Floor Statements

Madam President, I rise today to introduce the Clean Cooking Support Act. I am pleased to be joined in this effort by my friend and colleague Senator Durbin. Our bill aims to address a serious global public health and environmental issue where leadership by the United States can make a real difference.

Today, more than 2 billion people, or 30 percent of the global population, rely on ``dirty cooking,'' such as open fires or inefficient, polluting, and unsafe cookstoves that use agricultural waste, coal, dung, or other solid fuels, to cook their meals. The majority of people using these types of cookstoves and fuels are in developing countries in Africa, Asia, and Latin America.

Exposure to smoke from these traditional cooking methods and open fires, referred to as household air pollution, can cause chronic and acute diseases such as lung cancer, heart disease, and stroke. Alarmingly, the household air pollution caused by traditional cookstoves and open fires leads to 3.2 million premature deaths annually, including 450,000 children younger than 5

years of age, most of whom live in sub-Saharan Africa and Asia. Women and girls are disproportionately affected, as they spend hours cooking, inhaling toxic smoke, and collecting fuels.

These cookstoves also create serious environmental problems. Household air pollution does not remain in the home; it contributes to global ambient air pollution. Specifically, more than half of manmade black carbon emissions come from household fuel combustion. Black carbon is a powerful short-lived climate pollutant with warming impact on the climate that is 460 to 1,500 times stronger than carbon dioxide.

These cookstoves should be replaced with modern alternatives to reverse these alarming health and environmental trends. Since 2010, the Clean Cooking Alliance, an innovative public-private partnership hosted by the United Nations Foundation, has supported the adoption of clean cooking worldwide. Recognizing the serious health and environmental issues posed by traditional cookstoves, the alliance aims to save lives, improve livelihoods, empower women, and combat pollution by creating a thriving global market for clean and efficient household cooking solutions.

Our legislation reinforces our country's policy on promoting clean cookstoves and seeks to take a whole-of-government approach to address household air pollution. Specifically, the Clean Cooking Support Act would create an interagency working group, with representatives from at least six different Federal Agencies, committed to increasing access to clean cooking fuels and technologies worldwide. Our legislation explicitly spells out the role of each Federal Agency in the advancement of clean cooking as well. The Department of Energy, for instance, is tasked with research and development to spur the production of low-cost, low-emission, and high-efficiency cookstoves, while the Department of State is directed to engage in diplomatic activities across the globe to support the clean cooking and fuels sector. Finally, our would authorize funding for the U.S. Government to continue such activities through 2028 to ensure that these important efforts to prevent unnecessary illness and reduce pollution around the globe continue.

Our legislation would directly benefit some of the world's poorest people, including the women and girls who are disproportionately affected, and reduce harmful pollution that affects us all. I urge my colleagues to join me and Senator Durbin in supporting the Clean Cooking Support Act.

Madam President, I rise today to introduce the Special Diabetes Program Reauthorization Act of 2023 with Senator Jeanne Shaheen, my colleague from New Hampshire and cochair of the Senate Diabetes Caucus. Our bipartisan bill would reauthorize and strengthen vital type 1 diabetes research happening at the National Institutes of Health and renew critical treatment, education, and prevention programs for at-risk populations, specifically Native American and Alaska Native communities, who experience type 2 diabetes at nearly three times the national average. Together, these programs have become the Nation's most strategic and effective effort to combat diabetes and its complications, but, without an extension, both programs are at risk of expiring on September 30, 2023.

For more than 25 years, the Special Diabetes Program--comprised of the Special Statutory Funding Program for Type 1 Diabetes Research and the Special Diabetes Program for Indians, SDPI--has delivered meaningful resources and research breakthroughs for those with type 1 diabetes and also for Native Americans and Alaska Natives. This research has also led to advancements to the broader community, including the 37 million Americans with diabetes and 96 million with prediabetes. Our bill would continue these investments in the research aimed at developing a cure for diabetes and support the programs that help prevent and treat the disease and its complications.

In one of my very first meetings as a new Senator, I met a young Mainer with type 1 diabetes. I will never forget this 10-year-old boy looking up at me and telling me that he wished he could take just 1 day off from having diabetes--his birthday or Christmas--but of course he could not. This meeting led me to start the bipartisan Senate Diabetes Caucus and to begin fighting for a cure for this devastating disease.

Since then, we have made tremendous progress thanks to investments like the Special Diabetes Program. From new technologies that are making these children's lives easier to manage to treatments that can potentially delay the clinical diagnosis of type 1 diabetes, this program has generated a strong return on investment. Renewal of the SDP is absolutely critical to accelerating the progress we have made over the past two decades to treat and one day cure type 1 diabetes. Today's research represents tomorrow's cure.

As the cochairs of the Senate Diabetes Caucus, Senator Shaheen and I recently led a letter signed by 60 Senators advocating for the program's reauthorization and outlining why investing in the Special Diabetes Program is a cost-effective investment toward improving lives and reducing healthcare expenditures. The driving force behind this program is curing one of the United States' most costly diseases in both human and economic terms.

Our bill would reauthorize both components of the SDP through December 2025 at an annual funding level of $170 million per program. Congress has reauthorized the SDP with bipartisan support numerous times since the program's inception in 1997. Yet funding has not increased since fiscal year 2004. During this time period, the cost of research has increased, as has the size of the Indian Health Service population and the cost of medical care. For that

reason, our bill also proposes a $20 million increase per program. This would be the first increase for this program in 20 years.

The two programs in this reauthorization bill have had transformative effects on diabetes care. The first program is the Special Statutory Funding Program for Type 1 Diabetes Research, which provides funds to NIH's National Institute of Diabetes and Digestive and Kidney Diseases, NIDDK, for life-changing preventive diabetes research. For example, SDP-funded research laid early groundwork for artificial pancreas, AP, systems--or closed-loop ``all-in-one'' diabetes management systems-- that have shown great promise in improving glucose monitoring and insulin delivery. Advances in technology have helped reduce costly and burdensome complications and improved the quality of life for those with the disease. There are now multiple FDA-approved artificial pancreas systems, enabling individuals with type 1 diabetes and their doctors to choose the system that works best for them. According to one study, the use of AP systems in adults could save Medicare roughly $1 billion over 25 years.

SDP research has also helped researchers identify genes and environmental factors linked with type 1 diabetes, led to changes in clinical practice guidelines for diabetic eye care, and supported clinical trials on therapeutics to prevent and treat the disease. For example, landmark research conducted by SDP-funded TrialNet demonstrated for the first time ever that early preventive treatment with a drug targeting the immune system delayed onset of clinical-type 1 diabetes for 2 years. This drug has since been approved by the FDA and is the first ever disease modifying therapy for type 1 diabetes.

Continued investment in this program is essential to continue large- scale trials, plan next steps for research programs, conduct outreach and education, and allocate research resources effectively. As Dr. Griffin Rodgers, Director of the NIDDK, said when testifying at a Senate Aging Committee hearing I chaired in 2019, ``with continued research, it is possible to imagine that people could lead a life free of the burden of Type 1 diabetes and its complications.''

