Thomas Coburn

Mr. COBURN

Mr. COBURN. I was, but I would like to speak, if I might.

Mr. COBURN. Mr. President, I was going to call up amendment No. 2829, but I have chosen not to do that because of the plan of the manager of the bill to table it. So I will talk about what it is and make a few observations. Four years ago we got the GAO to start a process on duplication, to look at what we are doing in a multitude of areas across the whole Federal Government. That will be finished, and for the first time it will have taken a complete look. We will see it at the end of this month, the first part of the fourth report. One of their findings was, according to early learning and childcare programs, within 8 different departments there are 45 separate programs--8 different departments within the administration, 45 separate programs, spending $16 billion a year. So the amendment I was going to offer would have forced us to do the metrics to look at what our outcomes are. It would have forced us to consolidate programs, other than major programs such as this one we are debating today, which has been markedly improved and enhanced. Now, I don't want to put the Senate through a timely vote when I know what the outcome is going to be, so I won't call up that amendment. But I would remind my colleagues that the only way we are really ever going to get control of our budget is to do the hard work of eliminating duplication, so that when we have a program, such as the one the manager of the bill has on the floor today, it is really directed, it is focused, it has metrics, and we know what we are getting for what we are spending. Most people don't realize we have 45 of these programs in 8 different departments spending $16 billion a year. So I hope we will consider that this is a great movement on this one particular bill, and I congratulate the people who worked on it-- Senator Harkin and his staff, Senators Burr and Alexander and their staff--because I think they have done a good job. But it is not enough because we are still going to have 44 other programs and we are still going to have programs that don't have a metric on them. We are spending money on them, and we don't know if they are accomplishing what we want them to accomplish. The whole purpose of the amendment was to force us to do that. I understand that is not going to move, and I am fine with that. I will work in every other way behind the scenes to try to accomplish the same purpose.

Mr. COBURN. I yield for a question.

Mr. COBURN. To answer the Senator's question, I supported the Enzi amendment. I don't think it went far enough because you are not going to look at some of the programs that are outside the purview of the Senator's committee. We have eight different Federal departments running these programs. They come from eight different sets of authorizations. So the point is that I am going to work behind the scenes with Senator Burr and with Senator Harkin to try to accomplish this. Amendment No. 2830 Now I would like to call up amendment No. 2830 and ask unanimous consent to set aside the pending amendment.

Mr. COBURN. Yes.

Mr. COBURN. I ask unanimous consent that the amendment be considered as read.

Mr. COBURN. The desk has a modification of that amendment.

Mr. COBURN. Mr. President, what we are trying to accomplish with this amendment--and I have cleared it on our side, and I think it is being cleared on the other side as well--is to make sure the significant amount of money we spend in this area goes to people who really need it. So all this amendment does is require a self-certification when an individual acquires one of these grants that they don't have real assets greater than $1 million. If they do, maybe they should be spending their money rather than taxpayers' money on their kids' childcare. That is all this amendment does. All we have done is to put in there, in the application process, a box they have to check that says: I don't have real assets in excess of $1 million. This will ensure that we know that at least the vast majority--and by the way, 16 percent of this money has gone to people who are very wealthy, in terms of these vouchers. I have that data. I don't have it with me. Actually, I may have it with me, and I will pull it up and speak about that in a minute. But the fact is we want this money to help the people who need help, not to help people who don't need the help. So that is the purpose of this amendment. I have agreed, if it becomes acceptable, to have a voice vote. With that, I yield the floor.

Mr. COBURN

Mr. COBURN. Madam President, on rollcall vote 77 I voted ``aye.'' It was my intention to vote ``nay.'' I ask unanimous consent that I be permitted to change my vote since it will not affect the outcome.

Mr. COBURN

Mr. COBURN. Madam President, we yield back the time.

Mr. COBURN

Mr. COBURN. I will try to make my remarks short. I know several of my colleagues have places they need to be and have a time schedule they are on. I was involved in a committee hearing this afternoon and could not contribute to the debate on the floor on the Flood Insurance Program. I have about 8 months left in the Senate. I just want to remind us of what we have just done. We have solved a very short-term problem and made a long-term problem significantly worse. We did not really do our work because we were in such a hurry to take the political pressure off of the increases in the flood insurance rate. Addressing that issue was important, and I agree that we needed to make some adjustments. But what we did is we chose politicians to win and the future to lose when it comes to flood risk mitigation and flood risk cost for the American public. Are there some positive things in the bill? Yes. But what we did once again is we put our political positions ahead of the best interests of this country. The Biggert-Waters bill was a great reform bill. What happened is when we passed it, we did not recognize the tremendous rate increases many people would have. In the last 5 years in this country, we spent $1.6 billion at FEMA reevaluating all of the flood plains in this country. The whole purpose behind that was to really put a risk of what is out there based on what we have and slowly get to a point where we are actually measuring the risk. What have we actually done when we just passed this bill and sent it to the President? What you did is you asked everybody in the future to continue to pay an exorbitant amount of money for their insurance so people who are at risk will not have to pay ultimately what is due them. The only time we are going to see that actually happens now is when a property sells. That is when we are going to see it. Vacation homes are excepted. I understand that. We are not going to give rebates to people. I understand that. But the big problem is we undermined the incentive to mitigate for risk. We undermined it. So we now have a new flood insurance program. We have $18 billion worth of problems. We are getting ready to go to $26, $28 billion worth of problems, and that is on the heads of our kids. So we once again chose a position that put our kids at risk so we politically can be better off because we are going to alleviate the parochial scream. Rather than actually fix the scream, we are going to alleviate it, and we have eliminated all of that. So my disappointment is not that we responded to parochial requests; it is that we did not do the hard work of actually fixing the problem and addressing some of the parochial problems and anecdotal notes of massive increases in flood insurance. We could have done both, but we chose not to. It is so heartbreaking to me and to this country that we continually choose the politically expedient path that will bury our kids when we do not have to. That is a function of a lack of real leadership, of solving the real problems rather than treating the symptoms of the problems, which is what we did. We have wasted $1.6 billion now, essentially. We might recover it 30 years from now. But the Flood Insurance Program is now not in any better shape and will not be in any better shape 20 years from now than it is today. So I hope we are happy that we have solved the parochial problems, but when you go to sleep tonight think about who is going to pay that bill. It is not the people who are getting the benefit from the very large subsidized flood insurance. It is the kids of this country and what is not going to be provided for them. It is those on the really low rung of the ladder economically. We are not going to have the finances to actually care for those who need the care from us the most. Really, it is the well-healed or the more well-healed and the more well-connected. They won again. The builders and the developers won. The real estate firms won. Less than two-tenths of 1 percent of this whole thing, without even modifying Biggert-Waters, applied to people in the lower 40 percent of income in this country. Less than two-tenths of 1 percent. Seventy percent applied to the top 20 percent of the people. So we gave a break to the most well off people. Those are the numbers. You cannot dispute those numbers. So because they screamed and do not want to pay their fair share, we have now damaged the future potential for our children. I would say congratulations. We continue to do the same thing. No wonder the American people say: What is up with Congress? They do not have the courage to make a difficult, tough decision. What they do is they always make the politically expedient one. That is exactly what we did today. That is what the House did today. To me, it is sickening. The majority leader.

