as other parts of the country that encounter challenges of meeting the health care needs of medically underserved populations, these programs often have difficulty securing adequate financial resources to maintain and expand upon their services. As a result, many of these programs are significantly limited in their ability to meet the ongoing and emerging health demands of their communities.

The IOM report also noted that ``programs to support the use of community health workers . . . especially among medically underserved and racial and ethnic minority populations, should be expanded, evaluated, and replicated.''

I am introducing this legislation to increase resources for a model that has shown significant promise for increasing access to quality health care and health education for families in medically underserved communities.

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

Mr. President, I rise today to introduce the Medicare Quality and Payment Reform Act of 2009. This legislation will help improve the quality and efficiency of the Medicare program by analyzing readmission and resource use and adjusting Medicare payments accordingly. In addition, the legislation develops a large scale pilot project to allow for episodic payments to organized groups of multispecialty and multilevel providers for select, high cost diagnosis. Reforms such as these have been recommended by the non- partisan Medicare Payment Advisory Commission or ``MedPAC,'' the Commonwealth Fund and many other experts. In their December 2008 Budget Options report, the Congressional Budget Office, CBO, estimates reforms such as these could result in more than 28 billion dollars in savings to the Federal Government over 10 years.

For several years, growth in healthcare spending, including in the Medicare program, has far exceeded the rate of inflation for all other goods and services without a concomitant rise in health care quality. According to the 2007 report of the McKinsey Global Institute, ``Accounting for the Costs of Healthcare in The United States,'' the U.S. spends almost half a trillion dollars more on healthcare than other similarly situated countries, when adjusted for population and income. Moreover, according to a 2008 Dartmouth report, total waste in the U.S. healthcare system accounts for approximately $700 billion. These data are startling and deeply troubling to me and many of my colleagues in the Congress. As we move to consider comprehensive healthcare reform legislation in the 111th Congress, it is critical that we consider bold and decisive reforms to incentivize quality and efficiency in the U.S. healthcare system.

Many experts tell us that the present fee-for-service payment system does little to encourage the prevention of readmissions or control the volume of care and cost of services delivered. MedPAC, CBO, and others believe this fee-for-service distortion is a major driver of excess spending in the healthcare system. Consequently, per-beneficiary spending varies between regions by as much as one-third without any measurable difference in patient outcomes. In addition, a la carte health care delivery focuses on individual procedures and patient interactions without much regard for the integration of care and appropriate mix of services necessary.

For example, MedPAC reports that within 30 days of discharge, 17.6 percent of Medicare admissions are readmitted for which Medicare spent $15 billion in 2005. The Commonwealth Fund Commission on a High Performance Health System found that Medicare 30-day readmission rates varied from 14 percent to 22 percent with respect to the lowest and highest decile of states.

MedPAC and other expert groups report that the bundling of Medicare payments around episodes of care will align financial incentives within the program to maximize quality and efficiency for Medicare beneficiaries. It is

critical to note that such reforms not only lower overall healthcare costs but also have the potential to lower Medicare beneficiaries out of pocket expenses while improving their health. For example, the Medicare Participating Heart Bypass Center Demonstration conducted from 1990 to 1996 explored the utility of payment bundling. In this demonstration, participating centers were reimbursed with a bundled payment for episodes of care related to heart bypass cases. The demonstration resulted in reduced spending on laboratory diagnostics, pharmacy services, intensive care, and unnecessary physician consults while still maintaining a high quality of care. In the end, the demonstration saved the Medicare program approximately 10 percent on cost of bypass treatments.

There is considerable agreement in the health policy community about a move toward ``episodic'' or bundled payments. The 16th Commonwealth Fund/Modern Health Care Opinion Leaders Survey, released November 3, 2008, found that more than \2/3\ respondents reported that the fee-for- service system is not effective at encouraging high quality and efficient care. More than \3/4\ of respondents prefer a move toward bundled per patient payments. Shared accountability for resource use also was favored as a means for improving efficiency, and \2/3\ of the experts surveyed supported realigning provider payment incentives to improve efficiency and effectiveness.

This legislation makes three broad reforms to the Medicare program leading to higher quality and more efficient care. First, the legislation requires the U.S. Department of Health and Human Services, HHS, to report on risk adjusted readmission rates and resource use to Medicare providers, and over time, to the public. Second, the legislation establishes risk-adjusted benchmarks based upon these data that, over time, will be utilized to adjust Medicare payments. Finally, the legislation institutes a voluntary ``episodic payment'' pilot program.

Readmission will be defined by the Secretary of HHS and will include a time frame of at least 30 days between the initial diagnosis and readmission, insure that the readmission rate captures readmissions to any hospital and not be limited to the initial health care provider entity, and verify that the diagnosis for both initial and readmission are related. Within 1 year from enactment, HHS will be tasked with confidentially reporting to provider entities risk adjusted for readmission rates and risk adjusted resource use for select high-volume diagnosis-related groups, DRG, associated with high-rates of readmission. After 3 years, HHS will publically release these reports with an annual review of the list of DRGs reported. The data reported will be risk adjusted taking into account variations in health status and other patient characteristics. Physician's not reporting these data to HHS for analysis will be penalized; although physicians do have the ability to apply for hardship exceptions.

The legislation requires HHS to establish benchmarks for risk adjusted readmission rates and resource utilization for a given DRG and within 2 years of enactment, report to Congress on methodologies used to develop such benchmarks. Three years from the date of enactment, the base operating DRG payment to hospitals not meeting the established benchmarks will be reduced by 1 percent or an amount that is proportionate to the number of readmissions exceeding the benchmark. The Secretary of HHS will devise a mechanism to allocate accountability among providers associated with the episode of care with regard to penalty distribution. The benchmark and penalty will be evaluated and updated annually.

The legislation goes further and establishes a voluntary pilot program to allow for bundled episodic payments to organized groups of multispecialty and multilevel providers for select high cost interventions. Payments would be risk adjusted and would cover all Medicare Part A and B costs associated with a hospitalization episode including care delivered 30 days after discharge. Payments would be issued to the participating provider group which, in turn, would reimburse negotiated payments to all individual providers associated with episode of treatment. The pilot would include testing models in a variety of settings including rural and underserved areas. The initial pilot will begin 2 years from date of enactment and continue for a period of 5 years. If the pilot proves successful, the Secretary of HHS will have the authority to expand the payment mechanism to a larger set of providers.

I urge my colleagues to join me in supporting this important piece of legislation.

