Thomas Coburn

Mr. COBURN

Mr. COBURN. It is really interesting. The tax bill that the President is saying that he is going to veto also adds, for those people who work for an employer who does not provide it, above-the-line deduction for their health care benefit. So what we actually are doing with the tax bill that is going to the President is, if you work for an employer that does not provide health care, we are giving you the same benefit we are going to give that employer. You are going to be able to deduct that above the line of your adjusted gross income so that you do not pay taxes on that income, and it becomes a straight deduction. That is another way of giving you freedom.

Mr. COBURN. Well, if we think about it today, that if you are in a fee-for-service plan that you are paying for yourself, you have all of those rights. If you have no insurance, you have all of those rights today. The people that do not have those rights are in the programs that have been designed by the Federal Government and have been designed by the large corporations to try to control the costs. And there is no incentive for the individual consumer, who is a part of those systems, to help control the costs. So if in fact we move to a point where we had some personal responsibility and accountability and our health care was in our hands instead of some third party, whether it be the Federal Government or our corporation that we work for, which is a great benefit but, in fact, in today's time that is one of the things that is part of our remuneration is our health care. The other thing I would say is that most Federal employees have those rights, too. They get fee-for-service. We give Federal employees a wonderful choice of options, and they can go fee-for-service and they have every right there that they have. How is it that Federal employees, except military and retired military, how come people who are in fee-for-service that are paying for their own have those rights but the rest of us who are dependent on a program no longer have that freedom? That is a basic question that Americans ought to be asking themselves any time they hear any politician during this election cycle talking about a patients' bill of rights. They are talking about the wrong problem.

Mr. COBURN. Mr. Speaker, I thank the gentleman for his comments. I want to go back to really what we opened with, because so much partisanship has gone on and so much of the politics that the American people are seeing today throughout have to do with the patients' bill of rights. As I understand the medical system industry profession and patients today, and by the way I just remind my colleague, as he knows, that I have continued my practice, since I have been in medicine, delivered over 400 children since I have been here in this past 6 years and have continued to engage the managed care industry when I have been at home, we should not be having this debate. If Americans truly had the freedom that they once had, we would not be having a debate. We would not be about fixing the wrong problem.

Mr. COBURN. Mr. Speaker, there is no question today that oftentimes, and even as I have been in Congress as I have continued to practice medicine, proper care has been denied patients in my practice by HMOs and insurance companies. It is not just HMOs, it is insurance companies, as well, that are making those decisions. And it is not necessarily medical personnel within those companies, but clerks, trained individuals who know how to read a check-off chart that decide who gets care and who does not. I want to go back to what I talked about first. The greatest freedom we have in this country is the right to choose, the right to choose what kind of practitioner we are going to go to, whether or not we are agreeable to and satisfied with the individual that we have chosen to do very, very personal things with us as we manage our health care and do preventive health care. And in fact too many in this country have lost that right. I do not believe the answer to it is to create another government bill. Although that may be a short-term solution, it fixes the wrong problem. The problem is not allowing people the tax credits, the deductibility and the options of making those choices themselves and, most importantly, also having a small financial responsibility associated with that. One of the things that we know in medicine today is there is tremendous over-utilization. And one of the reasons it is over-utilized is because there is no personal cost to utilize it. And when we see that, what we know is we do not allocate the resource properly. So as individuals become empowered and they also take on a small portion of that responsibility, their decisions about how they utilize that asset and that service will change. But, most importantly, bureaucrats should not be making the decision and certainly not lawyers.