Mr. COBURN

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

Mr. COBURN. Mr. President, I come to the floor again to talk about-- it is my understanding we are not going to be allowed to offer any amendments again on a significant bill that spends billions, tens of billions of dollars--to talk about a couple of amendments I have. My staff recently talked with some veterans from Oklahoma, and I want to give you an anecdote that just happened. This is about VA care. This is a lady, a 100-percent disabled veteran, who has had knee replacements at a VA hospital. She did not have one knee replacement, she had two knee replacements. And then she had two knee replacements on the other knee. If you look at the statistics of a knee replacement having to be replaced, it is a very rare occurrence. But the fact that you would have two knee replacements, and both of them would have to be replaced is unheard of. The story does not end there. The story ends with the fact that during her second knee replacement, they broke her femur. So they had to put a rod into her femur. When they put the implant in, she ended up with one leg an inch longer than the other leg. The fact is that this all occurred at a VA hospital. And it is unheard of that somebody who has a knee replacement on one side would have to have another one done because of complications, and then have the other knee done, and have to have that knee redone because of a complication. But then on top of it, as to the skill of the surgeon in terms of doing a second replacement and having a rod, and then putting the wrong rod in, it creates a leg length discrepancy that can only be corrected now by her spending a significant amount of money on an orthotic shoe on the shorter leg which, if you know anything about medicine, changes the alignment of the spine, which causes tremendous arthritis in the spine of that patient. So here is a patient that if you look across the world in the private sector 99.9 percent of the time would not have had to have either of them replaced, would not have had to have a rod put in her femur, and would not have a leg-length discrepancy. I agree that is an anecdote. But those are the kinds of things that we are not holding the VA to account for. One of the amendments I was going to offer to this bill was a very straightforward amendment requiring every 6 months that the VA publish, in both their hospitals--outpatient--and nursing homes the quality of their care, the mortality rates, the complication rates, the infection rates, the wait times in their emergency rooms, the wait times for a screening examination, the wait times for an endoscopy, the complications associated with those, so veterans could actually see and compare it to the private sector--every other hospital knows all this stuff and publishes it--so they can see and compare the quality of care. Because we have an honor-bound commitment to offer care to those who have offered to sacrifice their life and their future for our freedom. But we are not going to be able to offer the first step in terms of accountability to the VA health system because we get to offer no amendments. What if you knew--and this does not apply and I do not mean to denigrate the whole VA system because there are some great VA hospitals, but in your area, where you have to go, if you knew the quality was 20 or 25 percent less than what you could get in your own hometown, would you still go to a VA hospital? Should veterans not know whether they are getting a standard of care that equates to what they could get in the private sector? They are not going to know because that is nowhere in terms of the accountability of the VA system I talked about yesterday. One of the other amendments I was going to offer would be to strike section 301. The chairman of the committee yesterday referenced section 302. He was actually talking about section 308 of his bill, not section 302 of his bill. But when you expand VA health care to Priority Group 8--these are people who do not meet the income, have no service- connected disability, and have no limited resources--to put them into the VA health care system, when we are not adequately treating the veterans who are eligible for service today in the VA health care system, what you are really doing is taking away our commitment to care for those to whom we have already promised care. So it is somewhat cynical that we would expand from 6 million to a potential of 22 million people in a system that is behind the curve already. The other thing that is important for that is the care for these veterans with nonservice-connected disabilities was excluded from the VA's priority group so the VA could focus--focus--its limited resources on our veterans with service-connected disabilities. In other words, they have a health complication because they served our country. As former Secretary Anthony Principi said: Remember, when everyone is a priority, no one is. That is exactly what this bill will do. It will take the priority away from our veterans with service-connected disabilities to where they will fall further through the cracks. The other thing in this section is--the only thing worse than them being in the Affordable Care Act, which is what this is really specifically designed to do, is to take them out of the exchanges and put them into the VA. So what we are saying under this bill is, if you are a high-income, nondisabled veteran, and the only health care coverage you have available to you is an ObamaCare exchange, then you now qualify for VA services. What is that about? What that is about is moving to a single-payer, government-run, totally government-run health care system. And this is about moving 16 million veterans--or the potential of up to 16 million veterans--to that position. So the only thing worse than being covered by the VA, where veterans are waiting for weeks to see a doctor and literally dying because of medical deficiencies, is being in an Affordable Care Act exchange. This amendment would strike the expansion from the legislation, which would ensure that the VA remains focused on the service-connected disabled and increasing the quality of care for more than 6 million veterans currently in the VA system. I want to talk a minute about why we did that. We created the VA health care system for those who have a complication of their service-- a complication of their service. Do we have a commitment, one, to ensure that those who have a complication from their service get the care we have promised them? I believe we do. Section 301 would markedly minimize that commitment to those who have a complication from their service. So how is it that we have come about, that we have this great big VA bill on the floor, without any oversight, aggressive oversight, on holding the VA accountable to do what it is supposed to be doing now--with a 59- percent increase in budget since October 1 of 2009, and expand it and blow it to an area where we are going to offer these same services, where we are not meeting quality outcomes, we are not meeting timeliness outcomes, we are not meeting care outcomes, and we are going to put that on the VA system? I would say the better way to honor our veterans who have a complication associated with their service is to hold the VA accountable through transparency of their quality. Here is the other thing that has not been studied, and we do not know the answer to this. I certainly do not know it. I cannot find it anywhere. It is this. What does it cost to do an ``X'' procedure in a VA hospital, totally absorbed, versus doing it in a nonVA hospital? Let's assume quality is the same. Would the American taxpayer be better off if, in fact, we delivered that service at a cost that is much less? But nobody has asked for those numbers. The VA cannot give those numbers. The VA does not know those numbers. So we are driving blind. We do not know what it costs to do a total knee in a VA hospital. We do know what it costs in Oklahoma City from every hospital. As a matter of fact, there is a wonderful hospital in Oklahoma City that advertises every price, all their complications, everything else out there. They have people from all across the country coming because they are so much cheaper and so much better than what people in the private market can get done where they live. Let's see how VA cost and quality and outcomes compare to that. If you really want to drive quality for our veterans, we have to have accountability in terms of how we spend money, accountability in terms of the outcomes, accountability in terms of the quality, and accountability in terms of the service. The other amendment that I have would allow service-connected veterans who are driving hundreds of miles--in my State--to get care with a pilot program which would allow them to go anywhere they wanted, to their home town, to the next town over if it is bigger and has higher quality, rather than drive 200 miles to get their care at a VA hospital. We would cover it under Medicare rates, since we do not know the cost ramifications of what we do at VA clinics and VA hospitals, in terms of the total absorbed cost, but we do know what the price would be if we had Medicare paying. My learned opinion is that, No. 1, veterans would have access to care closer to home, probably improved quality, and most probably a decreased cost for the Federal Government, i.e., the American taxpayers in terms of meeting this honor-bound commitment to our veterans. If, in fact, you served this country, and one of the benefits of serving this country--and you have a service-connected disability associated with that--is a promise of quality health care, why do we say you can only get it in a VA clinic or a VA hospital? If you served our country, why can't you get it wherever you want? I mean, you served our country to preserve our freedom of choice, our freedom to do and select what is best for us and our interests. Why can't a veteran have that privilege that he or she fought for and put their rear ends on the line for? Why do we not avail them of the freedom that they sacrificed for? Nobody will answer that question. Nobody will come down and answer that question. Those are knowable answers. They are moral questions. If you sacrifice, should you not have the benefits of the freedom for which you sacrificed? The other problem with this bill is it has a false pay-for, money that we might have spent on a war in Afghanistan. Because we are not going to spend it, we are going to spend it here and call that a pay- for. That is not a pay-for. It does not pass muster. It does not pass the budget point of order on it. Everybody knows that. So what we ought to be doing, instead of having this bill on the floor, we ought to have a bill on the floor that holds the VA accountable, that creates transparency in the VA so that everybody in the country, including the veterans can see outcomes, quality, and cost. Finally, we ought to give the veterans the freedom that they fought for; that if they are deserving of this benefit, they ought to be able to get the benefit anywhere they choose, because they are the ones who preserved the rights and the abilities and the capabilities for us to experience the freedoms to make choices for ourselves. I yield the floor and suggest the absence of a quorum.