Our bill would also provide $170 million per year to sustain a second program, the Special Diabetes Program for Indians, SDPI. SDPI supports type 2 diabetes treatment and prevention strategies for Native American and Alaska Native populations who are disproportionately burdened with type 2 diabetes at a rate of nearly three times the national average. In Maine this program benefits five Tribal communities across the state, providing approximately 5 million dollars in support for diabetes prevention activities in those Tribal populations. This Federal support is critical to reducing disparities. As Chief William Nicholas of the Passamaquoddy Tribe in Maine recently explained, ``Special Diabetes Program funding is instrumental and necessary to educate and address high rates of diabetes in Indian Country. Native Americans are high risk for diabetes, and the funding will continue the much-needed support, education, and treatment in our communities.''

Tremendous improvements are occurring in diabetes outcomes for Alaska Natives and Native Americans, and the SDPI has played a key role, just as Congress envisioned when the program was created. Although diabetes rates among the IHS service population remain high, with the help of this program, diabetes rates in youth in these communities have not increased in more than 10 years, and diabetes rates in Alaska Native and Native American adults have not increased since 2011. Communities with SDPI-funded programs have actually seen the diabetes incidence rate decrease consistently since 2013.

The program is effective by other measures as well. Since SDPI began, there has been a 50-percent reduction in diabetic eye disease rates among Alaska Natives and Native Americans; hospitalizations for uncontrolled diabetes among Alaska Native and Native American adults have dropped by 84 percent; and the rate of end-stage renal disease has fallen by more than 50 percent. These positive clinical outcomes have reduced the risk for blindness, amputations, and kidney failure, in addition to preventing the onset of type 2 diabetes.

The Special Diabetes Program is funding research that is leading directly to the development of new insights and therapies that are improving the lives of those with diabetes and accelerating progress toward curing and preventing the disease. Ruby Anderson, a young Mainer with type I diabetes who testified before the 2019 JDRF Children's Congress, put an even finer point on the need to reauthorize the SDP. Ruby she said she doesn't want her brother or sister to have to go through what she has experienced. As she told Senators, ``We need more research to find a cure. We need even better devices. And we need to figure out what causes TID so we can stop it.''

I couldn't agree more with Ruby, and I am confident the Special Diabetes Program will make these objectives possible. I urge my colleagues to support a multi-year extension of this important program so that one day we will find a cure to this debilitating disease.

Madam President, I rise today to introduce the Special Diabetes Program Reauthorization Act of 2023 with Senator Jeanne Shaheen, my colleague from New Hampshire and cochair of the Senate Diabetes Caucus. Our bipartisan bill would reauthorize and strengthen vital type 1 diabetes research happening at the National Institutes of Health and renew critical treatment, education, and prevention programs for at-risk populations, specifically Native American and Alaska Native communities, who experience type 2 diabetes at nearly three times the national average. Together, these programs have become the Nation's most strategic and effective effort to combat diabetes and its complications, but, without an extension, both programs are at risk of expiring on September 30, 2023.

For more than 25 years, the Special Diabetes Program--comprised of the Special Statutory Funding Program for Type 1 Diabetes Research and the Special Diabetes Program for Indians, SDPI--has delivered meaningful resources and research breakthroughs for those with type 1 diabetes and also for Native Americans and Alaska Natives. This research has also led to advancements to the broader community, including the 37 million Americans with diabetes and 96 million with prediabetes. Our bill would continue these investments in the research aimed at developing a cure for diabetes and support the programs that help prevent and treat the disease and its complications.

In one of my very first meetings as a new Senator, I met a young Mainer with type 1 diabetes. I will never forget this 10-year-old boy looking up at me and telling me that he wished he could take just 1 day off from having diabetes--his birthday or Christmas--but of course he could not. This meeting led me to start the bipartisan Senate Diabetes Caucus and to begin fighting for a cure for this devastating disease.

Since then, we have made tremendous progress thanks to investments like the Special Diabetes Program. From new technologies that are making these children's lives easier to manage to treatments that can potentially delay the clinical diagnosis of type 1 diabetes, this program has generated a strong return on investment. Renewal of the SDP is absolutely critical to accelerating the progress we have made over the past two decades to treat and one day cure type 1 diabetes. Today's research represents tomorrow's cure.

As the cochairs of the Senate Diabetes Caucus, Senator Shaheen and I recently led a letter signed by 60 Senators advocating for the program's reauthorization and outlining why investing in the Special Diabetes Program is a cost-effective investment toward improving lives and reducing healthcare expenditures. The driving force behind this program is curing one of the United States' most costly diseases in both human and economic terms.

Our bill would reauthorize both components of the SDP through December 2025 at an annual funding level of $170 million per program. Congress has reauthorized the SDP with bipartisan support numerous times since the program's inception in 1997. Yet funding has not increased since fiscal year 2004. During this time period, the cost of research has increased, as has the size of the Indian Health Service population and the cost of medical care. For that

reason, our bill also proposes a $20 million increase per program. This would be the first increase for this program in 20 years.

The two programs in this reauthorization bill have had transformative effects on diabetes care. The first program is the Special Statutory Funding Program for Type 1 Diabetes Research, which provides funds to NIH's National Institute of Diabetes and Digestive and Kidney Diseases, NIDDK, for life-changing preventive diabetes research. For example, SDP-funded research laid early groundwork for artificial pancreas, AP, systems--or closed-loop ``all-in-one'' diabetes management systems-- that have shown great promise in improving glucose monitoring and insulin delivery. Advances in technology have helped reduce costly and burdensome complications and improved the quality of life for those with the disease. There are now multiple FDA-approved artificial pancreas systems, enabling individuals with type 1 diabetes and their doctors to choose the system that works best for them. According to one study, the use of AP systems in adults could save Medicare roughly $1 billion over 25 years.

SDP research has also helped researchers identify genes and environmental factors linked with type 1 diabetes, led to changes in clinical practice guidelines for diabetic eye care, and supported clinical trials on therapeutics to prevent and treat the disease. For example, landmark research conducted by SDP-funded TrialNet demonstrated for the first time ever that early preventive treatment with a drug targeting the immune system delayed onset of clinical-type 1 diabetes for 2 years. This drug has since been approved by the FDA and is the first ever disease modifying therapy for type 1 diabetes.

Continued investment in this program is essential to continue large- scale trials, plan next steps for research programs, conduct outreach and education, and allocate research resources effectively. As Dr. Griffin Rodgers, Director of the NIDDK, said when testifying at a Senate Aging Committee hearing I chaired in 2019, ``with continued research, it is possible to imagine that people could lead a life free of the burden of Type 1 diabetes and its complications.''