Mr. COBURN. I do. I think, in fairness of the debate, I want to make sure that people are aware that, when that bill passed the House, I did indeed cast a vote for it. And there was a very good reason that I cast a vote for it. I thought we ought to move the process along to try to solve some of the problems. And it is very apparent to me that what I would like to see and I believe the gentleman from Arizona (Mr. Shadegg) would like to see in terms of deductibility and people truly having choices across this country is not going to happen this year. So then the question becomes should we do something in the meantime until we can put power of choice back into the hands of every American who needs health care. I can relate an experience that to me that I think just shows the problems associated with managed care in this country, and it is denial of care that is recommended by a doctor when in fact, and this is a real incident and I will not go into the details of the case or the individual's name out of medical confidentiality, but needless to say, I had a patient who needed a diagnosis that was turned down. As it ended up, I ignored them and went on and did it anyway. And it was a cancer and it was identified. And then they were all too happy to pay for the procedures that they had been denied prior to that. So how do we solve that? If you do not have an aggressive doctor that is going to buck the HMO and you have no external appeals panel, then the only way to solve that is to go to court. Well, that is not a good way to solve it because what happens is patients do not get treated. That is why the standard of care ought to be the professionally accepted standard of care across this country. That can best be decided not by an HMO bureaucrat and not by a doctor working for an HMO or managed care plan, because they quite frankly have a bias and that is for their employer, as it should be, but by three independent doctors. And every denial that is felt qualified by a doctor ought to have that chance to be reviewed by their peers to see if in fact that is the standard of care. There is a couple things that come out of that. Number one, where we know this is working, which is in Texas now, is that 45 percent of the time the doctors on the panel say the doctor is wrong. What happens then? It improves the quality of care because it raises the level of knowledge of the doctor that was asking for something. The 55 percent of the time when the plan is reversed, the patient gets the care that they need and the plan learns. So any system that is designed ought to be designed so that it advances care and lowers cost, not increases them. Delay in diagnosis, delay in treatment is the number one cause of medical malpractice suits in this country today. And I would tell you that the managed care industry is tantamount to being a large portion of that because of the restrictions. As my colleague has said, and I agree, we must have an exhaustion before we go to lawsuits before we are going to care for patients.

Mr. COBURN. Mr. Speaker, I rise tonight with the gentleman from Arizona (Mr. Shadegg) to talk about health care in America. It is Sunday night. We are in Washington. The politics, rather than people, are front and center stage within the House and the White House and the Senate. A lot has happened in the last 6 years since I have been in Congress, but nothing has happened to fix the real problems. I want to spend just a little bit of time creating a set of circumstances that the American public might hear tonight about where we find ourselves. If Americans are in an HMO today or in an insurance plan that is a PPO, a Medicaid HMO or if they happen to be fortunate enough to have pure fee-for-service medicine, the one thing that they know is that over the last 10 or 15 years they have lost a tremendous amount of their freedom. They have no ability to choose the physician or the health care provider that is going to care for them. That very personal aspect of their life, they no longer have a choice. If Americans are in Medicare, they cannot go outside of Medicare to a physician who would not take Medicare. They have no right to do that under the laws of Medicare. A doctor in this country today, if, in fact, they do not take Medicare and then treat a patient who is in Medicare, will be fined for treating that patient because they are not a contractor to Medicare, even though the patient might want to pay that money themselves. The point I am making is that all of us, the vast majority of us, have lost a significant amount of freedom when it comes to making decisions about our own health care. That has been displaced by one or two or three other organizations. The first place it has been displaced is by the Federal Government. The second it has been displaced by the payer, it is actually a part of wages, that benefit, that health care, who is making that decision for the employee. They decide what group of doctors they can go to. If Americans have Medicaid and are in a Medicaid HMO, they do not have the choice of going to the doctor that they want to. They will go to the doctors they are told to go to. Mr. Speaker, we have lost a tremendous amount of freedom. We have heard a lot of discussion in the campaign rhetoric about a patients' bill of rights. I want to say that if we really had our freedom back, a patients' bill of rights would not be necessary. And the way to get our freedom back is to allow each of us to have that benefit, and we decide personally what we do about our own health care. That is a huge step in the opposite direction the country is going. The second thing I want to talk about is what we have been hearing in the political rhetoric of the campaign about prescription drugs. Every politician in the country has an answer on prescription drugs, except the right answer. The problem with prescription drugs in this country is they are too expensive. And the reason they are too expensive is because there is no longer competition within the pharmaceutical industry. There is no longer a true competitive industry in the pharmaceutical industry. How do I know that? Because we have seen the studies. We have seen the collusion. We have seen the fines, hundreds of millions of dollars of fines being charged to pharmaceutical companies. A letter was sent over a month ago to the Attorney General of the United States asking her to look aggressively at competition in the pharmaceutical industry. She has yet to answer that letter that was sent by myself early this summer. The fact is we know in America, in our competitive society, that the best way to allocate resources, to keep prices the lowest they can be, is to make sure we have competition. What is the politician's answer? Let us create a Government program. Let us create more Government control, rather than less. Mr. Speaker, what we need to do in the pharmaceutical industry is to enhance and enforce the laws that we have today; and we will see pharmaceutical prices go down. The American public is subsidizing prescription drugs for the rest of the world. It is time that stopped. A Government program will not stop that. A Government Medicare program for prescription drugs will not stop that. All that will do is lower somewhat the prices for seniors and raise them for everyone else. So if we continue to fix the wrong problems in our country, what we are going to have is a worse health care system, not a better one. Some people would like to see that because they believe the Government ought to be in control of all of it. I do not happen to be one that feels that way. This House passed a bill this past year called the patients' bill of rights. It is extremely flawed in its ability to help patients and to put doctors back in charge, with their patients, of the care. It is a step in the wrong direction. We should not be doing a patients' bill of rights. What we should be doing is a patients' bill of fairness so that we own our health care, we make decisions about our own health care, and we are responsible for our own health care. Those benefits that now come to us through an employer should come to us directly, allowing us to choose. As a Medicare patient, allowing them to choose. As a Medicaid patient, allowing them to choose. The only people who really have freedom of their health care, and they do not have much health care because they do not have insurance, but nobody is telling them who they can and cannot go to. Mr. Speaker, our country was founded on liberty. We have lost tremendous liberty when it comes to health care in our country. A Government fix is not the answer. The answer is to reinstitute what we know works: Rigorous competition to allocate scarce resources. Mr. Speaker, I yield to the gentleman from Arizona (Mr. Shadegg).

