Floor Statements

Mr. President, I believe that perhaps the most effective way to improve the education of our children is to invest in their teachers, and make certain that quality teachers have the incentive to stay in the classroom.

Unfortunately, without new investments, our disadvantaged and rural schools may not be able to attract the qualified teachers needed to prepare our children for the 21st Century workplace. Isolated and impoverished, too many West Virginia schools must compete against higher paying, well-funded schools for scarce classroom talent. As a result, they face a shortage of qualified teachers, particularly in math, science and foreign languages.

Today, I am introducing a bill designed to invest in bringing dedicated and qualified teaching professionals to West Virginia and America's disadvantaged and rural schools. This bill will help give students the opportunity to learn and flourish, an opportunity that every child deserves. The Incentives To Educate American Children Act-- or I Teach Act--will provide teachers with a refundable tax credit every year they teach in the public schools with the most need. And it will give every public school teacher--regardless of the school they choose--a refundable tax credit for earning their certification by the National Board for Professional

Teaching Standards. Together, these two tax credits will give economically depressed areas a better ability to recruit and retain skilled teachers.

There are over 16,000 rural school districts in the U.S., and these schools face real challenges in recruiting and retaining teachers, as well as dealing with other issues related to their rural location. Disadvantaged urban schools must overcome similar difficulties. My I Teach Act will reward teachers willing to work in rural or disadvantaged schools with an annual $1,000 refundable tax credit. Additionally, teachers that obtain certification by the National Board for Professional Teaching Standards will receive an annual $1,000 refundable tax credit. Therefore, teachers who work in rural or disadvantaged schools and get certified will earn a $2000 credit. Schools that desperately need help attracting teachers will get a boost, and children educated in disadvantaged and rural schools will benefit most.

In my state of West Virginia, as in over 30 other states, there is already a state fiscal incentive for teachers who earn National Board certification. My legislation builds upon the West Virginia program. Together, they will create a powerful tax incentive for teachers to remain in the classroom and to use their skills where they are most needed.

Education is among our top national priorities. It is essential for all children and it is vital for our economic and national security. Teachers are a critical component of quality education, and they deserve the incentives to stay in the classroom.

Mr. President, I rise today to introduce legislation that will guarantee that Medicaid remains available as a critical safety-net for working families in the event of another economic downturn. Medicaid is consistently the first program slated for cuts during a State budget crisis. My legislation would establish an automatic trigger for a temporary FMAP increase so that state Medicaid assistance becomes available in a timely and targeted manner during significant economic challenges.

State cutbacks during the 2001-2003 recession eliminated public health coverage for more than one million Americans. According to the Kaiser Commission on Medicaid and the Uninsured, between fiscal years 2002 and 2005, the loss of revenue led all 50 States to reduce Medicaid provider payment rates and implement prescription drug cost controls, 38 States to reduce Medicaid eligibility and 34 States to reduce benefits. Many more Americans would have lost coverage if Congress had not provided states with $20 billion in Federal aid in 2003.

Now, once again, the country is facing economic challenges unlike anything else we have faced since the Great Depression. Fortunately, the American Recovery and Reinvestment Act, ARRA, included $87 billion in Federal Medicaid relief for States. It is estimated that through this temporary FMAP increase, my State of West Virginia will receive nearly $450 million in

Federal funding over the next 2 years to help meet the existing and growing enrollment needs in Medicaid. This temporary FMAP increase will protect the health care coverage of nearly 400,000 West Virginians, and approximately 58 million Americans, as this country works to pull itself out of the current economic recession.

After the last economic downturn, I joined a bipartisan group of my colleagues in requesting that the Government Accountability Office, GAO, study and report on options to protect Medicaid during future recessions. In response to this request, the GAO issued a report GAO- 07-97, entitled Medicaid: Strategies to Help States Address Increased Expenditures during Economic Downturn and developed a State and local government model that can simulate the fiscal outcomes for this sector in the aggregate for several decades into the future.

The legislation I am introducing today is based on the findings of this GAO study. As we have seen in the past two recessions, waiting for Congress to act to provide necessary Federal Medicaid relief results in harmful delays in families getting the assistance they need. I believe that there should be an automatic economic trigger for State fiscal relief--independent of Congressional intervention--during future recessions. My legislation would create such a trigger for a temporary FMAP increase.

State fiscal relief would become available when the average unemployment rate has increased by at least 10 percent in at least 23 States. This type of automatic trigger would provide states with the timely, targeted, and temporary Federal Medicaid assistance that they need in the face of a significant economic downturn. More importantly, it would help Americans maintain access to health care in tough times.