Mr. COBURN

Mr. COBURN. Mr. President, I would like to spend a little bit of time offering a viewpoint different from the viewpoint of the chairman of the committee on this bill. First of all, I want to say by context that my father and his two brothers all served in World War II. My two brothers served during the Vietnam era. There is no question we have an obligation to meet our commitments to those who have put their lives and futures on the line for this country. But it pains me that, although we have increased spending 58 percent in the VA programs since 2009, which was fiscal year 2010, what we have seen is a complete lack of oversight of what is happening. Let my give an example. The VA Committee in the Senate last year held 30 hearings, 4 of which were oversight. If you read the transcripts of those hearings, you cannot call them oversight hearings even though they were billed as oversight hearings. Why is that important? It is important because there are a multitude of significant, serious problems in the Veterans' Administration. Just 2 days ago it was discovered that in an L.A. VA clinic, the staff of the clinic destroyed the medical records of thousands of people so that when they do the metric on how far behind they are, we cannot measure it; or the fact that 82 veterans last year died of carcinomas through delayed diagnosis because they could not get a diagnostic procedure, such as a colonoscopy; or the fact that we have all these veterans who cannot access mental health care, and we see the suicide rate-- unacceptable, to say the least. So we have a bill on the floor that massively--and that is a small word for what this bill does--massively expands the authority and the ability of the VA to offer care to another 14 million veterans--from 6 million to 20 million. On a system today that cannot keep up, we have 600,000 people waiting for a disability determination. We are not having oversight hearings on that. We are not having oversight hearings on a South Carolina VA hospital where people are dying from malpractice like crazy. We are not having the oversight hearings to hold the VA accountable. What we are doing is putting a bill to expand their responsibilities instead of holding them accountable for the responsibilities they have today. That is what we should be doing. Instead, we are going to add $60 billion. And that is a conservative number. That is my number. But all you have to do is look at what the cost and the efficiency and the outcomes are through the VA system to see that we are going to diminish the veterans caregiver program by expanding it to everybody. We are going to create all sorts of new programs and no resources to actually provide them. And we are going to create more advanced funding, advanced appropriations, which will limit our ability to hold them capable and culpable in the future. There are a lot of things we ought to be doing for our veterans right now that are already in law that we are not doing, and we come to the floor with a massive expansion at a time when we cannot even care for what we are doing. As a physician who trained in VA hospitals, I know the difference in the level of care. I can assure you it has not gotten any better. From my colleagues I speak to in the medical profession and from the veterans whom I talk to who contact me, it has gotten far worse. It does not have to be that way, but it will always be that way if, in fact, we continue to not hold those in leadership positions accountable for not stepping to the bar for performance, quality, and outcome. From Congress to the Pentagon, we must reassess what laws, regulations, and rules can be changed to ensure that benefits and other decisions the Veterans' Administration makes are beyond reproach and based on the best facts available. Let's ensure that the Department's limited resources are focused on its core mission rather than disbursed in an effort to remedy every possible problem for every veteran. Remember, when everyone is first priority, no one is. That is what this bill is. We diminish the priority of the commitments we have made to the veterans who are out there today. Our veterans are looking to us for help. We are about to enact legislation that is going to further strain the ability of the VA to do its most basic charge: help with the health care, mental health, and capability of those who have put it all on the line for this country. It is shameful that Congress now is trying to claim credit for providing new benefits while our old promises are forgotten. Our heroes--our heroes--are literally dying at the hands of malpractice, incompetency, and delay. If we really wanted to care for our veterans--those with service- connected disabilities--what we would say is, go wherever you want to go to get whatever you need because you served this country. And it actually would cost less. But because we pile them into a broken system now--and that is not all VA organizations. Let me clarify that. There are some excellent VA hospitals that do great work. Their specialists are far ahead of the private sector. But on general grounds, to put a veteran at a place with less than the best possible care dishonors their service to this country--dishonors their service to our country. Veterans are our heroes. They are the symbol of our country of sacrifice, of giving for others. Yet we have four oversight hearings in a year? With the multitude of problems that are going on in the VA hospitals and the Veterans' Administration in terms of disability determination, we have four? The House had 34 oversight hearings, and they were rigorous. When you ask members of the committee: Have you read the House oversight hearings? No. They had 26 regular hearings and 34 oversight hearings trying to hold the VA accountable. We are not going to hold the VA accountable with this bill. We are going to make them less accountable. And that is a disservice to the very people who have honored us by serving in the military of this country. As of February 15, 2014, the VA has 677,000 claims pending for disability compensation. Why should it take a year for somebody who put their butt on the line for this country and received an injury and is disabled? Why should it take a year for us to determine that we owe them an extra bit of compensation and availability? What is being done to fix that? We have a VA regional center in my home town, with good employees, hard-working employees. They are not destroying files so they can say they met a metric. Veterans seeking mental health treatment still experience weeks-long delays