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

Mr. President, I rise today to introduce the Medicare Quality and Payment Reform Act of 2009. This legislation will help improve the quality and efficiency of the Medicare program by analyzing readmission and resource use and adjusting Medicare payments accordingly. In addition, the legislation develops a large scale pilot project to allow for episodic payments to organized groups of multispecialty and multilevel providers for select, high cost diagnosis. Reforms such as these have been recommended by the non- partisan Medicare Payment Advisory Commission or ``MedPAC,'' the Commonwealth Fund and many other experts. In their December 2008 Budget Options report, the Congressional Budget Office, CBO, estimates reforms such as these could result in more than 28 billion dollars in savings to the Federal Government over 10 years.

For several years, growth in healthcare spending, including in the Medicare program, has far exceeded the rate of inflation for all other goods and services without a concomitant rise in health care quality. According to the 2007 report of the McKinsey Global Institute, ``Accounting for the Costs of Healthcare in The United States,'' the U.S. spends almost half a trillion dollars more on healthcare than other similarly situated countries, when adjusted for population and income. Moreover, according to a 2008 Dartmouth report, total waste in the U.S. healthcare system accounts for approximately $700 billion. These data are startling and deeply troubling to me and many of my colleagues in the Congress. As we move to consider comprehensive healthcare reform legislation in the 111th Congress, it is critical that we consider bold and decisive reforms to incentivize quality and efficiency in the U.S. healthcare system.

Many experts tell us that the present fee-for-service payment system does little to encourage the prevention of readmissions or control the volume of care and cost of services delivered. MedPAC, CBO, and others believe this fee-for-service distortion is a major driver of excess spending in the healthcare system. Consequently, per-beneficiary spending varies between regions by as much as one-third without any measurable difference in patient outcomes. In addition, a la carte health care delivery focuses on individual procedures and patient interactions without much regard for the integration of care and appropriate mix of services necessary.

For example, MedPAC reports that within 30 days of discharge, 17.6 percent of Medicare admissions are readmitted for which Medicare spent $15 billion in 2005. The Commonwealth Fund Commission on a High Performance Health System found that Medicare 30-day readmission rates varied from 14 percent to 22 percent with respect to the lowest and highest decile of states.

MedPAC and other expert groups report that the bundling of Medicare payments around episodes of care will align financial incentives within the program to maximize quality and efficiency for Medicare beneficiaries. It is

critical to note that such reforms not only lower overall healthcare costs but also have the potential to lower Medicare beneficiaries out of pocket expenses while improving their health. For example, the Medicare Participating Heart Bypass Center Demonstration conducted from 1990 to 1996 explored the utility of payment bundling. In this demonstration, participating centers were reimbursed with a bundled payment for episodes of care related to heart bypass cases. The demonstration resulted in reduced spending on laboratory diagnostics, pharmacy services, intensive care, and unnecessary physician consults while still maintaining a high quality of care. In the end, the demonstration saved the Medicare program approximately 10 percent on cost of bypass treatments.

There is considerable agreement in the health policy community about a move toward ``episodic'' or bundled payments. The 16th Commonwealth Fund/Modern Health Care Opinion Leaders Survey, released November 3, 2008, found that more than \2/3\ respondents reported that the fee-for- service system is not effective at encouraging high quality and efficient care. More than \3/4\ of respondents prefer a move toward bundled per patient payments. Shared accountability for resource use also was favored as a means for improving efficiency, and \2/3\ of the experts surveyed supported realigning provider payment incentives to improve efficiency and effectiveness.

This legislation makes three broad reforms to the Medicare program leading to higher quality and more efficient care. First, the legislation requires the U.S. Department of Health and Human Services, HHS, to report on risk adjusted readmission rates and resource use to Medicare providers, and over time, to the public. Second, the legislation establishes risk-adjusted benchmarks based upon these data that, over time, will be utilized to adjust Medicare payments. Finally, the legislation institutes a voluntary ``episodic payment'' pilot program.

Readmission will be defined by the Secretary of HHS and will include a time frame of at least 30 days between the initial diagnosis and readmission, insure that the readmission rate captures readmissions to any hospital and not be limited to the initial health care provider entity, and verify that the diagnosis for both initial and readmission are related. Within 1 year from enactment, HHS will be tasked with confidentially reporting to provider entities risk adjusted for readmission rates and risk adjusted resource use for select high-volume diagnosis-related groups, DRG, associated with high-rates of readmission. After 3 years, HHS will publically release these reports with an annual review of the list of DRGs reported. The data reported will be risk adjusted taking into account variations in health status and other patient characteristics. Physician's not reporting these data to HHS for analysis will be penalized; although physicians do have the ability to apply for hardship exceptions.

The legislation requires HHS to establish benchmarks for risk adjusted readmission rates and resource utilization for a given DRG and within 2 years of enactment, report to Congress on methodologies used to develop such benchmarks. Three years from the date of enactment, the base operating DRG payment to hospitals not meeting the established benchmarks will be reduced by 1 percent or an amount that is proportionate to the number of readmissions exceeding the benchmark. The Secretary of HHS will devise a mechanism to allocate accountability among providers associated with the episode of care with regard to penalty distribution. The benchmark and penalty will be evaluated and updated annually.

The legislation goes further and establishes a voluntary pilot program to allow for bundled episodic payments to organized groups of multispecialty and multilevel providers for select high cost interventions. Payments would be risk adjusted and would cover all Medicare Part A and B costs associated with a hospitalization episode including care delivered 30 days after discharge. Payments would be issued to the participating provider group which, in turn, would reimburse negotiated payments to all individual providers associated with episode of treatment. The pilot would include testing models in a variety of settings including rural and underserved areas. The initial pilot will begin 2 years from date of enactment and continue for a period of 5 years. If the pilot proves successful, the Secretary of HHS will have the authority to expand the payment mechanism to a larger set of providers.

I urge my colleagues to join me in supporting this important piece of legislation.

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

Mr. President, I rise today to introduce the Municipal Bond Market Support Act of 2009. This bill is similar to one that Senator Crapo and I introduced in the 110th Congress, and I am grateful for Senator Crapo's continued leadership on this issue, as well as the cosponsorship of Senators Kerry, Snowe, and Schumer.

One of the most unfair--but least discussed--impacts of the credit crisis is its severe disruption of the municipal bond market. By reducing state and local governments' access to financing, increasing interest costs, and shrinking the universe of available investors, this disruption is threatening critical infrastructure investments that generate significant economic activity, just when the need for infrastructure enhancements could not be more apparent.