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

Mr. President, I believe that perhaps the most effective way to improve the education of our children is to invest in their teachers, and make certain that quality teachers have the incentive to stay in the classroom.

Unfortunately, without new investments, our disadvantaged and rural schools may not be able to attract the qualified teachers needed to prepare our children for the 21st Century workplace. Isolated and impoverished, too many West Virginia schools must compete against higher paying, well-funded schools for scarce classroom talent. As a result, they face a shortage of qualified teachers, particularly in math, science and foreign languages.

Today, I am introducing a bill designed to invest in bringing dedicated and qualified teaching professionals to West Virginia and America's disadvantaged and rural schools. This bill will help give students the opportunity to learn and flourish, an opportunity that every child deserves. The Incentives To Educate American Children Act-- or I Teach Act--will provide teachers with a refundable tax credit every year they teach in the public schools with the most need. And it will give every public school teacher--regardless of the school they choose--a refundable tax credit for earning their certification by the National Board for Professional

Teaching Standards. Together, these two tax credits will give economically depressed areas a better ability to recruit and retain skilled teachers.

There are over 16,000 rural school districts in the U.S., and these schools face real challenges in recruiting and retaining teachers, as well as dealing with other issues related to their rural location. Disadvantaged urban schools must overcome similar difficulties. My I Teach Act will reward teachers willing to work in rural or disadvantaged schools with an annual $1,000 refundable tax credit. Additionally, teachers that obtain certification by the National Board for Professional Teaching Standards will receive an annual $1,000 refundable tax credit. Therefore, teachers who work in rural or disadvantaged schools and get certified will earn a $2000 credit. Schools that desperately need help attracting teachers will get a boost, and children educated in disadvantaged and rural schools will benefit most.

In my state of West Virginia, as in over 30 other states, there is already a state fiscal incentive for teachers who earn National Board certification. My legislation builds upon the West Virginia program. Together, they will create a powerful tax incentive for teachers to remain in the classroom and to use their skills where they are most needed.

Education is among our top national priorities. It is essential for all children and it is vital for our economic and national security. Teachers are a critical component of quality education, and they deserve the incentives to stay in the classroom.

Mr. President, I rise today to introduce legislation that will guarantee that Medicaid remains available as a critical safety-net for working families in the event of another economic downturn. Medicaid is consistently the first program slated for cuts during a State budget crisis. My legislation would establish an automatic trigger for a temporary FMAP increase so that state Medicaid assistance becomes available in a timely and targeted manner during significant economic challenges.

State cutbacks during the 2001-2003 recession eliminated public health coverage for more than one million Americans. According to the Kaiser Commission on Medicaid and the Uninsured, between fiscal years 2002 and 2005, the loss of revenue led all 50 States to reduce Medicaid provider payment rates and implement prescription drug cost controls, 38 States to reduce Medicaid eligibility and 34 States to reduce benefits. Many more Americans would have lost coverage if Congress had not provided states with $20 billion in Federal aid in 2003.

Now, once again, the country is facing economic challenges unlike anything else we have faced since the Great Depression. Fortunately, the American Recovery and Reinvestment Act, ARRA, included $87 billion in Federal Medicaid relief for States. It is estimated that through this temporary FMAP increase, my State of West Virginia will receive nearly $450 million in

Federal funding over the next 2 years to help meet the existing and growing enrollment needs in Medicaid. This temporary FMAP increase will protect the health care coverage of nearly 400,000 West Virginians, and approximately 58 million Americans, as this country works to pull itself out of the current economic recession.

After the last economic downturn, I joined a bipartisan group of my colleagues in requesting that the Government Accountability Office, GAO, study and report on options to protect Medicaid during future recessions. In response to this request, the GAO issued a report GAO- 07-97, entitled Medicaid: Strategies to Help States Address Increased Expenditures during Economic Downturn and developed a State and local government model that can simulate the fiscal outcomes for this sector in the aggregate for several decades into the future.

The legislation I am introducing today is based on the findings of this GAO study. As we have seen in the past two recessions, waiting for Congress to act to provide necessary Federal Medicaid relief results in harmful delays in families getting the assistance they need. I believe that there should be an automatic economic trigger for State fiscal relief--independent of Congressional intervention--during future recessions. My legislation would create such a trigger for a temporary FMAP increase.

State fiscal relief would become available when the average unemployment rate has increased by at least 10 percent in at least 23 States. This type of automatic trigger would provide states with the timely, targeted, and temporary Federal Medicaid assistance that they need in the face of a significant economic downturn. More importantly, it would help Americans maintain access to health care in tough times.