Mr. COBURN. I thank the gentleman from Arizona (Mr. Shadegg). It a pleasure to work with the gentleman, as usual. I appreciate all of the work he has done in health care in this Congress. I think the American people ought to ask themselves one question, do I get to choose my doctor, my health plan, and, if not, why not? When you hear all of the political rhetoric, it will all pencil down to choice, and what is happening today in America is we are losing freedom, we are losing liberty, when we cannot even have the basic right to choose our own doctor.

Mr. COBURN

Mr. COBURN. Mr. Speaker, will the gentleman yield?

Mr. COBURN. Mr. Speaker, I have a question, not so much for the gentleman, because I have a great deal of respect for the fact he is indeed a fiscal conservative. Many of us are very upset that we are spending as much as we are. But if what the gentleman is saying is true, then perhaps what we ought to do is just go back and take the President's original request and pass them and send them down to the White House. Is the gentleman telling us that he believes the President would sign those bills in those amounts? That is a simple question, because, if that were true, that is what we ought to do, and we could all go home. But I know the gentleman from Texas (Mr. Stenholm) knows this as well as I do, every day the bar gets moved. We are not even talking about what the President asked for. Most of the stuff that has been put in the bill right now is at the President's or White House's request. We are upset we are going over the spending caps. We are now at over $1.9 trillion. We think that is enough. But every day the bar moves. When I have told some of our leaders, maybe we ought to go back to what the President asked for and give him exactly what he asked for, you know what they all say? He would veto it.

Mr. COBURN. Mr. Speaker, if the gentleman would yield further, I would say to the gentleman from Texas (Mr. Stenholm), I voted with you every time you put your budget up; and I want to tell you, your claim we would not be here I believe is in error, because this institution has a flaw in its design, and the design is it is easy to spend money and it is not easy not to spend it. If there is anything that needs changing in this Congress, it is the appropriations process, whereby staff members, not committee members, know what is in the bill, and backroom deals are done and the spending rises. That is the first thing. The second thing is the House is gamed against the Senate, the Senate is gamed against the House, and then the President games them both, and the American people are getting a raw deal.