Municipal bonds have long played an essential role in financing the construction, expansion, and repair of schools; highways, roads, and bridges; affordable housing; hospitals; public transit; water and sewage systems; and community-owned utilities. But currently, the municipal bond market is significantly impaired. This situation has been caused by reasons completely extrinsic to events in the municipal bond market; indeed, municipal bonds remain among the safest securities in the world, with extremely low default rates.

Because of this market impairment, states, municipalities and authorities have been and are continuing to face unreasonably high debt issuance costs. Due to these high costs, many other state and local governments are finding themselves suddenly unable to issue debt. For instance, in the fourth quarter of 2008, bond issuance fell 33 percent compared to the fourth quarter of 2007, representing a $35 billion drop.

The pain is being felt by States and municipalities across the country, which have had to curtail new bond issuances, delay, or withhold borrowing altogether from the capital markets. For instance, in Connecticut, the state sought to sell $500 million in General Obligation bonds, but was only able to sell $99 million. As an indication as to how interest rates have increased significantly, secondary market trading data indicates that, for instance, through the beginning of 2009 a Clayton, New Mexico, revenue bond series saw a 230 basis point increase. This increase is indicative of the increase in costs that the city would incur if they had to issue new bonds today, a rate of 7.60 percent, whereas a year ago the same issue would likely have been issued at 5.29 percent.

Infrequent issuers are experiencing an even more difficult time accessing the markets. A study by Municipal Market Advisors found that for issuers that borrow once a year or less, borrowing costs increased by at least 200 basis points during the last half of last year; in many cases, the increase exceeded 250 basis points. For a state or locality issuing $100 million in 30-year bonds, a 200 basis point increase translates to $60 million in additional interest payments over the 30 years. Ultimately, these higher costs will be the responsibility of taxpayers, through higher taxes and/or reductions in other investments or services.

As Congress looks to legislation that will spur a national economic recovery, we should enhance demand for municipal bonds by liberalizing restrictions on banks' ability to acquire municipal debt.

Since the enactment of the Federal income tax in 1913, Congress has supported the municipal bond market by exempting municipal bond interest from taxation. Tax exemption is an effective means of conferring Federal assistance on state and local capital investments; it also recognizes that decisions about which projects to fund are most appropriately made at the State or local level. Historically, banks were significant purchasers of tax-exempt debt. But the Tax Reform Act of 1986 severely curtailed banks' participation by automatically disallowing deductions for interest expense whenever municipal bonds are purchased. The Act left an exception only for bonds purchased from smaller municipalities, those selling no more than $10 million of bonds each year. In contrast, non-bank corporations are permitted to hold up to 2 percent of their total assets in tax-exempt bonds, regardless of the size of the issuer, without jeopardizing interest expense deductibility.

Given the severe challenges affecting the municipal bond markets, now is the time to modify these limitations and thus help channel additional capital to critical infrastructure projects.

First, the Act will extend the 2 percent de minimis rule to banks, placing them on the same footing as other corporate investors.

Second, the Act will raise the $10 million small issuer exception to $30 million. Because the $10 million level was not indexed to inflation, its purchasing power has eroded significantly since 1986, leaving many smaller governments either to defer projects to comply with this low limit or find non-bank purchasers.

Finally, the Act will ensure that the small issuer is made applicable at the ultimate borrower level, so that bonds benefiting non-profit universities and hospitals will not exceed the limitation merely because they issue bonds through statewide authorities.

Taken together, these steps promise to significantly boost municipal bond demand, adding liquidity to the market. For instance, Municipal Market Advisors projects that extending the 2 percent de minimis rule to banks would increase their municipal debt purchasing power by $56 billion. Additional demand will enable municipalities across the nation, and particularly those in small and rural communities, to finance the critical infrastructure projects that play an important role in growing our national economy.

Ten national organizations representing state and local governments are supporting the Act. I urge my colleagues to do the same.

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

Mr. President, I rise today to introduce the Municipal Bond Market Support Act of 2009. This bill is similar to one that Senator Crapo and I introduced in the 110th Congress, and I am grateful for Senator Crapo's continued leadership on this issue, as well as the cosponsorship of Senators Kerry, Snowe, and Schumer.

One of the most unfair--but least discussed--impacts of the credit crisis is its severe disruption of the municipal bond market. By reducing state and local governments' access to financing, increasing interest costs, and shrinking the universe of available investors, this disruption is threatening critical infrastructure investments that generate significant economic activity, just when the need for infrastructure enhancements could not be more apparent.

Municipal bonds have long played an essential role in financing the construction, expansion, and repair of schools; highways, roads, and bridges; affordable housing; hospitals; public transit; water and sewage systems; and community-owned utilities. But currently, the municipal bond market is significantly impaired. This situation has been caused by reasons completely extrinsic to events in the municipal bond market; indeed, municipal bonds remain among the safest securities in the world, with extremely low default rates.

Because of this market impairment, states, municipalities and authorities have been and are continuing to face unreasonably high debt issuance costs. Due to these high costs, many other state and local governments are finding themselves suddenly unable to issue debt. For instance, in the fourth quarter of 2008, bond issuance fell 33 percent compared to the fourth quarter of 2007, representing a $35 billion drop.

The pain is being felt by States and municipalities across the country, which have had to curtail new bond issuances, delay, or withhold borrowing altogether from the capital markets. For instance, in Connecticut, the state sought to sell $500 million in General Obligation bonds, but was only able to sell $99 million. As an indication as to how interest rates have increased significantly, secondary market trading data indicates that, for instance, through the beginning of 2009 a Clayton, New Mexico, revenue bond series saw a 230 basis point increase. This increase is indicative of the increase in costs that the city would incur if they had to issue new bonds today, a rate of 7.60 percent, whereas a year ago the same issue would likely have been issued at 5.29 percent.

Infrequent issuers are experiencing an even more difficult time accessing the markets. A study by Municipal Market Advisors found that for issuers that borrow once a year or less, borrowing costs increased by at least 200 basis points during the last half of last year; in many cases, the increase exceeded 250 basis points. For a state or locality issuing $100 million in 30-year bonds, a 200 basis point increase translates to $60 million in additional interest payments over the 30 years. Ultimately, these higher costs will be the responsibility of taxpayers, through higher taxes and/or reductions in other investments or services.