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

Mr. President, I rise to recognize that 146 years ago today, West Virginia became the 35th State to join the Union. The only State to have seceded from a Confederate State, West Virginia's birthday shines as an anniversary which commemorates the spirit, perseverance, optimism, and hard work of its people.

West Virginia is unique in countless ways; and her history is just the beginning. For almost 200 years, West Virginians have played a significant role in the development and advancement of our nation. From the Battle of Philippi in Barbour County, which was the first organized land battle of the Civil War, to John Brown's historic raid on the Arsenal in Harpers Ferry, we recognize the role our State has played in the making of America's history.

The only State to lie entirely within the borders of Appalachia, we remain incredibly diverse; our geography, population, and heritage are what have lead to our identity as the ``Wild and Wonderful'' State. From the renowned Greenbrier Hotel and Resort in White Sulphur Springs, to the New River Gorge in Fayetteville, which houses the longest steel- arch bridge in the United States, it is no wonder that we draw tourists here from all over the globe.

But it is not the many historical sites or beautiful landscapes that capture the fortitude of West Virginia, but rather, her people--people who continue to inspire with pride and honor, and overcome challenges with a resolve like no other.

Early last month, flash flooding devastated families throughout southern West Virginia, damaging at least 1,500 homes with the worst flooding the area has seen for quite some time. The humanitarian response within the State has been profoundly moving; with people traveling hours to donate their time and energy to assist their fellow West Virginians, and some 300 National Guard troops posted in the area--proving that goodwill is alive and well in West Virginia. Seeing this outpouring, I was reminded of serious flooding in our State when I was Governor. I opened National Guard armories to house displaced families but none showed up--because their neighbors had taken them in. That is a shining example of our Mountaineer spirit.

In addition to serving the people of our State, the West Virginia National Guard is committed to global security, with 38 active units serving around the world, including in Afghanistan and Kosovo. Our State motto, ``Mountaineers are always free,'' can be found resonating not only in all corners of the Mountain State but across the globe. And it is a motto that West Virginians have stood up for time and again--as our State's veterans are among the bravest, most selfless, and most devoted in the entire Nation.

West Virginians have the amazing ability to make sure our culture-- which we are so proud of--is also part of our future. Ours is a State wrapped in age-old traditions, but also a State with a readiness to adapt to its younger generations; a veritable melting pot of both old and new world. The Ramp Eating Capitol of the World is found in Richwood, where international crowds gathered in April for the annual Ramp Eating Contest to delight in this West Virginia favorite. And artists across our State are finding more innovative ways to market our cultural heritage, from Blenko Glass and amazing woodwork, to folk-art, quilts and Appalachian music.

Our schools, colleges and universities have inspired some of the best and brightest young leaders. West Virginia University and Marshall University have produced some of the greatest minds in some of the toughest fields worldwide, and have played an integral role in supporting the communities they inhabit. The Promise Scholarship, which pays instate collegiate tuition fees for those high school graduates with qualifying academic records, has helped thousands of students afford college since its inception. Thanks to this measure, admission to institutions of higher education in West Virginia has steadily increased, drawing students from across the Nation to study subjects such as biometrics, forensics, and defense.

Native West Virginians often joke that telephone calls placed to God are local, as our State is ``almost'' heaven. We love and are so proud of our awe-inspiring scenery and our towering mountains, and we can't wait to show them off to anyone who visits. And what those visitors also find when they come to our beautiful State is a population well- versed in humility and good-nature. It is indeed the people who pay the greatest tribute to our Mountain State, and it is my honor and privilege today to wish you on their behalf, the happiest of birthdays, West Virginia.

Mr. President, for the Committee on Commerce, Science, and Transportation I report favorably the following nomination lists which were printed in the Records on the dates indicated, and ask unanimous consent, to save the expense of reprinting on the Executive Calendar that these nominations lie at the Secretary's desk for the information of Senators.

Mr. President, I rise today to introduce the Keeping Families Safe Act of 2009 which seeks to keep families together when a parent is in a comprehensive residential family treatment program. Comprehensive residential family treatment is a unique program that serves parents and children together in a safe residential environment as the parent undergoes treatment for substance abuse.

Such programs tend to be small, but their results are impressive. One study found that 60 percent of mothers who participated in the Pregnant and Postpartum Women and Their Infants program were completely clean and sober six months after their discharge. This same study found that 88 percent of these children were still with their mothers six months after the mother was discharged. However, only 5 percent of all substance abuse treatment facilities are able to accommodate children. The goal of this legislation is to offer support and flexibility to such promising programs by allowing children who are in foster care be placed with their parent in the comprehensive residential family treatment center, and bring their foster care payment with them as their placement is transferred. By allowing these funds to follow the child to the residential facility, the chances for that family's success are much greater.