Our bill would also provide $170 million per year to sustain a second program, the Special Diabetes Program for Indians, SDPI. SDPI supports type 2 diabetes treatment and prevention strategies for Native American and Alaska Native populations who are disproportionately burdened with type 2 diabetes at a rate of nearly three times the national average. In Maine this program benefits five Tribal communities across the state, providing approximately 5 million dollars in support for diabetes prevention activities in those Tribal populations. This Federal support is critical to reducing disparities. As Chief William Nicholas of the Passamaquoddy Tribe in Maine recently explained, ``Special Diabetes Program funding is instrumental and necessary to educate and address high rates of diabetes in Indian Country. Native Americans are high risk for diabetes, and the funding will continue the much-needed support, education, and treatment in our communities.''

Tremendous improvements are occurring in diabetes outcomes for Alaska Natives and Native Americans, and the SDPI has played a key role, just as Congress envisioned when the program was created. Although diabetes rates among the IHS service population remain high, with the help of this program, diabetes rates in youth in these communities have not increased in more than 10 years, and diabetes rates in Alaska Native and Native American adults have not increased since 2011. Communities with SDPI-funded programs have actually seen the diabetes incidence rate decrease consistently since 2013.

The program is effective by other measures as well. Since SDPI began, there has been a 50-percent reduction in diabetic eye disease rates among Alaska Natives and Native Americans; hospitalizations for uncontrolled diabetes among Alaska Native and Native American adults have dropped by 84 percent; and the rate of end-stage renal disease has fallen by more than 50 percent. These positive clinical outcomes have reduced the risk for blindness, amputations, and kidney failure, in addition to preventing the onset of type 2 diabetes.

The Special Diabetes Program is funding research that is leading directly to the development of new insights and therapies that are improving the lives of those with diabetes and accelerating progress toward curing and preventing the disease. Ruby Anderson, a young Mainer with type I diabetes who testified before the 2019 JDRF Children's Congress, put an even finer point on the need to reauthorize the SDP. Ruby she said she doesn't want her brother or sister to have to go through what she has experienced. As she told Senators, ``We need more research to find a cure. We need even better devices. And we need to figure out what causes TID so we can stop it.''

I couldn't agree more with Ruby, and I am confident the Special Diabetes Program will make these objectives possible. I urge my colleagues to support a multi-year extension of this important program so that one day we will find a cure to this debilitating disease.

Mr. President, I rise today to commemorate the 250th anniversary of the town of Waldoboro, ME. Waldoboro was built with a spirit of determination and resiliency that still guides the community today, and this is a time to celebrate the generations of hard-working and caring people who have made it such a wonderful place to live, work, and raise families.

The year of Waldoboro's incorporation, 1773, is but one milestone in a long journey of progress. For thousands of years, the land where the Medomak River meets the Atlantic Ocean was the home of the Abenaki Tribe, who hunted and fished in the abundant region. The reverence the Abenaki had for the natural beauty and resources of the area is upheld by the people of Waldoboro today.

Waldoboro's roots run deep into American history. It originally was part of the lands granted by the British Crown to the Plymouth Colony in the early 1600s but remained unsettled frontier for more than a century. In 1729, a portion was acquired by General Samuel Waldo of Boston and a village called Broad Bay was established. Ongoing conflicts between England and France for control of the region stifled settlement until a peace treaty was reached in 1748.

In order to stimulate growth, General Waldo visited his family's ancestral home in Germany in 1752 and recruited about 1,500 immigrants. The industrious settlers created productive farms, saw mills and grain mills, churches, and a school to build a true community. On June 29, 1773, the settlement was incorporated as Waldoboro in honor of its founder.

The arrival of the railroad in the 19th century spurred greater development, including ironworks and textile and furniture mills. As Maine became a shipbuilding center, Waldoboro was at the forefront. On December 1, 1888, the first five-masted schooner and the largest cargo vessel in the world at the time, the Governor Ames, was launched at the Leavitt-Storer Shipyard in Waldoboro. Today, Waldoboro proudly cherishes its role in creating the pinnacle of wooden shipbuilding as ``The Home of the Five-Masted Schooner.''

The German influence in Waldoboro is evident in such cottage industries as cheesemaking and brewing. The town is known for its contributions to the fabric arts, and the luxurious ``Waldoboro Style'' of hooked rugs is a favorite among collectors. Among Waldoboro's architectural treasures is the well-preserved 1772 Old German Meeting House.

The cemetery of that historic Lutheran church is the final resting place of Conrad Heyer, a Revolutionary War veteran who possibly crossed the Delaware with General Washington in 1776. In 1852, he posed for a photograph at age 103 and is believed to have been the earliest born person ever to have been photographed.

Today, visitors and residents alike enjoy Waldoboro's thriving arts community, beautiful historic buildings, and exciting outdoor recreation opportunities. The energy and planning that are going into the town's 250th anniversary celebration demonstrate the pride townspeople have in their town.

Waldoboro's 250th anniversary is not merely about the passing of time. It is about human accomplishment. We celebrate the people who, for longer than America has been a nation, have pulled together, cared for one another, and built a great community. Thanks to those who came before, Waldoboro, ME, has a wonderful history. Thanks to those there today, it has a bright future.

Mr. President, shortly, the Senate will consider the debt ceiling package that passed the House last night by a strong vote.

I commend the Speaker for his hard work and his negotiations to prevent what would be a disastrous default, with catastrophic consequences for our economy, for the people who rely on important government programs, and for America's standing in the world. Nevertheless, there are two issues in this package that are very problematic.

The first, as you have heard from my colleagues, is the completely inadequate top-line number for our national defense.

The second is a harmful provision that would go into effect if any 1 of the 12 appropriations bills has not been signed into law. It would trigger an automatic, meat-ax, indiscriminate, across-the-board cut in our already inadequate defense budget and in the domestic discretionary nondefense funding. This would happen automatically if, in fact, all 12 appropriations bills have not been passed.

Now let me address both of those issues and offer to my colleagues what I believe are solutions.

The first is the inadequacy of the defense budget. As my colleagues have very well described, the defense budget submitted by President Biden and included as the top line in this package is insufficient to the task of fully implementing the national defense strategy at a time when we face serious and growing threats around the world.

As my friends and colleagues from South Carolina and Alaska and others have already described, this budget request would actually shrink the size of our Navy. We would end up with a fleet of 291 ships. Those are 6 ships fewer than today's fleet of 297 ships, and it is further--further--away from the Chief of Naval Operations' requirement, which is informed by scenarios involving China, for example. Meanwhile, what is China doing? China has the largest navy in the world now, and it is growing to 400 ships in the next 2 years.

The story is very similar if you look at the Air Force's tactical aircraft. So we have a real problem.

Let me give you another example. It is an example that all of us can relate to who fill our cars with gas or seek to heat our homes.

This budget request falls woefully short in funding the fuel costs of our military. The Government Accountability Office says the DOD's fuel costs are likely to be 20 percent higher than the amount of money that is included in the President's budget.

I asked the Chairman of the Joint Chiefs of Staff, General Milley, what the result would be, and he says it very clearly: It would translate into 20 percent fewer flying hours and steaming days, which would harm our military's training and readiness. So that is a very concrete area where the President's budget is clearly not going to be adequate.