scheduling appointments. The epidemic of overprescription of opiates--let me say that again--there is an epidemic of overprescription of opiates for those people who served our country, making them dependent addicts because we give them the wrong treatments. There are avoidable veterans deaths at the VA. In a recent story by CNN on misdiagnosis and improper care for gastrointestinal conditions, there were 2-year consultation delays--2 years to get in to see a specialist at the VA when you are losing blood. How do we explain that? Who is accountable? We are, because we are not holding them accountable. There were 82 deaths last year alone--I am sure that is a far understatement--because of delayed diagnosis for just investigative endoscopies. That is just what is documented. How do we accept that? Had they been in the private sector, they would not have had a delay. They would not be dead. So here is the proposal that I would put out. Do our veterans deserve the best of care in this country? I think they do. Should they be able to get that care where they know the quality, they know the outcomes and the transparency as to what their future might be or must they be forced into a system that is going to give them something less? That is where we are today. The chairman in his bill increases VA medical care for everybody who served without a disability. What will that do to the VA system? We cannot handle what we have in front of us now in terms of those who have a percentage medical disability that allows them access to the VA health care system. So when you triple that or more than triple it, where are the resources? If we really mean what we say in this bill, you are talking hundreds of billions of dollars over 10 years. You are not talking the $30 billion that the chairman says is what the cost is. You are talking hundreds of billions. But the point I would make is we have an infrastructure out there that can care for our veterans. It is the hospitals all around the country. It is the doctors all around the country. Does a veteran not have the right to get the best care? Should we not give him a card and say: You served this country. Here is your service connection. Here is your disability. You can get care at a VA hospital, if you want, or you can get care wherever you want. But I will guarantee you what will happen is, if we give what was promised to the veterans--not what we are giving today--real care, real opportunity with real transparency as the outcome, what you will see is marked improvement in care, marked improvement in outcomes, no change in additional cost--no change in additional cost--and access that is promised but not denied and delayed. In one South Carolina VA facility alone, 20 veterans are either dead or dying of cancer because of delayed diagnoses. They had the symptoms and presented them to the hospital, but because of delay and incompetency--just that one hospital. The other thing we know is veterans' malpractice claims are markedly increasing--markedly. All you have to do is look at the OIG report on the claims of deficiencies at the VA in New Haven, CT. Contamination, cross-contamination, inadequate procedures for infection precautions, absence of employees that are supposed to be on duty when they are not, failure to clean operating rooms properly, failure to have the proper ventilation system in an operating room for a contaminated case. That is just one hospital. What does that mean in real life? What that means in real life is the risk for iatrogenic or facility or physician-caused infection goes through the roof--not the fault of the physician but the fault of the VA for not managing the system properly. Former VA epidemiologist, Dr. Steven Coughlin, testified before the House Veterans' Affairs Committee that the VA failed to follow up on over 2,000 veterans who indicated in VA surveys that they were experiencing suicidal thoughts. When the HVAC followed up on Dr. Coughlin's claims, they found that they were validated. Unfortunately, too many of those who had suggested their problems committed suicide. It is a little late. Because Dr. Coughlin brought this up, he was admonished, bullied, and intimidated for speaking about the ethical lapses at the VA. Where is the oversight hearing? You see, if we are not going to hold the VA accountable, the quality of care is not going to rise to the level that our veterans deserve. Another area is this. The VA wasted $3 billion over the past 10 years because they failed to secure competitive market prices for surgical implants. That is $3 billion. That is documented. That is a GAO study. GAO did that. We did not do it. We did not find it. Oh, by the way, at the end of the year when they had some money to spend, about $600,000 worth of artwork was purchased, instead of putting it into additional doctors, cleaning operating rooms, additional people to secure clearances on disability. By expanding VA care and the potential of 22 million more veterans, you can guarantee that the veterans who are getting care now are going to get poorer quality and less access to care. You can guarantee that. That is what this bill is really about. This bill is really about a decrease in the requirements for care for our veterans. It is not about an increase. It is about a decrease because when you flood that system with people who do not have a service-connected disability, what will happen is this. Easy goes first and hard goes last. I have seen that in the VA my whole life. There is also an expansion in the caregivers program. I am not sure I disagree with it. But certainly, for those after 9/11 a commitment ought to not be diminished if we expand this program. The minimum cost for that is $9.5 billion. The VA has not yet met its full obligation under the VA caregivers law that we have today. Yet we are not holding them accountable. There is another area in this bill that I think is tragic. It is well intended, but it mandates that the University of West Virginia or the University of Oklahoma must give in-State tuition to anybody from anywhere that has ever served or they lose their benefits under the GI bill. That totally ignores the Constitution in this country. Now, 20 States have already said they are doing that. Ten others have bills in the process. Eight others have a partial. So we are at 38 of the 50 States right now. But in our vision, we are going to mandate that the Tenth Amendment does not mean anything, that the 80 percent of funding on higher education in Oklahoma that comes from people in the State of Oklahoma, that we can co-opt that and