Family based substance abuse treatment centers have proven to be an effective means of treating substance abuse and reuniting families, but most facilities are struggling to make ends meet. Many of the parents in treatment are motivated by the hope of overcoming their addiction and reuniting with their children. This bill is designed to give them that chance, and it will hopefully inspire them by allowing their children to be part of the recovery, in a completely safe environment. I urge my colleagues to support this important legislation to help keep families together and provide another funding source for these promising programs for children and parents.

Mr. President, I rise today to introduce the Keeping Families Safe Act of 2009 which seeks to keep families together when a parent is in a comprehensive residential family treatment program. Comprehensive residential family treatment is a unique program that serves parents and children together in a safe residential environment as the parent undergoes treatment for substance abuse.

Such programs tend to be small, but their results are impressive. One study found that 60 percent of mothers who participated in the Pregnant and Postpartum Women and Their Infants program were completely clean and sober six months after their discharge. This same study found that 88 percent of these children were still with their mothers six months after the mother was discharged. However, only 5 percent of all substance abuse treatment facilities are able to accommodate children. The goal of this legislation is to offer support and flexibility to such promising programs by allowing children who are in foster care be placed with their parent in the comprehensive residential family treatment center, and bring their foster care payment with them as their placement is transferred. By allowing these funds to follow the child to the residential facility, the chances for that family's success are much greater.

Family based substance abuse treatment centers have proven to be an effective means of treating substance abuse and reuniting families, but most facilities are struggling to make ends meet. Many of the parents in treatment are motivated by the hope of overcoming their addiction and reuniting with their children. This bill is designed to give them that chance, and it will hopefully inspire them by allowing their children to be part of the recovery, in a completely safe environment. I urge my colleagues to support this important legislation to help keep families together and provide another funding source for these promising programs for children and parents.

Mr. President, there is a stark choice looming before Congress. It is the choice between enacting a comprehensive reform bill that truly improves our health care system for the American people or enacting a mediocre reform bill that largely maintains the status quo--which is an ineffective and costly health care system run by the insurance industry. I know that most of my colleagues want the former--a 21st Century health care system that provides meaningful and affordable coverage for all, improves health outcomes, and brings accountability and responsibility back into health care.

I am absolutely convinced that the inclusion of a strong public health insurance plan option is the only way to guarantee that all consumers have affordable, adequate, and accountable options available in the insurance marketplace. It is for this reason that I rise today with my good friend, Senator Sherrod Brown of Ohio, to introduce the Consumers Health Care Act of 2009--legislation to provide a strong public plan option in the National Health Insurance Exchange.

One of the most contentious, yet critical, pieces of the national health care reform effort is whether or not Americans should have the option to buy their health insurance from a publicly run organization. In other words, in addition to choosing among numerous health plans run by private insurers, should consumers also have the option of choosing an affordable, stable, and transparent public plan when they are deciding what is best for them and their families? I believe consumers should have the option of choosing a public plan.

Opponents of giving Americans a public option regularly use alarmist rhetoric such as ``big government'' and ``socialized medicine.'' And, somehow, protecting the rights of private health insurers to make profits has become more important to some than offering Americans the choice of a plan that seeks to insure everyone, no matter how sick, that is less expensive, and that is responsible to the American people--not to private profit-seeking stockholders.

I'm not sure when the word ``public'' became such a bad word in the eyes of some of my colleagues. Public means acting in the interest of the general public--which is exactly what we should aspire to in comprehensive health reform.

The private health insurance market has significantly contributed to the broken nature of our health care system, with a long history of cutting coverage off or charging too much for too little. A public plan option--repeat, option--is an effective way to bring competition to the insurance market, hold down costs, and encourage innovation and quality improvements. To deny this option is not only shortsighted, but downright harmful.

Everyone knows the sobering statistics that have highlighted the need for comprehensive health reform. More than 45 million Americans are uninsured and another 25 million are underinsured. Since 1909, the average health insurance premium for a family has increased by 119 percent, from $5,791 in 1999 to $12,680 in 2008. Yet, Americans have seen their benefits decrease and have faced substantially larger out- of-pocket expenses. An estimated 62 percent of all personal bankruptcies involve medical expenses and 78 percent of the individuals who cited medical expenses in their bankruptcy claims had health insurance. Health care costs already consume 17 percent of the United State's gross domestic product, which everyone can agree is unsustainable.