Mr. COBURN

Mr. COBURN. Mr. Speaker, the fact is we passed a budget out of this House, and we passed the appropriation bills out of this House within $1 billion of that $601 billion. That is a fact. All 13 bills went out and went out on time. Now, the question is, the question the American public ought to be asking is, what happened after it left the House? And I hope some day they will know how this process works and put people up here who will not allow it to continue.

Mr. COBURN

Mr. COBURN. Mr. Speaker, let me just give my colleagues some facts. One of my friends that I went to high school with managed the health care for Wal-Mart. Wal-Mart discovered 7 years ago that HMOs are a terrible way to provide health care; it costs more. It costs them 19 percent more. They no longer have any HMOs. The other thing, and I am sure that the gentleman is not aware of this, is that both sides of the aisle, when these bills were both in the Committee on Ways and Means and in the Committee on Commerce, had near unanimous votes on all of these issues, specifically the HMO funding, much to my chagrin.

Mr. COBURN

Mr. COBURN. Mr. Speaker, if the gentleman will continue to yield, I see the gentleman from Louisiana (Mr. Tauzin) has already gotten into the gentleman's head, when the gentleman from Missouri calls my charges erroneous.

Mr. COBURN

Mr. COBURN. I thank the gentlewoman for that assurance.

Mr. COBURN. I yield to the gentlewoman from New York.

Mr. COBURN. I thank the gentlewoman, and I reclaim my time. I would just say the following thing: information is powerful. Women in our country are smart. They make good medical decisions. They can and must be informed of the risk of this virus. Seven million women this year will become infected with this virus. Not all of them will develop cervical cancer. But if one does, we have not done our job.

Mr. COBURN. I have the assurance of our leadership. What I want is the assurance of the Women's Caucus that they want women in this country to be informed about this risk.

Mr. COBURN. Mr. Speaker, I want to thank the gentlewoman from North Carolina, who is a very dear friend of mine, and want to say this: There is no question I have lost the battle on this bill to have women have the knowledge about what the risks are from this virus. And that has been my goal all along. Every Friday and every Monday that we are not here, I treat women. I hate this virus. I hate it worse than HIV. Because what it does is it takes the self-esteem away from a woman. A woman feels dirty when she finds out that she has got this virus. Unfortunately, we as a body have condoned the message in this country that says to our young children and young adults that they can have safe sex. That is a lie. A condom offers no protection from this virus. The NIH has stated so. As a matter of fact, NIH Dr. Richard Cosner has stated that no additional research should be done on the efficacy of condoms as related to this virus because the studies are irrefutable that a condom will not protect them. I understand the concerns of the gentlewoman from New York and the Women's Caucus in this. I want a breast and cervical cancer bill. I have three close family members with breast cancer. I want this. I want this for the women in my practice who have trouble getting treatment when they are working and do not have health insurance. I do not mean to be an impediment. But if we take the same track on cervical cancer, on prostate cancer, and now 20 percent of the gay men in this country have rectal dysplasia, which means they are going to have rectal cancer if we take the same track we did initially on HIV and offer treatment only, without education and information for prevention, what we have done is a very great disservice to the country. We have abrogated our responsibility. The fact is that we can prevent cervical cancer. Yes, we have set up a great screening system to find this. That is why we find it early. That is why we have such wonderful cure rates on cervical cancer. But we should not have as many women with cervical cancer as we do in this country: 3,800 women will die this year from cervical cancer; 30,000 will be diagnosed with cervical cancer in this country. Those are preventable diseases. As we discuss the health care dollars and the health care crisis in this country, to be spending money on treatments when we could have prevented it is very, very foolish. I would like to engage the gentlewoman from New York in a colloquy, if I might. I would like to just ask again, I heard her opening statement and I am very appreciative of it. Can I have a commitment from the Women's Caucus that before this session of Congress is over, that we in fact will have in some language somewhere a study and a prevention message for the young people in this country as relating to human papilloma virus?