Second is the harmful provision with the automatic 1 percent cut across the board. Think about this, if you are the Secretary of Defense. Let's say the Department of Defense appropriations bill is signed into law before the start of the fiscal year in October, as I hope that it will be, and I am working hard. It doesn't matter. Let's say the leg branch appropriations bill isn't signed into law by January 1 of next year. An order goes out that has to be implemented by April 30 which would cut every account across the board by 1 percent. How does that make sense? Think how harmful that would be. How in the world is the military going to enter into contracts if it doesn't know what its budget is going to be, despite the fact that its appropriations bill has been signed into law, but because of this threat hanging over the Department.

So what do we do? I don't want to see our country default for the first time in history. I do believe that would have catastrophic consequences. But we need to fix these problems.

The first problem of an inadequate defense budget could be addressed and remedied by having an emergency defense supplemental. That is what we need to do. That is what I would ask the administration and my colleagues on the other side of the aisle to commit to because we know that this budget is not adequate to the global threats that we face.

We know that it does nothing to deter Russian aggression in Ukraine. We know that it is not adequate to the challenge that we face from China. An emergency supplemental must be coming our way to remedy the first problem.

What should we do about the second problem, the threat of this 1 percent indiscriminate meat ax cut across the board? We need to pass each and every one of the 12 appropriations bills on time before the start of the fiscal year. In order to do that, I am working very hard with the chair of the committee, Senator Murray. But we need a commitment from the Senate majority leader that he will provide us with floor time. We will do our utmost to get every single one of the 12 appropriations bills marked up and reported out of the Appropriations Committee. But then I am asking the Senate majority leader to commit to bringing each of those bills to the Senate floor, either singly or individually or as minibuses, as we used to do, where we would pair a couple of the bills together. But it is essential. I would implore the Democratic leader to provide the commitment that he will bring each of the appropriations bills to the Senate floor so that we can avoid the threat of this indiscriminate, across-the-board cut.

I believe that is the path forward for us: an emergency defense supplemental to make up for the woefully inadequate budget that has been submitted by this administration for the Department of Defense for our national security; and, second, to prevent the 1 percent cut from ever being triggered, a commitment that all of the appropriations bills will be brought on time to the Senate floor.

Then, it seems to me, we can proceed with this package and avoid a catastrophic default for our country.

Madam President, I rise today to introduce the STEM Education in Accounting Act, which would help address workforce shortages in the accounting profession by recognizing accounting as part of a STEM education and adding accounting education programs as an allowable use of K-12 Federal grant funding. I want to thank Senator Rosen for coleading this bill with me.

Accountants play a key role in today's economy. They serve as trusted advisers for companies large and small, assist in measuring business performance, help individuals and businesses file their taxes in an accurate and timely manner, and even investigate instances of financial fraud. Yet, the United States is facing a shortage of accountants willing and able to fill this important economic role. In Maine, for example, municipalities have struggled to find public accountants to conduct their annual audits.

Recent trends suggest this shortage will continue. According to the Bureau of Labor Statistics, job openings for accountants and auditors are expected to grow by 6 percent from 2021 to 2031--about 136,400 openings each year. At the same time, fewer students are pursuing accounting degrees than in prior years.

The STEM Education in Accounting Act seeks to improve the accounting pipeline by expanding K-12 students' exposure to accounting programs. As with other areas of STEM education, this bill would qualify accounting instruction for Federal funds. This recognition aligns with the increasing need for accounting professionals to have high-level math and technology skills, including the ability to analyze big data, ensure data security, and manage cybersecurity risk.

In particular, this bill would allow States and school districts to use a portion of their Federal student support and academic enrichment grant funding to support accounting education, including accounting career awareness. The Student Support and Academic Enrichment Grant Program was created as part of the Every Student Succeeds Act and aims to help States and school districts offer a well-rounded educational experience to all students. The STEM Education in Accounting Act would also allow school districts to use this flexible grant to strengthen accounting curricula, including increasing access to high-quality accounting courses for members of groups underrepresented in the accounting profession.

Businesses and individuals rely on accountants to help them develop and reach their financial goals. The STEM Education in Accounting Act would help address the shortage of accountants by promoting accounting education and improving the pipeline of future accountants. I encourage my colleagues to support this bipartisan bill.

Madam President, I rise today to introduce the STEM Education in Accounting Act, which would help address workforce shortages in the accounting profession by recognizing accounting as part of a STEM education and adding accounting education programs as an allowable use of K-12 Federal grant funding. I want to thank Senator Rosen for coleading this bill with me.

Accountants play a key role in today's economy. They serve as trusted advisers for companies large and small, assist in measuring business performance, help individuals and businesses file their taxes in an accurate and timely manner, and even investigate instances of financial fraud. Yet, the United States is facing a shortage of accountants willing and able to fill this important economic role. In Maine, for example, municipalities have struggled to find public accountants to conduct their annual audits.

Recent trends suggest this shortage will continue. According to the Bureau of Labor Statistics, job openings for accountants and auditors are expected to grow by 6 percent from 2021 to 2031--about 136,400 openings each year. At the same time, fewer students are pursuing accounting degrees than in prior years.

The STEM Education in Accounting Act seeks to improve the accounting pipeline by expanding K-12 students' exposure to accounting programs. As with other areas of STEM education, this bill would qualify accounting instruction for Federal funds. This recognition aligns with the increasing need for accounting professionals to have high-level math and technology skills, including the ability to analyze big data, ensure data security, and manage cybersecurity risk.

In particular, this bill would allow States and school districts to use a portion of their Federal student support and academic enrichment grant funding to support accounting education, including accounting career awareness. The Student Support and Academic Enrichment Grant Program was created as part of the Every Student Succeeds Act and aims to help States and school districts offer a well-rounded educational experience to all students. The STEM Education in Accounting Act would also allow school districts to use this flexible grant to strengthen accounting curricula, including increasing access to high-quality accounting courses for members of groups underrepresented in the accounting profession.

Businesses and individuals rely on accountants to help them develop and reach their financial goals. The STEM Education in Accounting Act would help address the shortage of accountants by promoting accounting education and improving the pipeline of future accountants. I encourage my colleagues to support this bipartisan bill.

Madam President, I rise today to introduce the Carbon Removal and Emissions Storage Technologies Act, the CREST Act. I want to thank Senator Cantwell for her partnership in working on this bill. Our bipartisan bill would direct the Department of Energy to research and evaluate the feasibility of innovative carbon removal and storage pathways. The name the ``CREST Act'' alludes to the fact that we have reached the ``crest'' of our emissions, and we must work to reduce them.

With more and more private and public sector commitments to reach net-zero emissions within certain timeframes, companies are scrambling to invest in quantifiable, durable, and verifiable carbon removal solutions. Microsoft, for example, has made a commitment to be carbon negative by 2030. Even though Microsoft plans to reduce its greenhouse gas emissions by more than half, it will need to remove the rest of its carbon emissions. In order to do this, Microsoft plans to invest $1 billion in carbon removal technologies, such as direct air capture, forestation, and carbon mineralization.