However, representing the great state of West Virginia has shown me that the need for health reform is far more essential and personal than frightening statistics could ever show. I have listened at roundtable discussions where West Virginians described how the current health care system has failed them. One woman was really struggling to care for both herself and her son. She was uninsured because her son, who had a serious brain disorder, needed 24 hour a day, seven day a week, assistance. Another family wrote to me because their son, who was born with serious congenital heart defects, had reached the $1 million limit on his mother's insurance policy within the first nine months of his life. They were unsure of how to obtain lifesaving treatment for their son, now that the insurance company would no longer pay for his care. I have heard from countless other West Virginians who have been unable to find affordable health care, or have figured out too late that the health insurance they had was inadequate for what they needed.

As Congress works to achieve the transformative reform necessary to create a sustainable health care system, a vital component of this reform is the inclusion of a strong public plan option like the Consumer Choice Health Plan included in the Consumers Health Care Act. A public plan will help establish a new insurance framework, one that compels insurers to provide Americans with the best value for their health care at the best price, rather than the current insurance framework, which is focused on avoiding risk and increasing profits. The Consumer Choice Health Plan will be available for all individuals and small businesses, regardless of health status, and will not be concerned with paying a CEO salary or broker commissions.

The Consumers Health Care Act will increase transparency and accountability throughout the health insurance market, as well as give individuals guaranteed access to health care coverage should they be denied or priced out of affordable private insurance coverage. Currently, insurers are allowed to operate in a black box, with little oversight of their coverage and payment decisions. Individuals with pre-existing conditions are routinely denied access to affordable care. For years, United Health was able to underpay providers and overcharge patients for out-of-network services. The Consumers Health Care Act will address this and other issues by bringing greater transparency to the private health insurance market.

Consumer Choice Health Plans will serve as a vital safety-net of coverage for individuals and families that have been unable to obtain affordable and comprehensive health care coverage through the private market. A private insurance company's desire to earn greater profits will always trump over the need to make health care coverage affordable and accessible to all Americans, and greater insurance regulation is not enough. The Consumers Health Care Act is necessary in order to achieve the sustainable change that the health care system in this country needs.

I trust the good sense of the American public to choose the health coverage they want, and they deserve the choice of a public plan with lower costs and the guarantee of always being there when they need it. The American people trust us to get this right and deliver the best coverage options that will keep their families healthy and safe. The days of packaging half-baked legislation into a bill and calling it transformative reform when it is not have to end now, or the shame is on all of us:

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

Mr. President, there is a stark choice looming before Congress. It is the choice between enacting a comprehensive reform bill that truly improves our health care system for the American people or enacting a mediocre reform bill that largely maintains the status quo--which is an ineffective and costly health care system run by the insurance industry. I know that most of my colleagues want the former--a 21st Century health care system that provides meaningful and affordable coverage for all, improves health outcomes, and brings accountability and responsibility back into health care.

I am absolutely convinced that the inclusion of a strong public health insurance plan option is the only way to guarantee that all consumers have affordable, adequate, and accountable options available in the insurance marketplace. It is for this reason that I rise today with my good friend, Senator Sherrod Brown of Ohio, to introduce the Consumers Health Care Act of 2009--legislation to provide a strong public plan option in the National Health Insurance Exchange.

One of the most contentious, yet critical, pieces of the national health care reform effort is whether or not Americans should have the option to buy their health insurance from a publicly run organization. In other words, in addition to choosing among numerous health plans run by private insurers, should consumers also have the option of choosing an affordable, stable, and transparent public plan when they are deciding what is best for them and their families? I believe consumers should have the option of choosing a public plan.

Opponents of giving Americans a public option regularly use alarmist rhetoric such as ``big government'' and ``socialized medicine.'' And, somehow, protecting the rights of private health insurers to make profits has become more important to some than offering Americans the choice of a plan that seeks to insure everyone, no matter how sick, that is less expensive, and that is responsible to the American people--not to private profit-seeking stockholders.

I'm not sure when the word ``public'' became such a bad word in the eyes of some of my colleagues. Public means acting in the interest of the general public--which is exactly what we should aspire to in comprehensive health reform.

The private health insurance market has significantly contributed to the broken nature of our health care system, with a long history of cutting coverage off or charging too much for too little. A public plan option--repeat, option--is an effective way to bring competition to the insurance market, hold down costs, and encourage innovation and quality improvements. To deny this option is not only shortsighted, but downright harmful.

Everyone knows the sobering statistics that have highlighted the need for comprehensive health reform. More than 45 million Americans are uninsured and another 25 million are underinsured. Since 1909, the average health insurance premium for a family has increased by 119 percent, from $5,791 in 1999 to $12,680 in 2008. Yet, Americans have seen their benefits decrease and have faced substantially larger out- of-pocket expenses. An estimated 62 percent of all personal bankruptcies involve medical expenses and 78 percent of the individuals who cited medical expenses in their bankruptcy claims had health insurance. Health care costs already consume 17 percent of the United State's gross domestic product, which everyone can agree is unsustainable.