coerce them and tell them what they are going to do. It is well intended. But it is certainly not constitutional. It certainly does not respect the Tenth Amendment of the United States. Does Oklahoma or West Virginia have the right to make a decision on who they give in-State tuition to? Why not just pass a law that says: Every State will give in-State tuition to everybody. The reason it was connected with States is because of State funding. We totally trample that. Again, the advanced appropriations will limit our ability to hold those people accountable for the very things that I have described to you. But we are going to do it anyway. A proposal to expand VA advanced appropriations needs to be considered by the administration as a part of an across-the- government review of the advantages and disadvantages of such progress, not only for the VA but potentially other programs and agencies. Only in the context of such a broad review could the administration offer an opinion on making such a change for the VA. Therefore, we cannot offer a position. That is from the VA. The real answer is: Give us advanced appropriations, and then it is only after the fact that you can hold us accountable, not during the fact. Here is another GAO study that we should be highly concerned about. The VA--this is the GAO--has no idea how long most patients wait to receive care. They do not even know their own metrics. It is unclear how long veterans are waiting to receive care in VA's medical facilities because the reported data are unreliable, because VA hospitals have tried to cover up wait times, fudge numbers, and backdate delayed appointments in an effort to make things better than they are. That is directly from a GAO report. Where is the oversight hearing on that; or the L.A. facility that just destroyed medical records so nobody could know how long people had been waiting for appointments? Based on GAO recommendations to improve reliability of reported wait times for new medical appointments in 2013, the VA changed the way it tracks and calculates its performances. Using the new tracking method in 2013, the VA reported only 41 percent of veterans were scheduled for a new primary care appointment and only 40 percent of veterans were scheduled for a new specialty appointment within the 14-day standard. So 40 percent of the time, with the 6 million veterans we have now, they are getting adequate timely care, and 60 percent are not. Yet we are going to expand that to 22 million, and we don't have the resource base or the facility base or the employee base or the professional base or the caregiver base to do that? In contrast, in 2012 the VA reported that 90 percent of new primary appointments and 95 percent of specialty appointments had met the 14- day standard. The VA exam requests backlog purge. VA employees destroyed veterans' medical records to cancel backlog exam requests. That is from Patrick Howley, again. Oliver Mitchell, a marine veteran and former patient services assistant at the Los Angeles VA system, told the Daily Caller: We just didn't have the resources to conduct all those exams. Basically we would get 3,000 requests a month for medical exams, but in a 30-day period we only had the resources to do about 800. That is 25 a day. That rolls over to the next month and creates a backlog. It is a numbers thing. The waiting list counts against the hospital's efficiency. The longer a veteran waits for an exam, it counts against the hospital as far as productivity is concerned. Some patients were waiting 6 to 9 months for an exam, and the VA didn't know how to address the issue. Is the answer to open this to another 16 million veterans or is the answer to improve the efficiency, transparency, quality, and outcomes of the present VA system before we go about expanding this system to people who are otherwise covered? Mr. Mitchell, when he tried to sound the alarm on the VA's deliberate attempt to fraudulently reduce the backlog, was transferred out of his department and eventually terminated from his job. After he contacted Congress in 2011--2 months later when the VA found out about it--he was fired. So do we really want transparency in what we are doing? Do we really want to know what is going on? Do we really want to fix the system? Do we really want to offer health care to veterans and make it equal to what they can get in the private sector or do we want to say we want to offer all these new benefits at the same time we are not meeting our commitment on the benefits we have already promised? That is the game that is being played. Earlier I said the VA said the Committee on Veterans Affairs held 30 hearings. They only held 16--16 hearings; 1 every 3 weeks. The annual budget of the Department of Veterans Affairs exceeded $134 billion a year. Delay in vet care is not for the lack of money. The delay in vet care is not for the lack of money, it is for the lack of accountability in management. Case in point: More than 20 veterans have died or are dying due to late diagnosis and treatment of cancer at the William Jennings Bryan Dorn Veterans Medical Center in Columbia, SC. Documents show only one-third of that $1 million appropriated by Congress to fix the problem was used for its intended purpose at that VA facility. Only one-third of the money we appropriated to fix this problem was actually used to pay for care for veterans on waiting lists. At the same time, the documents show the waiting list at Dorn kept growing to 3,800 patients in December of 2011. I will be back to speak on the floor and offer amendments. I have pages and pages of examples of veterans who served this country honorably, proudly, and sacrificed to a great extent, who are getting substandard care in the system we are offering them today. Before we expand that system, what is needed is a rigorous oversight and debate about how we are doing what we are doing now. The promise of access to care for our veterans, as shown by VA centers and clinics all across this country, hospitals all across this country, diagnostic procedures all across this country, reflects that when access is delayed, that care is denied. And that is what is happening right now far too often to the people who have served this country. We ought to be about fixing that and holding accountable those in the responsible positions, and holding ourselves accountable to do what is necessary to give at least the standard of care they could get anywhere else in the country. That is the direction in which we should go. I thank the Presiding Officer for the time, and I yield the floor.