Despite the growing number of companies that are looking to offset their emissions, current cost estimates show that private sector investment alone will not be sufficient to research and deploy carbon removal pathways. I supported the Energy Act of 2020, which authorized the first comprehensive Federal carbon removal research and development program, and the bipartisan infrastructure bill, which invested $3.6 billion in direct air capture. Although these investments have been significant, more work is needed in further research, increased testing, and enhanced public-private partnerships to help aid in scaling carbon removal technologies.

The CREST Act would expand the Department of Energy's carbon removal research and development programs to include carbon removal pathways that can permanently sequester carbon dioxide or use carbon dioxide to produce biofuels or products. The key areas of focus for research and development in our legislation are biomass carbon removal and storage, geological removal, atmospheric and aquatic removal, carbon dioxide storage, and carbon dioxide removal quantification.

Our legislation also aims to accelerate the commercialization of innovative carbon solutions through a pilot program at the Department of Energy. This pilot program would be charged with accelerating the deployment of affordable and proven carbon removal technologies. This reverse-auction style pilot program would position the government to purchase innovative and promising technologies, subject to certain criteria, and reduce the costs of those technologies. This would allow companies that may not have as much purchasing power as Microsoft to participate in carbon removal to help offset emissions.

This pilot program could also support companies that are leading the way in carbon removal technology, like Running Tide in Maine, in bringing down the cost of its product. Running Tide captures carbon dioxide using kelp microforests, sun, ocean currents, and gravity. This new and exciting company grows floating kelp microforests attached to biodegradable buoys that sink as they break down. The carbon captured through the floating microforest is effectively removed for hundreds of years once it hits the ocean floor. Running Tide hopes to soon be selling ``kelp carbon credits'' to help offset private entities' emissions. They are currently working to commercialize quickly. These innovative approaches are the kinds that our new pilot program could encourage.

Climate change is a significant environmental challenge that requires innovative and global solutions to reduce greenhouse gas pollution. While carbon removal is only a small part of the solution, it is critical that we promote innovation in this area. Our bipartisan bill has earned endorsements from Bipartisan Policy Center Action,

ClearPath Action, Citizens for Responsible Energy Solutions, and many others. I urge my colleagues to join Senator Cantwell and me in supporting this legislation.

Madam President, I rise today to introduce the Carbon Removal and Emissions Storage Technologies Act, the CREST Act. I want to thank Senator Cantwell for her partnership in working on this bill. Our bipartisan bill would direct the Department of Energy to research and evaluate the feasibility of innovative carbon removal and storage pathways. The name the ``CREST Act'' alludes to the fact that we have reached the ``crest'' of our emissions, and we must work to reduce them.

With more and more private and public sector commitments to reach net-zero emissions within certain timeframes, companies are scrambling to invest in quantifiable, durable, and verifiable carbon removal solutions. Microsoft, for example, has made a commitment to be carbon negative by 2030. Even though Microsoft plans to reduce its greenhouse gas emissions by more than half, it will need to remove the rest of its carbon emissions. In order to do this, Microsoft plans to invest $1 billion in carbon removal technologies, such as direct air capture, forestation, and carbon mineralization.

Despite the growing number of companies that are looking to offset their emissions, current cost estimates show that private sector investment alone will not be sufficient to research and deploy carbon removal pathways. I supported the Energy Act of 2020, which authorized the first comprehensive Federal carbon removal research and development program, and the bipartisan infrastructure bill, which invested $3.6 billion in direct air capture. Although these investments have been significant, more work is needed in further research, increased testing, and enhanced public-private partnerships to help aid in scaling carbon removal technologies.

The CREST Act would expand the Department of Energy's carbon removal research and development programs to include carbon removal pathways that can permanently sequester carbon dioxide or use carbon dioxide to produce biofuels or products. The key areas of focus for research and development in our legislation are biomass carbon removal and storage, geological removal, atmospheric and aquatic removal, carbon dioxide storage, and carbon dioxide removal quantification.

Our legislation also aims to accelerate the commercialization of innovative carbon solutions through a pilot program at the Department of Energy. This pilot program would be charged with accelerating the deployment of affordable and proven carbon removal technologies. This reverse-auction style pilot program would position the government to purchase innovative and promising technologies, subject to certain criteria, and reduce the costs of those technologies. This would allow companies that may not have as much purchasing power as Microsoft to participate in carbon removal to help offset emissions.

This pilot program could also support companies that are leading the way in carbon removal technology, like Running Tide in Maine, in bringing down the cost of its product. Running Tide captures carbon dioxide using kelp microforests, sun, ocean currents, and gravity. This new and exciting company grows floating kelp microforests attached to biodegradable buoys that sink as they break down. The carbon captured through the floating microforest is effectively removed for hundreds of years once it hits the ocean floor. Running Tide hopes to soon be selling ``kelp carbon credits'' to help offset private entities' emissions. They are currently working to commercialize quickly. These innovative approaches are the kinds that our new pilot program could encourage.

Climate change is a significant environmental challenge that requires innovative and global solutions to reduce greenhouse gas pollution. While carbon removal is only a small part of the solution, it is critical that we promote innovation in this area. Our bipartisan bill has earned endorsements from Bipartisan Policy Center Action,

ClearPath Action, Citizens for Responsible Energy Solutions, and many others. I urge my colleagues to join Senator Cantwell and me in supporting this legislation.

Madam President, I rise today to introduce the Reach Every Mother and Child Act of 2023, known as the Reach Act. This bipartisan legislation would strengthen the United States' efforts to end preventable deaths of mothers, newborns, and young children in developing countries by 2030. I want to thank Senator Coons for his partnership on this important bill, and I also appreciate the cosponsorship of Senator Durbin and Senator Wicker.

Senator Coons and I have led efforts to ensure robust funding for the U.S. Agency for International Development's maternal and child health programming. These programs have been the backbone of the United States'' commitment to helping to end preventable child and maternal deaths globally.

Due in part to American leadership and generosity, many lives have already been saved. While progress has been made in reducing maternal mortality rates, recent data suggest that these improvements are slowing. Far too many mothers, newborns, and young children under the age 5 continue to succumb to disease and malnutrition that could easily be prevented.

Nearly 300,000 women die annually from causes related to pregnancy and childbirth, with 99 percent of maternal deaths occurring in developing nations. In addition, a significant proportion of the deaths of children under the age of 5 occur in the first 28 days after birth, with newborns accounting for nearly 50 percent of all under 5 deaths. In 2021, 5 million children under the age of 5 died from mainly preventable and treatable diseases.

The Reach Act aims to help these mothers and children with simple, proven, costeffective interventions that we know will help them survive. A concentrated effort could end preventable maternal and child deaths worldwide by the year 2030, but continued U.S. leadership and support from the international community are critical to achieve this goal.

To advance this cause, our bill would require the implementation of a strategy focused on bringing to scale the highest impact, evidence- based interventions, with a focus on country and

community ownership. These interventions would be specific to each country's needs and include support for the most vulnerable populations. We do not have to guess what interventions will work--the reality is that thousands of children die each day of conditions we know how to treat.