As Congress looks to legislation that will spur a national economic recovery, we should enhance demand for municipal bonds by liberalizing restrictions on banks' ability to acquire municipal debt.

Since the enactment of the Federal income tax in 1913, Congress has supported the municipal bond market by exempting municipal bond interest from taxation. Tax exemption is an effective means of conferring Federal assistance on state and local capital investments; it also recognizes that decisions about which projects to fund are most appropriately made at the State or local level. Historically, banks were significant purchasers of tax-exempt debt. But the Tax Reform Act of 1986 severely curtailed banks' participation by automatically disallowing deductions for interest expense whenever municipal bonds are purchased. The Act left an exception only for bonds purchased from smaller municipalities, those selling no more than $10 million of bonds each year. In contrast, non-bank corporations are permitted to hold up to 2 percent of their total assets in tax-exempt bonds, regardless of the size of the issuer, without jeopardizing interest expense deductibility.

Given the severe challenges affecting the municipal bond markets, now is the time to modify these limitations and thus help channel additional capital to critical infrastructure projects.

First, the Act will extend the 2 percent de minimis rule to banks, placing them on the same footing as other corporate investors.

Second, the Act will raise the $10 million small issuer exception to $30 million. Because the $10 million level was not indexed to inflation, its purchasing power has eroded significantly since 1986, leaving many smaller governments either to defer projects to comply with this low limit or find non-bank purchasers.

Finally, the Act will ensure that the small issuer is made applicable at the ultimate borrower level, so that bonds benefiting non-profit universities and hospitals will not exceed the limitation merely because they issue bonds through statewide authorities.

Taken together, these steps promise to significantly boost municipal bond demand, adding liquidity to the market. For instance, Municipal Market Advisors projects that extending the 2 percent de minimis rule to banks would increase their municipal debt purchasing power by $56 billion. Additional demand will enable municipalities across the nation, and particularly those in small and rural communities, to finance the critical infrastructure projects that play an important role in growing our national economy.

Ten national organizations representing state and local governments are supporting the Act. I urge my colleagues to do the same.

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

Mr. President, as I understand it, we now have 10 minutes equally divided to complete debate on S. 22, and then there will be a vote on passage. Is that correct?

Mr. President, in just a few minutes, the Senate will vote on S. 22, the Omnibus Public Land Management Act. The vote will culminate years of work on more than 160 bills that are included in this package and represents a major achievement for the protection of our Nation's natural, cultural, and historic resources. Taken collectively, I believe the package represents the most significant conservation legislation passed by the Senate in many years.

In addition, it will finally resolve three very important, very complex water rights settlements in three different States ending, literally, decades of litigation and controversy.

Amendments Nos. 23 and 24, en bloc

Before concluding, I wish to take care of a few administrative matters. The unanimous consent agreement for the bill today allows for the adoption of managers' amendments if they have been cleared by the managers and leaders on both sides. We have two such amendments which are at the desk. I understand they have been cleared by all my colleagues. These amendments make a number of technical, clerical, and clarifying corrections.

At this time I ask unanimous consent to call up those two amendments and have them considered and adopted en bloc, as provided for in the unanimous consent agreement.

Madam President, I ask unanimous consent that the reading of the amendments be dispensed with.

Madam President, the Senate is now considering the Omnibus Public Land Management Act of 2009, S. 22, a bill that contains a number of important water resource initiatives. Given the ongoing need to work closely with the states on water resource issues, I believe it important as chairman of the Energy and Natural Resources Committee for myself, and the new ranking member of the Committee, to acknowledge the hard work of representatives from the Colorado River Basin States of New Mexico, Colorado, Utah, Wyoming, Arizona, Nevada, and California, in reaching agreement regarding certain provisions in title X, subtitle B of S. 22, which contains the Northwestern New Mexico Rural Water Projects Act, hereafter referred to as the ``Act''.

On August 27, 2008, the Governors' representatives on Colorado River Operations sent a letter to me and Senator Domenici, then the ranking member of the committee, requesting certain modifications to the Northwestern New Mexico Rural Water Projects Act. These modifications, which were subsequently incorporated, reflect the joint

consideration, input, and understandings of the Governors' representatives from the Basin States concerning the act and how it relates to the interstate compacts for the Colorado River system. I want to congratulate the representatives on reaching agreement regarding what I recognize are complicated legal and operational issues associated with the Colorado River.

Madam President, I ask unanimous consent that the August 27, 2008, letter be printed in the Record.

The Senator from Colorado is correct.

Madam President, I concur in the statements made by the Senator from Colorado and thank him for working carefully with me and my staff to resolve these issues in a way that will ensure protection of park resources and provide for the continued operation of the Grand River Ditch and the Colorado-Big Thompson Projects.

Madam President, earlier today the Senate passed S. 22, the Omnibus Public Lands Management Act of 2009. As I said during the debate, S. 22 includes over 160 bills from the Committee on Energy and Natural Resources and reflects many years of hard work.

This achievement would not have been possible without the hard work of our outstanding staff. Both our ranking member, Senator Murkowski, and I are very fortunate to have a very dedicated and experienced professional staff. They service the committee and the Senate well. They deserve our thanks.

On the Democratic staff of the committee, I would like to thank the committee's staff director, Bob Simon, and chief counsel, Sam Fowler, for all of their work on this legislation, as on all the legislation that comes through our committee. I would also like to thank senior counsel Patty Beneke; counsel Mike Connor, who worked on all of the water issues included in the bill; counsels David Brooks, Kira Finkler, and Scott Miller, who coordinated all of the park and public lands bills; professional staff members Jorge Silva-Banuelos, who worked very hard on many of the New Mexico land bills; and Jonathan Epstein; and two National Park Service fellows, Karl Cordova, who worked on the committee last year, and Mike Gauthier, who is on the staff for the current year.

I would also like to thank the committee's chief clerk, Mia Bennett; executive assistant Amanda Kelly; communications director Bill Wicker; press secretary David Marks; and staff assistants Rachel Pasternack, Gina Weinstock, and Rosemarie Calabro.

On the Republican side, let me acknowledge Senator Murkowski's new staff director, McKie Campbell, and chief counsel Karen Billups. I would also like to note my thanks to former Senator Domenici's staff director during the previous Congress, Frank Macchiarola; and former minority chief counsel, Judy Pensabene. I would also like to recognize counsel Kellie Donnelly; as well as professional staff members Frank Gladics, Josh Johnson, and Tom Lillie, all of whom made significant contributions to this bill.