Mr. COBURN

Mr. COBURN. Mr. Speaker, I want to first recognize Paul Kim for his great help on the gentleman from California's (Mr. Waxman) staff; Marc Wheat, the majority counsel on our side; and Roland Foster, a staff member of mine who has been with me for 6 years since I have been in Congress. This is a good bill. There is no question about it. But this bill is not enough. Forty thousand people this year are going to become infected with HIV. It does not have to happen. We should be asking the CDC, we should be asking the FDA, we should be asking the NIH why they would not use proven public health policy to stop this epidemic. The best way to treat people with HIV today is to make sure no one else ever encounters this disease. This is a preventable disease. Although we have gone a long way from where we were in putting in the public health policies that should be there, they are still not there. The reason they are not there is not a good enough reason. We have proven in the medical community that we can secure and hold confidentially anybody's HIV status. We have been perfect on that score. And to use that as a reason now not to move to the next step, I challenge my friend, the gentleman from Ohio (Mr. Brown), and I challenge the gentleman from Florida (Mr. Bilirakis) that in the next Congress and the Congress that follows that you will look very closely at what public health policies could do to prevent that 40,000 people from never getting the disease. We know. We handled the tuberculosis epidemic in this country. We stopped it dead with a whole lot less effort. This is something we can accomplish. We have proven with this bill that if we will work and talk together and understand each other's motivations, problems and concerns, that through discussion and bipartisan approach that we can solve those problems. The 40,000 people out there this year that are going to get infected deserve for us to do that. As I leave this body, what I would ask is the Members of this body, look at real problems, not the political things that surround it; and if we will do that, 40,000 people will not be infected. I thank the gentleman from Ohio (Mr. Brown) for his work. The gentleman from California (Mr. Waxman) has been great to work with. I appreciate the ability that we can express ourselves through true concern and solve a problem. I would hope that every Member of this body will support this bill. I also would leave one message with my colleagues. There are diseases much greater than this disease that face our country today. Diabetes will take tons more people than HIV. Breast cancer will take tons more people than HIV. And yet we are not anywhere close to the same dollar commitment in those diseases as we are HIV. Because we have had a misguided policy on treatment of HIV, we are spending dollars that could be spent in other areas. I would beg the body to look at that.