These lifesaving interventions include clean birthing practices, vaccines, nutritional supplements, handwashing with soap, and other basic needs that remain elusive for far too many women and children in developing countries. This must change.

Our bill would require the establishment of a Maternal and Child Survival Coordinator at 1USAID who would focus on implementing the 5- year strategy and verifying that the most effective interventions are being scaled up in key countries. The Coordinator would identify and promote the most effective interventions to end preventable maternal and child deaths globally, which would improve the efficiency of the programs operating across several Agencies.

To promote transparency and greater accountability, our bill would also require detailed public reporting on progress toward implementing the strategy.

The Appropriations Subcommittee on State and Foreign Operations recently heard testimony from USAID Administrator Samantha Power. During that hearing, asked Administrator Power about the Reach Act and emphasized the critical reforms needed to increase the success and impact of USAID's maternal and child survival programs.

Administrator Power testified to sharing the goals that motivate this important legislation.

She agreed about the importance of resourcing key U.S. investments, scaling them up, and getting them to mothers and children living in remote areas.

Other bipartisan initiatives, such as the successful President's Emergency Plan for AIDS Relief, or PEPFAR, which was started by President George W. Bush, demonstrate that results-driven interventions can turn the tide for global health challenges. Applying lessons learned from past initiatives, our bill would provide the focus and tools necessary to accelerate progress toward ending preventable maternal and child deaths.

I urge my colleagues to join Senator Coons, Senator Durbin, Senator Wicker, and me in supporting this legislation that will save the lives of mothers and children around the world.

Madam President, I rise today to introduce the Reach Every Mother and Child Act of 2023, known as the Reach Act. This bipartisan legislation would strengthen the United States' efforts to end preventable deaths of mothers, newborns, and young children in developing countries by 2030. I want to thank Senator Coons for his partnership on this important bill, and I also appreciate the cosponsorship of Senator Durbin and Senator Wicker.

Senator Coons and I have led efforts to ensure robust funding for the U.S. Agency for International Development's maternal and child health programming. These programs have been the backbone of the United States'' commitment to helping to end preventable child and maternal deaths globally.

Due in part to American leadership and generosity, many lives have already been saved. While progress has been made in reducing maternal mortality rates, recent data suggest that these improvements are slowing. Far too many mothers, newborns, and young children under the age 5 continue to succumb to disease and malnutrition that could easily be prevented.

Nearly 300,000 women die annually from causes related to pregnancy and childbirth, with 99 percent of maternal deaths occurring in developing nations. In addition, a significant proportion of the deaths of children under the age of 5 occur in the first 28 days after birth, with newborns accounting for nearly 50 percent of all under 5 deaths. In 2021, 5 million children under the age of 5 died from mainly preventable and treatable diseases.

The Reach Act aims to help these mothers and children with simple, proven, costeffective interventions that we know will help them survive. A concentrated effort could end preventable maternal and child deaths worldwide by the year 2030, but continued U.S. leadership and support from the international community are critical to achieve this goal.

To advance this cause, our bill would require the implementation of a strategy focused on bringing to scale the highest impact, evidence- based interventions, with a focus on country and

community ownership. These interventions would be specific to each country's needs and include support for the most vulnerable populations. We do not have to guess what interventions will work--the reality is that thousands of children die each day of conditions we know how to treat.

These lifesaving interventions include clean birthing practices, vaccines, nutritional supplements, handwashing with soap, and other basic needs that remain elusive for far too many women and children in developing countries. This must change.

Our bill would require the establishment of a Maternal and Child Survival Coordinator at 1USAID who would focus on implementing the 5- year strategy and verifying that the most effective interventions are being scaled up in key countries. The Coordinator would identify and promote the most effective interventions to end preventable maternal and child deaths globally, which would improve the efficiency of the programs operating across several Agencies.

To promote transparency and greater accountability, our bill would also require detailed public reporting on progress toward implementing the strategy.

The Appropriations Subcommittee on State and Foreign Operations recently heard testimony from USAID Administrator Samantha Power. During that hearing, asked Administrator Power about the Reach Act and emphasized the critical reforms needed to increase the success and impact of USAID's maternal and child survival programs.

Administrator Power testified to sharing the goals that motivate this important legislation.

She agreed about the importance of resourcing key U.S. investments, scaling them up, and getting them to mothers and children living in remote areas.

Other bipartisan initiatives, such as the successful President's Emergency Plan for AIDS Relief, or PEPFAR, which was started by President George W. Bush, demonstrate that results-driven interventions can turn the tide for global health challenges. Applying lessons learned from past initiatives, our bill would provide the focus and tools necessary to accelerate progress toward ending preventable maternal and child deaths.

I urge my colleagues to join Senator Coons, Senator Durbin, Senator Wicker, and me in supporting this legislation that will save the lives of mothers and children around the world.

Mr. President, on April 10, 1998, the governments of the United Kingdom and the Republic of Ireland signed the Good Friday Agreement, giving birth to a new era of peace in Northern Ireland. On this 25th anniversary, I join my colleagues in sponsoring a resolution commemorating a historic success that marked the end of decades of conflict and that remains crucial to peace today and in the future. This resolution passed the Senate Foreign Relations Committee unanimously just yesterday and will be passed shortly by the full Senate.

The recent celebration of this landmark event in Belfast brought together the three leaders of the day: Prime Minister Tony Blair, Taoiseach Bertie Ahearn, and President Bill Clinton. The highlight of that gathering was the unveiling at Queen's University of a bust of Senator George Mitchell, the architect of the Good Friday Agreement-- this Chamber's former majority leader and my fellow Mainer. And I know I speak for my fellow Mainers when I say how proud we were of this extraordinary accomplishment. And we salute Senator George Mitchell on this, the 25th anniversary.

During the three decades that the Troubles plagued Northern Ireland, some 3,500 people were killed and 50,000 injured in sectarian violence. In 1996, during one of the many sporadic and ineffective ceasefires, George Mitchell, 1 year after his retirement from the Senate, stepped forward to serve as America's special envoy to Northern Ireland. He was committed, determined to forge a lasting peace. And he did.

George Mitchell approached this daunting task with the statesmanship and dedication to justice that has defined his life. For nearly 2 years, Senator Mitchell worked with unyielding energy and endless patience to bring together the many parties and conflicting interests. Despite arguments, controversies, and walkouts, the talks were held together by his leadership and by his Mitchell Principles, which, first and foremost, held that political issues must be resolved by democratic and exclusively peaceful means.

Finally, on Good Friday, 1998, 1 day and a long sleepless night after the deadline Senator Mitchell had set to complete the complex negotiations, the agreement was, in fact, reached. Six weeks later, the voters in Northern Ireland and the Republic of Ireland endorsed the pact with overwhelming margins.

The Good Friday Agreement has been a remarkable success in meeting its primary goal of ending bloodshed and bringing sustainable peace. The resolution that I introduced with Senator Menendez, the Chairman of the Senate Foreign Relations Committee, calls upon Congress to reaffirm its steadfast support for this historic agreement and to the principles of peaceful and democratic participation as the only way to settle political differences. And, equally important, it recognizes George Mitchell's pivotal role.