Mr. COBURN

Mr. COBURN. Madam President, regardless of which side one falls on the Ryan-Murray budget deal reduction in the annual COLA increase for working age military retirees, the sad fact is with the passage of this legislation we are breaking our previous promise to taxpayers to reduce the deficit. Instead of coming up with a real offset for a mere $6.2 billion in spending, the Senate has chosen to resort to budgetary gimmicks to disguise the true cost of our politically expedient decisions, and has yet again punted the hard decisions that must be made to future generations. By offsetting real and immediate spending with a promise of future spending reductions with the extension of sequestration cuts to Medicare through 2024, beyond the 10-year budget window, the savings from this budget trick will not materialize and taxpayers will not be made whole. By passing this legislation, we are sending a signal that this body does not have the fortitude to lead as our constituents have chosen us to do--to take on the sacred cows like military compensation that must be part of the national conversation about our spending and reform. As we prepare to pass this legislation, every Member of this body would do well to consider these words by former Joint Chiefs Chairman Admiral Mike Mullen: ``The most significant threat to our national security is our debt.'' We best honor the sacrifice of our military veterans and realize a more safe and secure future by keeping our promise to reduce the national debt. By refusing to come up with a real offset to pay for the repeal of the COLA cut, the Senate is undermining our veterans, our country, and our future. I yield the floor.

Mr. COBURN

Mr. COBURN. Mr. President, I have 20 to 30 minutes. I would appreciate it if the Presiding Officer would notify me when I have consumed 15 minutes.