In addition, I am very grateful to the committee's nondesignated staff: Anna-Kristina Fox, Dawson Foard, Nancy Hall, Amber Passmore, Monica Chestnut, and Wanda Green.

S. 22 contains over 1,200 pages of text, and was the subject of numerous revisions. I am grateful to the help of the Senate legislative counsel office, and Gary Endicott, Heather Burnham, and Colin Campbell in particular.

I would also like to thank Cliff Isenberg from the Senate Budget Committee for his help as well as Deb Reis from the Congressional Budget Office, and Tyler Kruzich, formerly with CBO.

Finally, let me acknowledge the great help in bringing the bill to the floor we received from the majority leader and his staff: Neil Kornze, Chris Miller, Randy DeValk, Gary Myrick, and, as always, the secretary for the majority, Lula Davis, as well as Tim Mitchell, the assistant secretary for the majority. I would also like to thank the cloakroom staff, Joe Lapia, Meredith Mellody, Brandon Durflinger, and Estaban Galvan, for all of their assistance.

All of these fine staff members had a hand in putting S. 22 together and moving it through the legislative process. We would not have been able to pass the bill without their hard work and their professionalism. I wish to thank each and every one of them for their good work.

Madam President, this package would not have been possible without the dedicated work of the majority leader over the past several months. I wish to particularly thank him for his commitment to calling up this bill early in this Congress and proceeding with it. I wish to also acknowledge the excellent work and energy of the Natural Resources Committee's new ranking minority member Ms. Murkowski. We have been able to work together to develop a truly bipartisan combination of bills which is reflected in the broad support for this package. Of course, I wish to acknowledge the role of Senator Domenici, who was the ranking member in the prior Congress, for his hard work that also is reflected in this legislation.

I wish to also recognize the work of three of our subcommittee chairmen and ranking members: Senators Akaka and Burr on the National Parks Subcommittee, Senators Wyden and Barrasso from the Public Lands and Forests Subcommittee, Senator Johnson and Senator Corker of the Water and Power Subcommittee. Most of the hearings for the bills in this package were held in those subcommittees. These Senators laid much of the groundwork for today's vote. Of course, I wish to recognize Chairman Rahall of the House Natural Resources Committee for all his work and the work of his staff to resolve any differences that could have existed with the other body.

We have had superb staff work in developing this legislation. Let me particularly mention David Brooks, Kara Finkler and, of course, our staff director, Bob Simon, as well as Sam Fowler, the counsel for our Energy and Natural Resources staff; also, Mike Connor, who worked very hard on many of the water provisions contained in the legislation; Scott Miller, who worked on many of the forest-related sections of this legislation. I know Senator Murkowski and, prior to her, Senator Domenici, also had excellent staff work on the Republican side, which resulted in this legislation coming together in a bipartisan fashion.

So I will put a more complete statement acknowledging the great work of members of our committee staff in the Record and elaborate on that as the day proceeds, but I do wish to mention them now.

Madam President, I see my colleague from Oklahoma is here to speak. How much time remains on the two sides? I know he has 5 minutes. Is there any time remaining on our side?

I yield the floor.

Madam President, I suggest the absence of a quorum.

Madam President, I ask for the yeas and nays.

Mr. President, I ask unanimous consent that the Committee on Armed Services be authorized to meet during the session of the Senate on Thursday, January 15, 2008, at 9:30 a.m.

Mr. President, I ask unanimous consent that the Committee on Banking, Housing, and Urban Affairs be authorized to meet during the session of the Senate on January 15, 2009, at 10 a.m.

Mr. President, I ask unanimous consent that the Committee on Energy and Natural Resources be authorized to meet during the session of the Senate to conduct a hearing on Thursday, January 15, 2009, at 9:30 a.m., in room SD-366 of the Dirksen Senate Office Building.

Mr. President, I ask unanimous consent that the Committee on Finance be authorized to meet during the session of the Senate on Thursday, January 15, 2009, at 11:15 a.m., in room 215 of the Dirksen Senate Office Building.

Mr. President, I ask unanimous consent that the Committee on Foreign Relations be authorized to meet during the session of the Senate on Thursday, January 15, 2009, at 9:45 a.m., to hold a nomination hearing for the Honorable Susan E. Rice.

Mr. President, I ask unanimous consent that the Committee on Health, Education, Labor, and Pensions be authorized to meet, during the session of the Senate, to conduct a hearing entitled ``Investing in Health IT: A Stimulus for a Healthier America'' on Thursday, January 15, 2009. The hearing will commence at 10 a.m. in room 430 of the Dirksen Senate Office Building.

Mr. President, I ask unanimous consent that the Committee on Homeland Security and Governmental Affairs be authorized to meet during the session of the Senate on Thursday, January 15, 2009, at 10 a.m.

Mr. President, I ask unanimous consent that the Committee on Indian Affairs be authorized to meet on Thursday, January 15, 2009 at 2:30 p.m. in room 628 of the Dirksen Senate Office Building to conduct an oversight hearing on Job Creation and Economic Stimulus in Indian Country.

Mr. President, I ask unanimous consent that the Senate Committee on the Judiciary be authorized to meet during the session of the Senate, to conduct a hearing on the nomination of Eric H. Holder, Jr., to be Attorney General of the United States on Thursday, January 15, 2009, at 9:30 a.m., in room SR-325 of the Russell Senate Office Building.

Mr. President, I suggest the absence of a quorum and ask unanimous consent that the quorum call time be charged equally between the two sides.

Mr. President, how much time remains on both sides?

Mr. President, shortly, the Senate will vote on cloture on S. 22, the Omnibus Public Lands Act. I obviously support going ahead with cloture on that legislation. Let me explain briefly why and then respond to a few of the points that my colleague from Oklahoma made.

Yesterday, we did spend several hours trying to determine if it was possible to develop a unanimous consent agreement so that we could have a couple of votes today on amendments that the Senator from Oklahoma has proposed. Despite good-faith efforts on both sides, we were unable to reach that agreement. I appreciate Senator Coburn's willingness to work with us. Also, I appreciate Senator Murkowski's involvement in those discussions.

I have spoken at some length earlier this week about this package of bills, so I will not repeat the details that I talked about before, but I would like to briefly summarize the bill.

This legislation contains over 160 separate public land and related bills, with roughly an equal number of provisions sponsored by Democratic and Republican Senators. Apart from the bipartisan makeup of the package, almost all of these bills were considered in the Energy Committee and were reported in our committee after amendment. I should emphasize that there was an extensive process of amending these bills in our committee. They were reported after amendments by unanimous vote. We have made some further modifications to some of these bills in an effort to address any remaining concerns.