Mr. COBURN. Mr. Speaker, I yield myself such time as I may consume. Mr. Speaker, this is a bill that is long overdue. Before we get into the topic of discussions on this bill, I think it is important that the American public know that this reauthorization is going to allow at least $1 billion per year to be spent in Ryan White CARE Act policies and procedures. Also, the American public should know that we are going to spend about $10 billion a year on this epidemic, both in terms of research, drug treatments, and all associated factors with it. As we think about that, if we were to apply the same efforts to many other diseases in our country, we would be achieving far more than we are today. This bill is long overdue. It is long overdue in a lot of ways. It is long overdue because the government has failed through the CDC and the FDA and the NIH to appropriately handle this epidemic. Two decades ago, the HIV/AIDS epidemic was recognized. Our Federal response to HIV/AIDS epidemic at that time was to ignore proven public health policies. This bill institutes for the first time in the Ryan White CARE Act proven public health policies that will, in fact, make a difference in the number of people who are infected. These include ensuring medical access to all who are infected, not a special select few; early intervention in people who are infected; reliable disease surveillance and partner notification, including a responsibility to not infect anyone else with this disease. We will also, for the first time, recognize all of those living with HIV rather than focusing exclusively on those with AIDS. There are many other noteworthy changes made by this bill. Waiting lists to access life-saving HIV medications under the AIDS Drug Assistance program will be eliminated. Prevention will be incorporated as part of the comprehensive care program. Planning councils will be more representative of the infected population. Patients who rely on the CARE Act for their well-being will be given a greater voice in priority setting, and accountability safeguards will ensure that Federal AIDS funds will be spent on needed patient care. This bill will also provide Federal assistance to States to ensure that all pregnant women with HIV and their children are identified and provided care. One of the most promising victories in the battle against AIDS was a 1994 finding that the administration of a drug could significantly reduce the chance that a child born to an HIV positive mother would become infected. Yet, despite these miracles, a significant number of women still are not tested for HIV during their pregnancy, and hundreds of children are needlessly infected each year with an incurable disease that will prematurely claim their lives. This bill will provide up to $400 million annually to any State that makes identifying and ensuring proper care for HIV and infected women and their HIV-exposed newborns a priority. The two States with such baby AIDS laws, New York and Connecticut, have experienced great success. Universal newborn HIV testing has resulted in the identification of all HIV-exposed births and has allowed hospital and health department staff to ensure that over 98 percent of HIV positive mothers are aware of their HIV status and have newborns referred for early diagnosis and care of HIV infection. That is according to Dr. Guthrie Birkhead, the director of the New York AIDS Institute. Dr. Birkhead noted that the rates of prenatal care have been increasing, not decreasing as we were told would happen. There has been no detectable change in prenatal participation trends that might be related to the newborn testing program. The Connecticut baby AIDS law, which requires every newborn to be screened for HIV if the mother's status is unknown, was enacted almost a year ago. In the first 10 months, 26 newborns who were perinatally exposed to HIV have been identified. This is more than four times as many as were diagnosed with HIV in the previous 3 years combined. This substantial financial incentive amounts to a Federal endorsement of universal HIV newborn testing as a routine medical practice. I must regrettably note that the organization in my profession that purports to represent physicians who care for mothers and women has yet to endorse this. The question we ought to ask ourselves is why the American College of Obstetricians and Gynecologists, knowing that we can save children's lives and we can treat women, has failed to yet endorse this. This bill will also provide additional resources to support partner notification programs so that everyone who has been exposed to HIV is given the right to know that exposure. In addition, it will empower those who are infected to protect others from infection by providing prevention counseling as a part of a comprehensive care program. This includes providing advice on how to disclose one's HIV status to a potential partner and emphasizing to those living with HIV that they have a responsibility not to give this disease to anyone else. Finally, the bill recognizes everyone living with HIV and guarantees access to life-saving treatment to all who are infected. Current funding formulas are based on AIDS infection, the end stage of HIV infection. The CDC only recently recommended that States begin tracking the full scope of the epidemic, not just AIDS. The American public ought to be asking why has it waited so long. Over 12 years ago, the Presidential Commission on HIV warned the continual focus on AIDS rather than the full spectrum of HIV disease has left our Nation unable to deal adequately with the epidemic. Well, this bill changes that. This observation was absolutely correct. Yet, it was ignored by the CDC and Federal policy makers. The results have been devastating. While our attention was placed on AIDS, the virus silently spread through communities of color, and more and more women became unknowingly infected. Only now are AIDS statistics revealing the paths that the virus took 10 years ago. Unfortunately, the casualties are increasingly rising for women and women of color. While women and African-Americans comprise the majority of new HIV infections, they also receive less appropriate care according to the General Accounting Office. This is a direct result of the CARE Act's misplaced emphasis on AIDS data and determining funding and priority setting. That has changed with this bill. All of these changes, while long overdue, will do much to improve our Nation's responsibilities to HIV and AIDS by ensuring medical access to all of those who are infected and by providing the proper care for all. Mr. Speaker, I include the following letter for the Record, as follows: General Accounting Office, Washington, DC, August 24, 2000. Hon. Tom A. Coburn, Vice Chair, Subcommittee on Health and Environment, Committee on Commerce, House of Representatives. Subject: Ryan White CARE Act: Title I Funding for San Francisco Dear Mr. Coburn: This letter responds to your request for additional information regarding funding for San Francisco under the Ryan White CARE Act. Specifically, you asked that we compare San Francisco's fiscal year 2000 title I grant award, which was determined using the act's hold-harmless provision, with what the award would have been had deceased AIDS cases been included in the calculation. You also asked how funding for San Francisco that was based on the inclusion of deceased AIDS cases would have compared with the amount San Francisco would have received if the fiscal year 2000 hold-harmless level had been reduced by 25 percent. In brief, San Francisco's fiscal year 2000 title I grant award would have been 26 percent less had both living and deceased AIDS cases been used to calculate the award instead of the current hold-harmless provision. The reason for this result is the substantial decline in newly reported AIDS cases in San Francisco compared with other eligible metropolitan areas (EMA). Therefore, a 25-percent reduction in the current hold-harmless level would have provided San Francisco with funding comparable to what it would have received if title I grants had been calculated on the basis of both deceased and living cases. This analysis is based on data obtained from the Centers for Disease Control and Prevention and computer models we developed to calculate how funding would change under various formula scenarios. We performed our work in August 2000 according to generally accepted government auditing standards. Background The Ryan White CARE Act of 1990 provides health care and preventive services to people infected with the human immunodeficiency virus. Prior to the 1996 reauthorization of the act, the number of both living and deceased AIDS cases was used to distribute title I funds among EMAs. Under this practice, areas of the country with the longest experience with the disease had the most deceased cases and therefore received funding disproportionate to their share of living cases in need of care. The 1996 reauthorization eliminated this practice by counting only live AIDS cases. The effect of the change was to shift funding away from EMAs with higher proportions of deceased cases and toward those with newly diagnosed cases. As geographic trends in the disease change, the revised formula automatically realigns funding with the current distribution of the disease. A hold-harmless provision was also included in the 1996 reauthorization to provide for a gradual transition to new funding levels for those EMAs that would otherwise have experienced substantial funding decreases. This provision allowed grant awards for affected EMAs to decline by no more than 5 percent by fiscal year 2000. In fiscal year 1996, four EMAs benefited from the hold-harmless provision: San Francisco, New York, Houston, and Jersey City. By fiscal year 1999, all but San Francisco had made the transition to the new formula. Under the current title I formula, EMAs receive grant awards that are proportional to the number of living AIDS cases. In fiscal year 2000, Los Angeles had 6.9 percent of all AIDS cases nationally and received 6.7 percent of title I funding. Similarly, Miami had 4.4 percent of all AIDS cases and received 4.3 percent of title I funding. EMAs received $1,290 in title I funds per AIDS case in fiscal year 2000. However, because of the hold-harmless provision, San Francisco's grant award was substantially higher: it received $2,360 per AIDS case, or 80 percent more than other EMAs. As a consequence, San Francisco received 6.7 percent of title I formula funding even though it had just 3.8 percent of all living AIDS cases.