However, representing the great state of West Virginia has shown me that the need for health reform is far more essential and personal than frightening statistics could ever show. I have listened at roundtable discussions where West Virginians described how the current health care system has failed them. One woman was really struggling to care for both herself and her son. She was uninsured because her son, who had a serious brain disorder, needed 24 hour a day, seven day a week, assistance. Another family wrote to me because their son, who was born with serious congenital heart defects, had reached the $1 million limit on his mother's insurance policy within the first nine months of his life. They were unsure of how to obtain lifesaving treatment for their son, now that the insurance company would no longer pay for his care. I have heard from countless other West Virginians who have been unable to find affordable health care, or have figured out too late that the health insurance they had was inadequate for what they needed.

As Congress works to achieve the transformative reform necessary to create a sustainable health care system, a vital component of this reform is the inclusion of a strong public plan option like the Consumer Choice Health Plan included in the Consumers Health Care Act. A public plan will help establish a new insurance framework, one that compels insurers to provide Americans with the best value for their health care at the best price, rather than the current insurance framework, which is focused on avoiding risk and increasing profits. The Consumer Choice Health Plan will be available for all individuals and small businesses, regardless of health status, and will not be concerned with paying a CEO salary or broker commissions.

The Consumers Health Care Act will increase transparency and accountability throughout the health insurance market, as well as give individuals guaranteed access to health care coverage should they be denied or priced out of affordable private insurance coverage. Currently, insurers are allowed to operate in a black box, with little oversight of their coverage and payment decisions. Individuals with pre-existing conditions are routinely denied access to affordable care. For years, United Health was able to underpay providers and overcharge patients for out-of-network services. The Consumers Health Care Act will address this and other issues by bringing greater transparency to the private health insurance market.

Consumer Choice Health Plans will serve as a vital safety-net of coverage for individuals and families that have been unable to obtain affordable and comprehensive health care coverage through the private market. A private insurance company's desire to earn greater profits will always trump over the need to make health care coverage affordable and accessible to all Americans, and greater insurance regulation is not enough. The Consumers Health Care Act is necessary in order to achieve the sustainable change that the health care system in this country needs.

I trust the good sense of the American public to choose the health coverage they want, and they deserve the choice of a public plan with lower costs and the guarantee of always being there when they need it. The American people trust us to get this right and deliver the best coverage options that will keep their families healthy and safe. The days of packaging half-baked legislation into a bill and calling it transformative reform when it is not have to end now, or the shame is on all of us:

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

Mr. President, once tourists come to West Virginia, they often return. From the Appalachian Trail to the Monongahela National Forest, the beauty of our State is unparalleled and our people are welcoming.

Tourism in West Virginia also creates jobs. As a result, our State spends money to promote West Virginia in the surrounding States as a tourist destination. But we surely would welcome more international tourists as well.

Increasing overseas travel and tourism is a shovel-ready economic stimulus that will create thousands of jobs across the country-- including West Virginia. With the dollar at a low compared to other currencies, America is a bargain. We are open and ready for business. Unfortunately, the rest of the world doesn't know it.

Compared to other countries, the United States fails to effectively advertise and promote itself overseas as a tourism destination. In 1992, the United States attracted 9.4 percent of all international tourists; in 2007, the United States attracted only 6.8 percent. Since 2000, the United States' share of international travelers has declined by 20 percent.

Meanwhile, the rest of the world is promoting itself--often employing the best Madison Avenue techniques used for marketing heart medications and luxury cars. We all see enticing television advertisements to visit Italy, Greece, Jamaica, Ireland, Canada, Australia and Brazil. But few residents of those countries see advertisements enticing them to come to the United States--and to spend their money in the United States.

If the United States had simply kept pace with global travel trends, 58 million more overseas travelers would have visited the United States between 2000 and 2008. Those travelers would have generated 245,000 tourism jobs in 2008 alone.

The average overseas visitor to the United States spends $4,500 per visit. That means every 23,000 overseas visitors pump $100 million into the U.S. economy.

We have spent billions of dollars to prevent the collapse of industries and billions of dollars to put people to work. But today, through the Travel Promotion Act of 2009, just $10 million will plant the seeds for leveraging private sector investment to increase the number of U.S.-based tourism jobs.

Americans always have had a healthy skepticism about the role of government--what it should do and what it shouldn't do. To promote travel and tourism, we have long thought that the private sector--the companies that make money from tourism--should promote themselves. And some of the larger private sector players have promoted their specific interests overseas.