S. 22 incorporates 15 new wilderness bills, which combined will result in over 2 million acres of new additions to the National Wilderness Preservation System in nine different States. It will add over 1,000 miles of new rivers to the National Wild and Scenic Rivers System. It will add over 2,800 miles to the National Trails System. It will add three new units to the National Park System and enlarge the boundary of over a dozen existing parks. It will designate a new national monument, three new national conservation areas, and legislatively establish the Bureau of Land Management's National Landscape Conservation System.

The bill will protect over 1 million acres of the Wyoming Range for hunting, fishing, and other recreational uses. And to help reduce the catastrophic fire problems of recent years, it authorizes a new forest landscape restoration program.

In addition to the public land components of the package, the bill will ratify three extremely important water rights settlements. Those are located in California, in Nevada, and in my home State of New Mexico. The legislation related to those settlements will end literally decades of litigation. And it includes many other land and water authorizations to help local communities throughout the country but especially in Western States.

Despite the scope of the conservation measures included in the package, it is not, as some have suggested, inconsistent with our national energy policy. I heard my colleague indicate that in his view this legislation in total would--I believe the phrase he used was-- markedly undermine energy independence in our country. I strongly disagree with that characterization of what we are doing. Almost none of the wilderness areas designated by the bill are in areas with significant energy development potential.

As to the one area which does contain energy potential--that is the Wyoming Range Legacy Act legislation--let me give some details as to that legislation. The legislation seeks to protect from future oil and gas activity lands in the Wyoming Range not currently under lease. As of November 6, 2007, there were 18 oil and gas leases within the proposed withdrawal area. Those leases cover a total of 70,600 acres. These leases represent valid existing rights and will not in any way be canceled by this legislation. The leases are primarily located in the area that has some of the most significant mineral development potential.

In addition to those oil and gas leases, there are 35 oil and gas leases covering 44,977 acres that have either been issued and are under protest or have been sold but not yet issued. This bill, again, does not in any way cancel or impede development of those leases.

Under the estimated U.S. Geological Survey's estimates, they believe the natural gas potential for the area is 1.5 trillion cubic feet, and the mean oil potential is 5 million barrels. Relative to other known gas reserves in the area, the numbers are smaller in both size and scope.

There are approximately 4,300 producing oil and gas wells in the three counties that are touched by this legislation. There is a proposal being considered for up to 4,339 additional wells that would not be affected by the legislation. There is production currently taking place nearby that will not be stopped by the provisions here.

We had the Congressional Budget Office look at this, and they have issued a statement which I will quote for information of Senators. When they refer to S. 2229, that is the legislation that is incorporated in this bill. They say:

Based on information from the U.S. Forest Service and the

Bureau of Land Management, CBO estimates that enacting S.

2229 would have no significant effect on the Federal budget.

Under the current law, CBO anticipates that neither agency

will offer to sell mineral leases or other interests in land

that would be withdrawn by the bill within the next 10 years;

hence, we anticipate no foregone receipts from sales of such

interests over the period of 2009 through 2018.

So as I was saying, the legislation, in my view, does not markedly undermine energy independence, it does very little to impede our ability to develop oil and gas resources, and this is a piece of legislation that is strongly supported by the Senators from Wyoming, it is strongly supported by the Governor of Wyoming, and it is legislation that I myself support as well.

Several Senators have previously spoken about the many years they have spent working on some of the provisions in this package. Especially in the West, there are few issues as complex and difficult to resolve as land and water use issues. Given the years of work invested by interested citizens and communities, by State and local governments and by individual Senate delegations to address and resolve the many competing issues, it is time to bring these issues to closure. There has been an extensive public process for the individual bills contained in this package, both locally and in the Congress, with almost all receiving the unanimous approval of our committee, the Energy and Natural Resources Committee, which has jurisdiction over these matters.

For all these reasons, I urge my colleagues to vote to invoke cloture this morning on S. 22, the Omnibus Public Lands Act, so we can advance this long overdo legislation forward for Senate approval.

Mr. President, how much time remains for the majority?

Mr. President, at this time, I yield the remainder of my

time to my colleague, the Senator from Alaska, Ms. Murkowski.

Mr. President, the time of 10:30 is about to arrive. I yield my time. The yeas and nays have already been ordered or are they mandatory?

Cloture Motion

Mr. President, I suggest the absence of a quorum.

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

Mr. President, I ask unanimous consent to proceed as in morning business.

Mr. President, I am here today to speak about the growing violence in Gaza. I support the United Nations Security Council resolution calling for an immediate and durable cease-fire. In my view, both the Israeli airstrikes and the Palestinian rocket attacks must stop immediately, and Israeli ground forces should withdraw from Gaza. I regret that President Bush chose to have the United States be the only Security Council member not to support this U.N. resolution.

I ask unanimous consent that the full text of the U.N. resolution be printed in the Record.

Last week, the Senate responded to the hostilities by passing S. Res. 10, a resolution that I do not support. While I agree with some parts of the resolution, I believe it left out important provisions. The resolution called for Hamas to end the rocket and mortar attacks but it did not call on Israel to stop its airstrikes and ground assault. Nor did the resolution call on Israel to withdraw from Gaza. Moreover, I believe the resolution downplayed the humanitarian situation in Gaza. Thousands of people in Gaza do not have access to food, clean water, or medical care. The U.K. Foreign Minister, David Miliband, speaking about humanitarian conditions in Gaza said, ``the word `crisis', which is sometimes overused, is wholly appropriate'' to describe how bad things are. He made that statement to describe how bad he saw that things are at this time.

I support Israel's right to defend itself. Israel has no stronger ally than the United States, and we have no better friend in the region than Israel. But friends can make mistakes.

The rocket attacks that Israel has suffered are unacceptable. But I believe Israel's use of force has been excessive and I do not believe it will help Israel achieve its long-term goals. Instead of weakening Hamas, the incursion is boosting support for Hamas both among Palestinians and the Arabic world and it is undermining support for moderates in the region. Instead of making Israel's enemies fear its military power, I believe this conflict shows its enemies that they can taunt Israel into reacting so strongly that it undermines its international support. Instead of rebutting the accusations that Israel has ignored the long-deepening humanitarian crisis in Gaza, the growing death toll and worsening living conditions will fuel similar accusations long into the future.