Mr. COBURN. Mr. Speaker, I ask unanimous consent that the remainder of the time on our side be controlled by the gentleman from Florida (Mr. Bilirakis).

Mr. COBURN. Mr. Speaker, pursuant to House Resolution 611, I call up the Senate bill (S. 2311) to revise and extend the Ryan White CARE Act programs under title XXVI of the Public Health Service Act, to improve access to health care and the quality of care under such programs, and to provide for the development of increased capacity to provide health care and related support services to individuals and families with HIV disease, and for other purposes, and ask for its immediate consideration.

Mr. COBURN. Mr. Speaker, I yield such time as he may consume to the gentleman from Florida (Mr. Bilirakis), the chairman of the Subcommittee on Health of the Committee on Commerce.

Mr. COBURN

Mr. COBURN. Mr. Speaker, I yield such time as he may consume to the gentleman from New Hampshire (Mr. Bass).

Mr. COBURN. Mr. Speaker, I yield myself such time as I may consume. Mr. Speaker, October is National Breast Cancer Awareness Month. In our country this year, 175,000 women will be diagnosed with breast cancer. That is very personal to me in that my sister has been diagnosed with it, my sister-in-law, and a very close first cousin recently died of this disease. The facts that face American women is one in eight women in this country will encounter this disease at some time in the future. Prevention is a key to diagnosis. And as a practicing physician that has diagnosed multiple women with breast cancer, I know the importance of improving awareness and improving the knowledge of women in our country and men as to the preventive measures that can take place. I also think it is incumbent upon me to make sure that the American public is aware of the connection between the incidence of breast cancer and abortion. There has now been, throughout the United States and Europe, 32 studies of which 29 absolutely connect a marked increase in the likelihood of breast cancer when one has had an abortion. That goes up if that abortion occurred before 18 or after 30, but nevertheless, the risk is twofold. Unfortunately, many in our country do not want the benefits of that scientific data known, and that is unfortunate. Nevertheless, I think the key thing is that we want women to be aware of what they can do to protect themselves against breast cancer. We want to encourage the awareness on the part of women in our country for risk factors associated with that besides family members, smoking, as well as abortion. Mr. Speaker, I reserve the balance of my time.