Mr. COBURN. I have been in the Congress for a lot of farm bills. I saw ``Freedom to Farm.'' I saw the last farm bill, the one before that, and now I am looking at this one. It reminds me of the auto commercial--something's up. Well, it sure is. Only in Washington can we claim a bill saves $24 billion when it increases the spending 43 percent over the next 10 years. How does that fit? Is that just the language of Washington? In fact, we are going to spend almost $1 trillion over the next 10 years on what should be called a food security bill rather than a farm bill because this is not a farm bill. This is a food security bill. The language we hear from our colleagues is totally parochial or product based. We hear all the claims that we are thinking about the best interests of the Nation. What we are truly thinking about is the best interests of the parochial values for our own States. That is how we get this conflagration of people coming together to pass a bill that, I admit, has some limited reforms in it. I just heard the Senator from North Dakota talk about how we create wealth. I could not disagree more. We create wealth by making sure the risk of capital investment is responsive to market forces. This farm bill is anything but that. There is no response to market forces because there is no place else in this country where someone can go into a business or an enterprise and be guaranteed that their revenue is going to be secure. We even added a new supplemental low-cost Crop Insurance Program that all of us who are not farmers in America are going to pay the deductible on. Plus, we are going to subsidize 62 to 63 percent of all the crop insurance in the country. When we subsidize crop insurance, what we are doing is taking the capital risk and modifying the risk; therefore, markets are not going to work. We talk about sugar prices. Americans are losing candy manufacturers like crazy. Why is that? Because Americans pay twice as much as the rest of the world for sugar because we are protecting cane sugar and beet sugar farmers rather than letting market forces work. I am very disturbed at the process of this bill as well. Senator Durbin and I tried to put some income limitations on the benefits to the wealthiest in this country when it comes to crop insurance. It passed this Senate with 64 or 65 votes. It was in the bill when it left here. The House passed the same thing by a voice vote and the conferees took it out. What is the farm bill about? It is about protecting the well-heeled and well-connected in the agricultural community. I know a little bit about agriculture. My dad ran a ranch with 5,000 mother cows. I worked on it in the summer and after school. Back then-- in the 1970s--there were no benefits for a cattle rancher. That has come into the farm program since the 1970s. It guarantees them that now they will make decisions that are against market forces but will farm the government. So I say again, only in Washington when we are going to spend $350 billion more on a program over the next 10 years will somebody claim we are cutting spending $14 to $20 billion. Only in Washington will that happen. It is unique Washington accounting. We have heard all the proponents say what a great job they did. Let me talk a little bit about some of the details of this farm bill. One of the things the President talked about--he just put Joe Biden in charge of the job training programs. He is supposed to look at all of them to see if they have metrics. The GAO has studied that. I have looked at every job training program--State and Federal--in my State. They have 10 job training pilot programs in this bill. We don't need any more job programs. What we need to do is make sure the ones we have work and have metrics on them. We need to make sure that when we spend American taxpayers' dollars that we are actually giving somebody a life skill rather than filling the coffers of the companies that contract to do all the job training programs or allowing the small bureaucracies that suck up the grants. Oklahoma's Federal programs are highly ineffective--especially when we compare them to the State-run programs, which are highly effective. So in this farm bill we are creating more job-training programs. It sounds good. It is a good sound bite on the floor, and it is a good sound bite in the press back home. But something is up, and what is up is we continue to make the same mistakes as a legislative body. That mistake is that we want to please constituents at home more than we want to fix the real problems in front of this Nation. Let me talk about SNAP for a minute. There is not anybody in this country I want to go hungry. When this country was first founded, we used some very good principles that the Senate and the House have totally disregarded in terms of how to help people. I reference the historical blueprint from a book written by a man by the name of Marvin Olasky. The title of that book was called ``The Tragedy of American Compassion.'' It talks about how we used to help people versus how we are helping them now; how did we build up people as we helped them versus now; how are we tearing down people as we help them. It talks about creating dependency versus creating responsibility. He outlines several factors this country has used in the past that we ought to be reembracing. Let me list a couple of them. One is we should give relief to people only after one-on-one personal investigation of their need. Let me say that again. We ought to know they need it. Contrast where the money is coming from. The money is not coming from today's taxpayer when we are running a $640 billion deficit. The money is coming from our kids and our grandkids. Do we not have an obligation to know that when we give somebody a SNAP card they truly need it versus the fact that the SNAP cards and PIN numbers get sold? The SNAP card is then used by somebody else. That is going on throughout this country. That is not to say that most of the people who are getting this benefit don't need it. Because there is no personal investigation into it and there is no accountability on the part of the receiver or the giver, we are creating a situation in our country where we are undermining self-reliance. The second point he made was to give necessary articles and only what is immediately necessary. That means you have to investigate it in order to give what is least susceptible to abuse; to give only in small quantities and in proportion to immediate needs and less than might be procured by labor except in cases of sickness. That is a great principle. Let's help people, but let's help people help themselves. Let's don't create a situation of temptation to do the wrong thing; to give assistance at the right moment, not prolong it beyond duration of the necessity which calls for it. We don't do that at all in any of our programs; to require each beneficiary absence from intoxicating liquors and drugs; to discontinue relieving all who manifest a purpose to depend on alms rather than their own exertion for support. I don't have one problem paying my taxes to make sure people don't go hungry and have food on the table for their kids. I just watched a documentary my daughter referred to me. I have to say, as a physician, I understand the scientific tests and the great research that went into this. It is called ``Forks Over Knives.'' It makes the case that most of our health care cost is based on our diet. It is very accurate and well done--except we have no limitations. Senator Harkin and I have tried for years to get limitations on how food stamps and SNAP cards are used. We can't budge anybody to say we ought to limit it to healthy foods, because for every $1 we spend on food, we are creating $1 in health care costs down the road. I recommend that my colleagues watch that study. It is unbelievable in terms of heart disease, diabetes, and hypertension. No medicine, just a change in diet, and all of a sudden those things go away. They go away because we take Big Agribusiness's push to use what is profitable out of the food chain and then start supplying foods that are actually good for us. It seems to me Congress looks backward instead of forward when it comes to the farm bill. One of the things we ought to do is look at the world and what the population is. I also wish to say that some of the hardest working people in this country are the people who are in agriculture. I don't say these things to demean them, but markets do work. We hurt our farmers when we take them away from market forces because that will cause them to make decisions that are false choices when it comes to capital investment, and those are false choices for our country because that means capital is going into something that is subsidized by the government rather than going into something that is not subsidized that will create a greater good and more wealth for our country. This bill does exactly that. You realize in this bill you are guaranteed 86 percent of your revenue. Let me think about that. Do you know anywhere else where you can get your revenue on your crops guaranteed at 86 percent and the Federal taxpayer is paying most of the cost of the insurance for that? Individuals in Oklahoma, Maine, and Virginia are paying higher tax dollars so we can create a system where we are investing in crops that are not necessarily good for us and causes us to pay a higher price for a domestically produced crop versus world markets; whereas, we could direct the same inputs into a product that is much better for us and we would be much more competitive. One of the points I wish to make is that in 2013, net farm income was $131 billion. That is 16.5 percent over what it was the year before, in an economy that is only growing less than 2 percent. Yet we are going to spend almost $100 billion a year in the future, of which only 18 percent of that will be for agricultural programs, outside of the Food Stamp Program. We are going to spend $18 billion to misdirect capital in a way that, in the long run, we won't see that kind of growth. I will finish with other commentary. It is necessary that we have a farm program, but there is one little trick in this farm bill that everybody ought to be aware of. It is the pressure for the next farm bill that is put in this farm bill, and my colleagues know what it is. They didn't eliminate any of the permanent law that is on the books; they just let it stay there, and then we created the farm bill for 5 years. What is the purpose of that?