This violence is but another chapter of violence in the long history of the Middle East. What is needed is an international effort to broker an immediate truce and to build that into a lasting peace.

A lasting peace requires a two-state solution. It is hard to see how such an agreement can be achieved without the deep involvement and leadership of the United States. I have been disappointed that the Bush administration has failed to lead the peace process for the past 8 years. President Obama should not repeat that mistake after he takes office next week. He should appoint a special envoy to the region soon after his Secretary of State is confirmed by the Senate. President Obama should commit his administration to a steady and persistent effort to engage both Israelis and Palestinians in finding a political solution to the conflict that has long plagued this region.

Exhibit 1

Resolution 1860 (2009)

Adopted by the Security Council at its 6063rd meeting, on 8 January

2009

The Security Council,

Recalling all of its relevant resolutions, including

resolutions 242 (1967), 338 (1973), 1397 (2002), 1515 (2003)

and 1850 (2008),

Stressing that the Gaza Strip constitutes an integral part

of the territory occupied in 1967 and will be a part of the

Palestinian state,

Emphasizing the importance of the safety and well-being of

all civilians,

Expressing grave concern at the escalation of violence and

the deterioration of the situation, in particular the

resulting heavy civilian casualties since the refusal to

extend the period of calm; and emphasizing that the

Palestinian and Israeli civilian populations must be

protected,

Expressing grave concern also at the deepening humanitarian

crisis in Gaza,

Emphasizing the need to ensure sustained and regular flow

of goods and people through the Gaza crossings,

Recognizing the vital role played by UNRWA in providing

humanitarian and economic assistance within Gaza,

Recalling that a lasting solution to the Israeli-

Palestinian conflict can only be achieved by peaceful means,

Reaffirming the right of all States in the region to live

in peace within secure and internationally recognized

borders,

1. Stresses the urgency of and calls for an immediate,

durable and fully respected ceasefire, leading to the full

withdrawal of Israeli forces from Gaza;

2. Calls for the unimpeded provision and distribution

throughout Gaza of humanitarian assistance, including of

food, fuel and medical treatment;

3. Welcomes the initiatives aimed at creating and opening

humanitarian corridors and other mechanisms for the sustained

delivery of humanitarian aid;

4. Calls on Member States to support international efforts

to alleviate the humanitarian and economic situation in Gaza,

including through urgently needed additional contributions to

UNRWA and through the Ad Hoc Liaison Committee;

5. Condemns all violence and hostilities directed against

civilians and all acts of terrorism;

6. Calls upon Member States to intensify efforts to provide

arrangements and guarantees in Gaza in order to sustain a

durable ceasefire and calm, including to prevent illicit

trafficking in arms and ammunition and to ensure the

sustained reopening of the crossing points on the basis of

the 2005 Agreement on Movement and Access between the

Palestinian Authority and Israel; and in this regard,

welcomes the Egyptian initiative, and other regional and

international efforts that are under way;

7. Encourages tangible steps towards intra-Palestinian

reconciliation including in support of mediation efforts of

Egypt and the League of Arab States as expressed in the 26

November 2008 resolution, and consistent with Security

Council resolution 1850 (2008) and other relevant

resolutions;

8. Calls for renewed and urgent efforts by the parties and

the international community to achieve a comprehensive peace

based on the vision of a region where two democratic States,

Israel and Palestine, live side by side in peace with secure

and recognized borders, as envisaged in Security Council

resolution 1850 (2008), and recalls also the importance of

the Arab Peace Initiative;

9. Welcomes the Quartet's consideration, in consultation

with the parties, of an international meeting in Moscow in

2009;

10. Decides to remain seized of the matter.

Mr. President, I yield the floor and suggest the absence of a quorum.

Mr. President I rise today with my colleague Senator Akaka to introduce legislation today designed to make several very important changes to current law to ensure that U.S. citizens receive the Medicaid to which they are entitled.

Since July 1, 2006, most U.S. citizens and nationals applying for or renewing their Medicaid coverage face a new Federal requirement to provide documentation of their citizenship status. Recent reports indicate that tens-of-thousands of U.S. citizens, and in particular children, inappropriately are being denied Medicaid benefits simply because they don't have access to newly required documentation. The articles below and report by the Center on Budget and Policy Priorities highlight this very serious problem. Hospitals, physicians, and pharmacies may not be willing to treat these individuals until they have a source of payment, but they cannot qualify for Medicaid until they produce a birth certificate and ID.

This new Federal requirement was added to Medicaid by the Deficit Reduction Act of 2005, DRA, enacted February 8, 2006. The Tax Relief and Health Care Act of 2006, TRHCA, signed into law December 20, 2006, included some amendments to the DRA citizenship documentation requirement, primarily to exempt certain groups. Prior to enactment of the DRA, states were permitted to use their discretion in requiring such citizenship documentation.

Under Section 6036 of the DRA, citizens applying for or renewing their Medicaid coverage must provide ``satisfactory documentary evidence of citizenship or nationality.'' The DRA specifies documents that are acceptable for this purpose and authorizes the HHS Secretary to designate additional acceptable documents. No Federal matching funds are available for services provided to individuals who declare they are citizens or nationals unless the state obtains satisfactory evidence of their citizenship or determines that they are subject to a statutory exemption.

According to a CRS Report for Congress updated April 15, 2008, ``Based on a recent survey by the Government Accountability Office, GAO, 22 of 44 states report declines in enrollment due to the new citizenship documentation requirement. Based on another survey by the Kaiser Commission on Medicaid and the Uninsured, 13 states report a significant negative impact on enrollment and another 24 states report a modest impact. Among seven states detailed in an earlier report from the Center on Budget and Policy Priorities, only Wisconsin has a data system that

can identify denials and terminations due to a lack of citizenship documentation, and it reports that about 19,000 people had their Medicaid eligibility denied or terminated for this reason between July 31, 2006, and March 1, 2007.''

A second wave study conducted from September 2007-March 2008 by the Department of Health Policy at the George Washington University School of Public Health published October 2008, ``Another distressing finding is the impact the citizenship documentation requirements appear to be having on SCHIP. Many states, for important reasons, use joint applications for both Medicaid and separate SCHIP programs. The effect, however, is to apply the citizenship documentation requirements to both programs, thereby delaying coverage for both groups of children.''