But a private sector effort to fund a general ``Come to America'' campaign targeting overseas travelers has never fully materialized. When a resort or theme park spends advertising money overseas, they want the viewers to visit their destination, not just the United States. Some of our larger States promote themselves overseas. But, as you would expect, the advertisements entice foreigners to visit their States.

As a result, potential tourists overseas may not be aware that the United States has far more to offer than California, New York, and Florida. They likely have never heard of hiking, rafting, or fishing in the mountains of West Virginia. For anyone who has not enjoyed those activities in my State, you are really missing something special.

Because the hotels and tourist destinations of States like West Virginia cannot effectively launch their own international promotional campaigns, we must find a mechanism to pool and leverage resources so that these States become part of the international tourism economy.

After the terrorist attacks of 2001, the subsequent security measures deterred overseas tourists. Many of those entry problems have been corrected now. But the negative perception still remains. Potential foreign tourists still are reluctant to deal with what they believe will be a difficult time entering the United States. No private sector company--and certainly not the hotels and tourist destinations in the States I have mentioned--will spend their own money to promote the improved process for entering the United States. Only a national, coordinated campaign--with some help from the Federal Government--can accomplish that goal.

We have occasionally appropriated one-shot advertising campaigns to promote the United States overseas. But the Travel Promotion Act of 2009 will create a sustained and stable public-private sector partnership in which Federal seed money is leveraged to increase private investment to promote tourism overseas.

The bill would establish a travel promotion fund that is capitalized by a $10 fee paid by foreign travelers from visa-waiver countries. The bill would require the travel industry to match those contributions--50 percent in 2011 and 100 percent thereafter. The fund would receive $10 million in Federal seed money for 2010. The new fee for foreign travelers would cumulatively provide the means to lure them to the United States, but is too small to have any impact on an individual's decision whether to come to the United States.

The funds would be used for overseas advertising campaigns to promote travel to the United States, including to areas not traditionally visited by overseas tourists. More importantly, the advertising campaigns would educate potential foreign travelers about U.S. visa and entry policies. Removing fears about entering the United States would dramatically increase tourism among overseas residents who might consider a range of vacation choices. If foreign tourists better understand U.S. entry and visa policies, the more likely it is that they will come to the United States--and the more likely it is that they will spend their money here, creating the jobs we so desperately need.

Drug companies and luxury automakers spend billions of dollars on advertising for one reason: it works. The State of Florida estimates that its own State travel promotion campaign returns $3 in increased sales tax revenue for every dollar spent on promotion. The countries advertising foreign tourist destinations on American television

every night would not spend the money to do it but for one reason: it works. The United States--with so many spectacular destinations--must embark on its own worldwide promotion program because it will work.

A sustained and stable tourism promotion program is a small investment that will generate huge dividends when foreign tourists spend their money in the United States, generating jobs and local revenue. Foreigners visiting the first time have the potential to become repeat visitors and will tell their friends to visit as well.

In addition to stimulating jobs, we will improve America's image around the world through tourism. People who visit the United States are more likely to have a favorable opinion of America when they return home. Developing that kind of good will in a changing world makes travel promotion worthwhile.

I would like to thank the sponsors of this bill: Senator Dorgan, Senator Inouye, Senator Reid, Senator Klobuchar, Senator Begich, Senator Mikulski, Senator Bennet, Senator Udall of New Mexico, Senator Udall of Colorado, Senator Ensign, Senator Martinez, and Senator Vitter.

America is open for business. The people who work in our tourism industries are ready to work. Now we need to tell the world.

vote explanation

Mr. President, oceans affect human health both directly and indirectly from the water quality at our beaches to the safety of seafood at U.S. markets; therefore, it is important to understand the relationship between environmental stressors, coastal conditions, climate change, and human health. Over the last several decades ocean and coastal waters have become channels for environmental threats to human health including infectious disease, harmful toxins from algae, and chemical pollutants from contact with contaminated seafood, polluted drinking water, and dirty beaches. Since the 1960s, scientists have realized that marine plants, animals, and microbes can also produce substances that benefit human health, such as anticancer, anti-inflammatory, and antibiotic medicines.

Through well designed research and monitoring programs, we can maximize the health benefits derived from the oceans, improve the safety of American seafood, reduce beach closures, and detect emerging threats to human health in a proactive rather than reactive manner.

In 2004, Congress enacted the Oceans and Human Health Act which authorized the National Oceanic and Atmospheric Administration, the National Science Foundation, and the National Institutes of Health to conduct research to improve understanding of the connection between the oceans and public health. Today, Senator Inouye, Senator Cantwell, and I are introducing the Oceans and Human Health Reauthorization Act of 2009.