Senator George Mitchell himself defined leadership as having the wisdom to know what is right, the courage to say what is right, and the strength to do what is right. This is not merely a definition he has offered throughout an inspiring life of service but also an example he set for others.

I appreciate my colleagues' support of this resolution in his honor as we seek to commemorate this historic anniversary of the agreement that he forged--an agreement that would not have come about but for George Mitchell's endless leadership and patience.

I suggest the absence of a quorum.

Madam President, I rise today to introduce the Educational Opportunity and Success Act, which would reauthorize and strengthen the Federal TRIO Programs. I want to thank Senators Tester, Capito, and Baldwin for being original cosponsors. Senator Tester and I are cochairs of the Congressional TRIO Caucus.

I have been a longtime champion of TRIO, which helps students get the supports they need to prepare for, succeed in, and graduate from college. Prior to my election to the Senate, I worked at Husson University in Bangor, many of whose students are the first in their families to go to college, and I saw firsthand the importance of programs like TRIO.

Maine's 30 TRIO Programs serve more than 7,500 students throughout the State and are focused on increasing educational opportunities for first-generation and low-income students, as well as students with disabilities. I have been inspired by the stories of TRIO students from all across Maine and have seen how TRIO opens doors to the opportunities that come with pursuing and completing postsecondary education.

For example, Myles Ouellette, who currently resides in Van Buren, ME, credits TRIO not only with helping him to complete postsecondary education but also with saving his life. Myles participated in Upward Bound and Educational Talent Search at Van Buren High School. He enlisted in the Army after high school and developed an addiction to painkillers following an injury. After being released from prison, he enrolled in the University of Maine at Augusta, where he participated in the TRIO Student Support Services Program. With help and support from this program, Myles earned a bachelor's degree in applied science. He then went on to complete an MBA in healthcare management from Husson University. According to Myles, Maine TRIO helped him find his life's purpose and empowered him to reach his full potential.

Congress created the TRIO Programs because it recognized that low- income, first-generation college students often face significant obstacles in accessing and completing higher education. Our bipartisan bill would reauthorize these programs, modestly increase grant sizes, and make it easier for administrators to reach students who would benefit from TRIO. It updates the way that programs are evaluated and streamlines the application process. In addition, the bill would increase stipends for students participating in TRIO Programs and create a new stipend for veterans participating in the Veterans Upward Bound Program.

The Educational Opportunity and Success Act would also institute a commonsense process for correcting TRIO applications with minor errors and prevent the Department of Education from rejecting applications simply on the basis of formatting criteria. In 2017, the Department initially rejected dozens of Upward Bound applications based on arbitrary, nonsubstantive formatting criteria, such as line-spacing and font size irregularities. One of these applications was from the University of Maine at Presque Isle, which had used one-and-a-half spacing instead of double spacing in text appearing in graphics on 2 of its application's 65 pages.

The Department's bureaucratic decision would have denied 960 disadvantaged Maine high school students the chance to fulfill their academic potential. After months of advocacy, I worked with the Department and my Appropriations colleagues to reverse this ill- conceived policy, and the University of Maine at Presque Isle received a well-deserved TRIO grant to serve those students.

TRIO Programs have changed the lives of first-generation students in Maine and across the country. The Educational Opportunity and Success Act would improve these important programs and help ensure they are reaching the students who need them most. I urge my colleagues to support this bipartisan bill.

Madam President, I rise today to introduce the Educational Opportunity and Success Act, which would reauthorize and strengthen the Federal TRIO Programs. I want to thank Senators Tester, Capito, and Baldwin for being original cosponsors. Senator Tester and I are cochairs of the Congressional TRIO Caucus.

I have been a longtime champion of TRIO, which helps students get the supports they need to prepare for, succeed in, and graduate from college. Prior to my election to the Senate, I worked at Husson University in Bangor, many of whose students are the first in their families to go to college, and I saw firsthand the importance of programs like TRIO.

Maine's 30 TRIO Programs serve more than 7,500 students throughout the State and are focused on increasing educational opportunities for first-generation and low-income students, as well as students with disabilities. I have been inspired by the stories of TRIO students from all across Maine and have seen how TRIO opens doors to the opportunities that come with pursuing and completing postsecondary education.

For example, Myles Ouellette, who currently resides in Van Buren, ME, credits TRIO not only with helping him to complete postsecondary education but also with saving his life. Myles participated in Upward Bound and Educational Talent Search at Van Buren High School. He enlisted in the Army after high school and developed an addiction to painkillers following an injury. After being released from prison, he enrolled in the University of Maine at Augusta, where he participated in the TRIO Student Support Services Program. With help and support from this program, Myles earned a bachelor's degree in applied science. He then went on to complete an MBA in healthcare management from Husson University. According to Myles, Maine TRIO helped him find his life's purpose and empowered him to reach his full potential.

Congress created the TRIO Programs because it recognized that low- income, first-generation college students often face significant obstacles in accessing and completing higher education. Our bipartisan bill would reauthorize these programs, modestly increase grant sizes, and make it easier for administrators to reach students who would benefit from TRIO. It updates the way that programs are evaluated and streamlines the application process. In addition, the bill would increase stipends for students participating in TRIO Programs and create a new stipend for veterans participating in the Veterans Upward Bound Program.

The Educational Opportunity and Success Act would also institute a commonsense process for correcting TRIO applications with minor errors and prevent the Department of Education from rejecting applications simply on the basis of formatting criteria. In 2017, the Department initially rejected dozens of Upward Bound applications based on arbitrary, nonsubstantive formatting criteria, such as line-spacing and font size irregularities. One of these applications was from the University of Maine at Presque Isle, which had used one-and-a-half spacing instead of double spacing in text appearing in graphics on 2 of its application's 65 pages.

The Department's bureaucratic decision would have denied 960 disadvantaged Maine high school students the chance to fulfill their academic potential. After months of advocacy, I worked with the Department and my Appropriations colleagues to reverse this ill- conceived policy, and the University of Maine at Presque Isle received a well-deserved TRIO grant to serve those students.

TRIO Programs have changed the lives of first-generation students in Maine and across the country. The Educational Opportunity and Success Act would improve these important programs and help ensure they are reaching the students who need them most. I urge my colleagues to support this bipartisan bill.

Mr. President, I am pleased to rise this evening with my colleague and dear friend Senator Jeanne Shaheen to discuss the compelling need to lower the cost of insulin for Americans with diabetes by reforming the system for getting the drug from the manufacturer to the consumer and by capping the out-of-pocket price.

I want to commend Senator Shaheen for her longstanding devotion and hard work on this issue. For her, this is both a matter of policy and personal, as she has described. And I could have no better cochair of the Senate Diabetes Caucus than my colleague from New Hampshire.

We are focused on policies that will improve the lives of those who are living with diabetes. Building on our past efforts, we have introduced a new bill, the Improving Needed Safeguards for Users of Lifesaving Insulin Now--or the INSULIN--Act of 2023.