``Even if most or all of the reported Medicaid enrollment declines are due to the citizenship documentation requirement, a key question is whether the people who are being denied, terminated, or deterred from applying are U.S. citizens, rather than unauthorized aliens or other ineligible noncitizens. Of the 22 states reporting enrollment declines to GAO, a majority (16 states) attribute them to Medicaid coverage delays or losses for people who appear to be U.S. citizens.''

It is important to note that citizenship documentation requirements do not affect Medicaid rules relating to immigrants--they apply to individuals claiming to be citizens. Most new legal immigrants are excluded from Medicaid during their first five years in the U.S. and undocumented immigrants remain eligible for Medicaid emergency services only.

The legislation I am introducing would make several very important changes to current law to ensure that U.S. citizens receive the Medicaid to which they are entitled.

First, the legislation would restore citizenship verification to a state option. Specifically, states would be permitted to determine when and to what extent citizenship verification is required of U.S. Citizens. States would also be permitted to utilize the standards most appropriate to the their population as long as such standards were no more stringent than those currently used by the Social Security Administration and includes native American tribal documents when appropriate.

Second, the legislation would ensure that individuals are afforded a reasonable time period to provide citizenship documentation utilizing the same reasonable time period standard that is available to legal immigrants to provide satisfactory evidence of their immigration status.

Third, the legislation protects children who are U.S. citizens by virtue of being born in the United States from being denied coverage after birth because of citizenship verification requirements.

Fourth, the legislation also clarifies ambiguities in Federal law to ensure that these citizen children, regardless of the immigration status of their parents, are treated like all other low-income children born in the United States and are deemed eligible to receive Medicaid services for one year.

Finally, the legislation also ensures that the thousands of citizen children and adults, who were erroneously denied Medicaid coverage, may receive retroactive Medicaid eligibility for coverage they were inappropriately denied because of citizenship verification requirements.

I urge my colleagues in the Senate to support this critical legislation, which protects low-income U.S. citizens from being inappropriately denied Medicaid coverage because of lack of documentation.

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

Mr. President I rise today with my colleague Senator Akaka to introduce legislation today designed to make several very important changes to current law to ensure that U.S. citizens receive the Medicaid to which they are entitled.

Since July 1, 2006, most U.S. citizens and nationals applying for or renewing their Medicaid coverage face a new Federal requirement to provide documentation of their citizenship status. Recent reports indicate that tens-of-thousands of U.S. citizens, and in particular children, inappropriately are being denied Medicaid benefits simply because they don't have access to newly required documentation. The articles below and report by the Center on Budget and Policy Priorities highlight this very serious problem. Hospitals, physicians, and pharmacies may not be willing to treat these individuals until they have a source of payment, but they cannot qualify for Medicaid until they produce a birth certificate and ID.

This new Federal requirement was added to Medicaid by the Deficit Reduction Act of 2005, DRA, enacted February 8, 2006. The Tax Relief and Health Care Act of 2006, TRHCA, signed into law December 20, 2006, included some amendments to the DRA citizenship documentation requirement, primarily to exempt certain groups. Prior to enactment of the DRA, states were permitted to use their discretion in requiring such citizenship documentation.

Under Section 6036 of the DRA, citizens applying for or renewing their Medicaid coverage must provide ``satisfactory documentary evidence of citizenship or nationality.'' The DRA specifies documents that are acceptable for this purpose and authorizes the HHS Secretary to designate additional acceptable documents. No Federal matching funds are available for services provided to individuals who declare they are citizens or nationals unless the state obtains satisfactory evidence of their citizenship or determines that they are subject to a statutory exemption.

According to a CRS Report for Congress updated April 15, 2008, ``Based on a recent survey by the Government Accountability Office, GAO, 22 of 44 states report declines in enrollment due to the new citizenship documentation requirement. Based on another survey by the Kaiser Commission on Medicaid and the Uninsured, 13 states report a significant negative impact on enrollment and another 24 states report a modest impact. Among seven states detailed in an earlier report from the Center on Budget and Policy Priorities, only Wisconsin has a data system that

can identify denials and terminations due to a lack of citizenship documentation, and it reports that about 19,000 people had their Medicaid eligibility denied or terminated for this reason between July 31, 2006, and March 1, 2007.''

A second wave study conducted from September 2007-March 2008 by the Department of Health Policy at the George Washington University School of Public Health published October 2008, ``Another distressing finding is the impact the citizenship documentation requirements appear to be having on SCHIP. Many states, for important reasons, use joint applications for both Medicaid and separate SCHIP programs. The effect, however, is to apply the citizenship documentation requirements to both programs, thereby delaying coverage for both groups of children.''

``Even if most or all of the reported Medicaid enrollment declines are due to the citizenship documentation requirement, a key question is whether the people who are being denied, terminated, or deterred from applying are U.S. citizens, rather than unauthorized aliens or other ineligible noncitizens. Of the 22 states reporting enrollment declines to GAO, a majority (16 states) attribute them to Medicaid coverage delays or losses for people who appear to be U.S. citizens.''

It is important to note that citizenship documentation requirements do not affect Medicaid rules relating to immigrants--they apply to individuals claiming to be citizens. Most new legal immigrants are excluded from Medicaid during their first five years in the U.S. and undocumented immigrants remain eligible for Medicaid emergency services only.

The legislation I am introducing would make several very important changes to current law to ensure that U.S. citizens receive the Medicaid to which they are entitled.

First, the legislation would restore citizenship verification to a state option. Specifically, states would be permitted to determine when and to what extent citizenship verification is required of U.S. Citizens. States would also be permitted to utilize the standards most appropriate to the their population as long as such standards were no more stringent than those currently used by the Social Security Administration and includes native American tribal documents when appropriate.

Second, the legislation would ensure that individuals are afforded a reasonable time period to provide citizenship documentation utilizing the same reasonable time period standard that is available to legal immigrants to provide satisfactory evidence of their immigration status.

Third, the legislation protects children who are U.S. citizens by virtue of being born in the United States from being denied coverage after birth because of citizenship verification requirements.

Fourth, the legislation also clarifies ambiguities in Federal law to ensure that these citizen children, regardless of the immigration status of their parents, are treated like all other low-income children born in the United States and are deemed eligible to receive Medicaid services for one year.

Finally, the legislation also ensures that the thousands of citizen children and adults, who were erroneously denied Medicaid coverage, may receive retroactive Medicaid eligibility for coverage they were inappropriately denied because of citizenship verification requirements.

I urge my colleagues in the Senate to support this critical legislation, which protects low-income U.S. citizens from being inappropriately denied Medicaid coverage because of lack of documentation.

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