This legislation would direct the President, working through the National Science and Technology Council, to coordinate a national research program to improve understanding of the role of the oceans, coasts and Great Lakes in human health and deliver information, products, and services to assist the nation in reducing public health risks, including those related to climate change, and enhancing health benefits from the ocean. It would establish the Oceans and Human Health Task Force that will include a number of federal agencies, such as the National Oceanic and Atmospheric Administration, the National Institutes of Health, the National Science Foundation, the National Institute for Environmental Health Science, and the Center for Disease Control. It would direct the Interagency Oceans and Human Health Task Force to develop an implementation plan that: establishes the goals and priorities for federal research that advance scientific

understanding of the connections between oceans and human health; provides information for the prediction, surveillance, and forecasting of marine-related public health problems, including those related to climate change; and uses the biological and chemical potentials of the oceans to develop new products for the prevention and treatment of diseases and to increase our understanding of the biological properties of ocean resources. The legislation would also reauthorize the National Oceanic and Atmospheric Administration's Oceans and Human Health Initiative and establish a Distinguished Scholars program for scientists to work with the National Oceanic and Atmospheric Administration on the oceans and human health initiative.

Importantly, this bill would recognize the effects of climate change on oceans and human health. The effects of climate change do not stop with sea level rise and increased water temperatures. Without physical and ecological boundaries, climate change causes a cascade of effects throughout ocean environments that can result in surprising impacts on ocean and human health. This reauthorization bill would include climate change and oceans and human health as a new research area.

Our oceans impact every American and they are a foundation of America's economy. The research and monitoring supported by this bill will help make sure we have healthy oceans where people can swim, fish, play, and eat seafood. It will also help us develop new blue jobs in marine natural products and lead to new discoveries in medicines to cure deadly diseases.

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

Mr. President, oceans affect human health both directly and indirectly from the water quality at our beaches to the safety of seafood at U.S. markets; therefore, it is important to understand the relationship between environmental stressors, coastal conditions, climate change, and human health. Over the last several decades ocean and coastal waters have become channels for environmental threats to human health including infectious disease, harmful toxins from algae, and chemical pollutants from contact with contaminated seafood, polluted drinking water, and dirty beaches. Since the 1960s, scientists have realized that marine plants, animals, and microbes can also produce substances that benefit human health, such as anticancer, anti-inflammatory, and antibiotic medicines.

Through well designed research and monitoring programs, we can maximize the health benefits derived from the oceans, improve the safety of American seafood, reduce beach closures, and detect emerging threats to human health in a proactive rather than reactive manner.

In 2004, Congress enacted the Oceans and Human Health Act which authorized the National Oceanic and Atmospheric Administration, the National Science Foundation, and the National Institutes of Health to conduct research to improve understanding of the connection between the oceans and public health. Today, Senator Inouye, Senator Cantwell, and I are introducing the Oceans and Human Health Reauthorization Act of 2009.

This legislation would direct the President, working through the National Science and Technology Council, to coordinate a national research program to improve understanding of the role of the oceans, coasts and Great Lakes in human health and deliver information, products, and services to assist the nation in reducing public health risks, including those related to climate change, and enhancing health benefits from the ocean. It would establish the Oceans and Human Health Task Force that will include a number of federal agencies, such as the National Oceanic and Atmospheric Administration, the National Institutes of Health, the National Science Foundation, the National Institute for Environmental Health Science, and the Center for Disease Control. It would direct the Interagency Oceans and Human Health Task Force to develop an implementation plan that: establishes the goals and priorities for federal research that advance scientific

understanding of the connections between oceans and human health; provides information for the prediction, surveillance, and forecasting of marine-related public health problems, including those related to climate change; and uses the biological and chemical potentials of the oceans to develop new products for the prevention and treatment of diseases and to increase our understanding of the biological properties of ocean resources. The legislation would also reauthorize the National Oceanic and Atmospheric Administration's Oceans and Human Health Initiative and establish a Distinguished Scholars program for scientists to work with the National Oceanic and Atmospheric Administration on the oceans and human health initiative.

Importantly, this bill would recognize the effects of climate change on oceans and human health. The effects of climate change do not stop with sea level rise and increased water temperatures. Without physical and ecological boundaries, climate change causes a cascade of effects throughout ocean environments that can result in surprising impacts on ocean and human health. This reauthorization bill would include climate change and oceans and human health as a new research area.

Our oceans impact every American and they are a foundation of America's economy. The research and monitoring supported by this bill will help make sure we have healthy oceans where people can swim, fish, play, and eat seafood. It will also help us develop new blue jobs in marine natural products and lead to new discoveries in medicines to cure deadly diseases.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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