A little background may be useful. As my colleague from New Hampshire has mentioned, when a team of three scientists at the University of Toronto first isolated insulin in 1921, they sold the patent for $1 each to the university--an act intended to ensure that those in need of insulin would always have an affordable access.

They explicitly stated that profit was not their goal nor their motive. And yet in recent years, the cost of insulin has soared, and insulin costs have become unaffordable for far too many individuals with diabetes.

Between 2007 and 2018, the average list price of insulin increased by 262 percent. In 2019, nearly 9 percent of patients with private insurance paid, on average, $403 per month for their insulin.

This shows the huge increase in the list price between 2012 and 2021. This is the net price. I will explain that in a moment.

Tens of millions of Americans rely on insulin as part of their daily treatment. For children, teens, and adults with type 1 diabetes, insulin is not optional. It is literally a matter of life and death. About 20 percent of those with type 2 diabetes rely on insulin.

I have heard far too many stories from people in my State and from across the country who, because of the escalating cost, have had to ration their insulin--an extremely dangerous practice. These drastic measures can result in major risks that can compromise their health and even jeopardize their lives.

Let me share one such story. Recently, I met with Bek Hoskins of Chelsea, ME, through her advocacy with JDRF. Bek was diagnosed with type 1 diabetes at age 10. When we discussed insulin affordability, Bek shared her insulin story. As a young adult, shortly after she was no longer covered by her parents' insurance, Bek was forced to ration her insulin to make it last longer because she simply could not afford the exorbitant price.

In one profoundly memorable instance, Bek pushed her body's limit too far. Her husband, Barrett, rushed her through a snowstorm to an emergency room as she was in excruciating pain. Bek nearly died because she tried to go without her lifesaving, fast-acting insulin for 2 days.

The situation that Bek faced, sadly, is not an isolated example. We simply must address this problem.

Senator Shaheen and I have long led action in the Senate to improve the lives of those living with diabetes and to reduce insulin prices. We spearheaded the bipartisan INSULIN Act last Congress to comprehensively reform the system that determines the cost of this lifesaving drug. And I am pleased that the market has been responding to our efforts.

The recent decisions by the three major manufacturers of insulin to cut list prices is certainly encouraging, but there is more work to be done. We need legislation to reform the fundamental factors that distort the insulin market, including a purchasing system that is rife with perverse incentives, conflicts

of interest, and very limited biosimilar competition.

And we have introduced legislation to do just that. It would guarantee out-of-pocket limits for patients with commercial insurance, encourage biosimilar development to lower list prices through competition and reform the practices of Pharmacy Benefit Managers. That would improve the insulin market, giving patients long-term benefits.

First, our bill would limit cost sharing to no more than $35, or 25 percent of the list price per month, starting in 2024, for at least one insulin in each type or dosage form. Under our bill, insurers and Pharmacy Benefit Managers, known as PBMs, would be prohibited from placing utilization obstacles--such as prior authorizations or step therapy--on products with capped costs. These important protections deliver immediate out-of-pocket relief.

Second, our bill would tackle the perverse incentives that encourage the high list prices. Many people wonder why price variations of a product that has been available for more than 100 years has increased dramatically, and the answer is that the market is rife with conflicts of interest and lacks transparency. What happens is the PBMs negotiate discounts from the list price to the net price of insulin.

Well, what happens to the money that is in between? There is an incentive for the pharmacy benefit manager to select the high-cost insulin because they are paying based on a percentage of the cost in many cases. So that is what you see here. A lot of the benefit of this lower net price that has been negotiated does not reach the consumer.

In 2018, as chair of the Senate Aging Committee, I held a hearing that examined the role of PBMs and rebates and the insulin supply chain and their effect on the increasing insulin prices. At the hearing, an American Diabetes Association expert displayed this chart that I am showing on the Senate floor, which is called ``Insulin Supply Chain: A Complex System.'' I think that understates the situation. This is so convoluted and lacks transparency that no wonder we end up with a system that is rife with conflicts of interest.

One thing is clear: The way that the rebate functions in the current market is a key factor, not in lowering the cost to the consumer but in driving up insulin costs. The way the rebate system works encourages PBMs to select a higher priced insulin for an insurer's formulary. PBMs often choose the highest cost insulin because, as I mentioned, their compensation in the form of sharing part of the rebates is based frequently on percentage of the list price.

Let me now give you one case study that involves biosimilars. Biosimilar products are generic forms of biologics like insulin. And like generics, they are lower costs. But the PBM incentive structure can be stacked against them.

For example, Sanofi manufactures a popular product called Lantus. In 2021, Viatris launched two identical versions of its interchangeable biosimilar for Lantus. One was a branded interchangeable product with a high list price. The second was an unbranded interchangeable biosimilar with a low list price. The higher priced version of the exact same insulin-interchangeable drug was selected for formularies that are run by the insurers, while the lower price one was not.

Think about that.

This proves the perverse incentives in the system. No major formulary preferred the lower list price version, even though it is the exact same product and costs less. That is how this system operates. Rebating practices have slowed biosimilar adoption, and lower priced products are still struggling to compete. To date, no major formulary prefers the lower list price versions of the branded products.

Insulin rebates average between 30 and 50 percent and can reach as high as 70 percent for the most commonly used insulin products, significantly higher than the average rebate for other types of drugs.

Our INSULIN Act addresses the current distortions in the market that decrease affordability for patients by requiring PBMs to pass through 100 percent of the insulin rebates. By removing the PBM share of the rebate, the INSULIN Act would eliminate the incentive for PBMs to choose the higher list price product.

Finally, our bill takes a number of steps to promote biosimilar competition. More choices in the insulin market would drive down prices by creating competition.

The INSULIN Act would create a new expedited FDA pathway to promote biosimilar competition. This provision is modeled after a successful law I authored with former Senator Claire McCaskill in 2017 to improve competition for generic drugs. According to the FDA, nearly 200 products have benefited from the process we created. Let's extend that to biosimilars as the Shaheen-Collins bill would do.

The INSULIN Act would take similar steps to enhance that regulatory certainty for biosimilar drug companies. It is ironic that there is a biosimilar insulin available in Canada and Europe right now that cannot be produced for U.S. distribution because the FDA has taken nearly 10 months to reinspect the safety of the facility where the drug is being manufactured. What we want to do is expedite the regulatory process.

We know regulatory barriers are not the only challenge for biosimilars. The incentives in the current insulin market for PBMs often prohibit biosimilars from securing fair formulary placement as indicated by the example I described earlier.

One other step that our bill would take to ease some of the access challenges for biosimilar drugs is to provide CMS with the authority to approve midyear Medicare Part D formulary changes when a biosimilar enters the market.

The INSULIN Act of 2023 would address the fundamental issues facing the insulin market: convoluted and opaque rebates pocketed by PBMs, a lack of biosimilar competition, and patient affordability.

Like Senator Shaheen, I am so pleased that our bill has been endorsed by the American Diabetes Association, JDRF, and the Endocrine Society. I thank them for their support of this bipartisan legislation. I encourage our colleagues to join us in supporting these much needed reforms.