Mr. COBURN. I thank the Chair. The purpose is so that in 10 years, and in 5 years when we come to another farm bill, the default position will fall back to 1940s-era agricultural law, which will create pressure to do a farm bill again. If we do the same next time, it is going to cost $1.5 trillion over the following 10 years. My best friend is a feed corn, soybean, and wheat farmer. The farm is in excess of 2,000 acres in Oklahoma. On breaks, when they are harvesting, I go down there and drive a grain buggy. I have only bent the auger on it once. I hear it from a farmer's perspective. Do my colleagues know what he tells me? He tells me we don't need this anymore. We don't need it. We need decisions on capital investment to be made on risks and markets. No one can tell me, when we have $131 billion in net farm income this year, that we need to be subsidizing 86 percent of everybody's product, guaranteeing them, no matter what happens in yield or price, they are going to get 86 percent. The cost of this bill isn't just the $1 trillion we are talking about; it is going to be much higher. We have had historically high commodity prices. They have moderated somewhat, but if they go back anywhere close to historical prices, this bill is going to cost at least another $100 billion, just in one program alone. CBO's assumption is that we are not going to do that. But most of the leading agricultural economists in this country think corn is going to be under $4, it is going to be $3.75, and wheat will decline and soybeans will decline. So the score we have on this bill is nonsense because it doesn't reflect the reality of what is happening out there. I appreciate the hard work people did on the farm bill. I am highly critical of adding new job programs. I think we have missed it completely. We don't even know what the real problem is in terms of job training in this program, and the 10 pilot programs aren't going to make a difference anywhere. What we ought to have is real programs that are WTO-compliant, that reconnect capital investment with the real world forces of market prices and markets. We spend $200 million a year just on one program--assisting farmers selling their products overseas. Do we know what sells products overseas? Price, quality. But we have a little $200 million program that everybody in organized agriculture gets to take advantage of. They get a couple of trips a year on the Federal taxpayer. It ought not be so. If we want to promote products, we ought to be out promoting them. We shouldn't be promoting private brands with Federal Government money. We ought to create the opportunity to promote it, but we shouldn't be doing it. Needless to say, I will not be voting for cloture. I will reemphasize that Senator Durbin and I had a great amendment. Those who signed the conference report and took that out can't stand up and say anything about anybody who is wealthy in this country or the tax rates or anything else, because they just gutted one of the things that would have put back equality in terms of the farm program for the very wealthy in this country. We are continuing to pay hundreds of millions, if not billions, of dollars monthly to the most well-connected, well- financed, wealthiest people in this country because they are farming the farm program. By taking that out, those who did lost all moral authority to ever say anything again about income inequality in this country, because those who signed the conference report chose to take that out. We understand how politics works. I understand how politics works. But credibility is important in our country and we are losing it. We are losing it here. Look at the polls. We have lost it in the Nation's Capital as far as the American people are concerned. We haven't just lost credibility; we are losing legitimacy, because we wink and nod to do the parochial vote, even though in the best long-term interests of our country we are doing the wrong thing. But it sure sells well at home. I yield the floor.

Mr. COBURN

Mr. COBURN. Mr. President, what the sponsors claim about my amendment is factually incorrect. Their statement is that all the States and everybody wants to do the NARAB bill. I agree, we should do it, but if all the States really want to do it, my amendment has no effect whatsoever because it allows an opt-out for a State that doesn't want to do it. So either it is true that they all want to do it or it is not true that they all want to do it, and we are going to force some States to not do it. An opt-out protecting 10th Amendment privileges of the State is highly required to make sure we do not go outside the bounds of our legal obligations. I reserve the remainder of my time.

Mr. COBURN. Mr. President, if this is true, with no opt-out, then why not do it for lawyers? Why not do it for doctors? Why not do it for every other thing that is licensed that would be better for consumers? To not give an opt-out is not right to the individual States. I support the bill; I just think we need to have a protection for the States. And the reason there is opposition to this is because there is obviously some people who don't agree that everybody is on board. I yield back.

Mr. COBURN

Mr. COBURN. Madam President, I am waiting on Senator Menendez to come to the floor on a point of order, but I do ask unanimous consent that we temporarily set aside the pending amendment so I may call up my amendment No. 2697.

Mr. COBURN. I ask unanimous consent that the amendment be considered as read.

Mr. COBURN. I see Senator Menendez is now on the floor, and what I wish to do is talk a little about this bill. This bill is going to add $900 million in additional budget authority and outlays over the next 5 years with no offsets, period. The sponsors claim the bill is offset over 10 years but relies on a budget gimmick that assumes Congress would not raise the NFIP borrowing authority once it hits the cap. That has never happened. And in the absence of sufficient borrowing authority, the program would delay payments of insurance claims until additional resources became available. So in reality this bill will add another $2.1 billion in debt to the NFIP while making no substantive changes to address affordability issues. Even the administration states that delaying implementation of these reforms would further erode the financial position of the NFIP, which is already $24 billion in debt. This delay would also reduce FEMA's ability to pay future claims made by all policyholders. NFIP is unaffordable to the American people as the program is currently already more than $24 billion in debt. The pending measure, S. 1926, a bill to delay the implementation of certain provisions of the Biggert-Waters Flood Insurance Reform Act of 2012, and to reform the National Association of Registered Agents and Brokers, and for other purposes, would violate the Senate pay-go rule and increase the deficit. Therefore, I raise a point of order on this measure, pursuant to sections 201(a) of S. Con. Res. 21, the concurrent resolution on the budget for fiscal year 2008.

Mr. COBURN. Madam President, this country is in serious trouble with its debt, its unfunded liabilities, and its continual habit by its elected representatives to not live within its means. Waiving the Budget Act so that we can delay a reform on something that needs to be reformed does not make sense. I have no doubt I won't win this budget point of order, but the American people need to be paying attention. Here we go again, not doing the hard, tough work of making choices about priorities. We passed a bill, the Biggert-Waters bill, it was signed into law, and now, because it is starting to come into effect, we are going to delay it for 4 years. It is going to cost billions. Then we are not going to solve the problem. And don't forget, this is not about keeping Biggert-Waters intact, it is about making it go away. That is what it is about. I am adamantly opposed to the waiver of the Budget Act and I will await the call of the Chair on the vote. I yield the floor.

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