Bob Casey

Mr. CASEY

Mr. CASEY. Madam President, I rise to speak about health care, as we begin the debate in the Senate. I am grateful we are finally at this point where the Senate at long last will be debating our health care bill. It has been a long time in coming. Some of us have waited years, some have waited for decades to be at this point in our history. On the Senate floor now is the Patient Protection and Affordable Care Act, and we are going to be discussing various aspects of that over the next couple of weeks. I am reminded, as I rise today, of something Hubert Humphrey said a long time ago. He said the test of the government is how it treats those in the dawn of life--our children--those in the shadows of life-- those who have challenges in their life, as we try to help them--and those in the twilight of life--older citizens across America. In large measure, we will be talking about each of those Americans in one way or another and a lot of other Americans as well. I rise to speak of our children but also to spend a couple of moments talking about older citizens, especially in light of some of the arguments made most recently on the Senate floor. I will start with our older citizens. I come from the State of Pennsylvania where in our little State, with more than 12 million Pennsylvanians, we have almost 1 million Pennsylvanians over the age of 65. We have a very high number of Pennsylvanians on Medicare and also a lot of families who rely upon that kind of health care coverage, as we have for many generations. So when we speak of those in the twilight of life, we speak of many Americans who are covered by Medicare. I want to make a couple of points about the bill that is on the floor now. First of all, with regard to older citizens, a couple of basic points on which I will provide a little more background. First of all, this bill, as it relates to Medicare, will protect Medicare's already guaranteed benefits. The bill also reduces premiums and copays for older citizens. It will ensure that older citizens can keep their own doctor or doctors with whom they have developed a relationship, on whom they have come to rely, and in whom they have confidence. So we want to make sure they can keep their own doctors. The bill keeps Medicare from going bankrupt in 8 years by stopping waste, fraud, and abuse and by other provisions as well. The bill provides new preventive and wellness benefits--something we have talked about for every age group, but we are finally going to do something about it to give people better health care options. The bill also, as it relates to older citizens, lowers prescription drug costs. We will talk more about that. We have had a lot of discussion over the last couple of years about the so-called doughnut hole. That is a very nice-sounding way of describing falling into a period of coverage, if you are an older citizen getting prescription drug coverage, where you have to pay the whole freight, so to speak. This bill provides relief for those who are in that so-called doughnut hole with regard to Medicare prescription drug coverage. Finally, this bill keeps older citizens in their homes and limits those who would be compelled, if they didn't get additional help, to go into nursing homes. Some do. Some choose to do that. But we want to provide more opportunity for people to stay in their homes, if they can. In terms of preserving Medicare without the changes made in this bill, Medicare is going broke in 8 years--not 18, not 80, but 8 years-- if we do nothing. Older citizens will have trouble accessing their doctors if we don't take action. Older citizens will have trouble affording prescription drugs if we don't take action. Finally, without reform, cost sharing for older citizens will increase to completely unaffordable levels. Next, we have to make sure older citizens across America have the opportunity to continue to receive guaranteed protection for hospital stays, access to doctors, home health care, nursing home, and prescription drug coverage. We have to make sure we extend the life of the Medicare trust fund beyond 2022. Without reform, we cannot extend the Medicare trust fund beyond 2022. Without reform, we do not have the opportunity to ensure that trust fund will be there for older citizens across America. Finally, health reform will not interfere with any medical decisions made by patients and their doctors. Let me step back a moment and reflect upon what we are talking about with regard to Medicare: Protecting our seniors, protecting their benefits. It is interesting to note this whole debate started January of 2009, in a fully engaged way, when staffs of all relevant committees were working on this, month after month. Then it went into the summer, working on health care reform in the Health, Education, Labor, and Pensions Committee and the Finance Committee, improving bills, changing the bills. Now we have one bill that is the result of all that work. So this has been going on for months and months. I keep hearing criticisms from my Republican colleagues on various aspects of the bill. There is nothing unusual about that. It is natural to have a decision and a debate. We are starting that today, at least on the floor. But we have been having a debate over many months. My point is that on the one hand you have the legislation that resulted from work by the two committees into one bill, so you have the Patients Protection and Affordable Care Act on the floor and you have had basically the ideas contained in that being discussed for many months. But what we have not seen, what I have been waiting for and have not seen, is a bill by the other side. In other words, when we were working in June and July in the HELP Committee or when the Finance Committee was working all summer and into the fall, you would think that one of the results from that would be that Democrats had a point of view and they produced a bill; Republicans had a point of view. But they did not produce a bill. So you basically have a choice before the American people: the bill before us, which will change and which will be amended. I have some things I would want to change. But the answer cannot be let's go back to square one, where we were a year ago or 5 years ago or 10 years ago and just cancel this and try to start over. This is the result of many years of work, especially many months of work by people at the staff level and Senators across the board. Unfortunately, the other side does not have a plan, so I can only conclude they want to stay with the status quo. They think where we are in health care is OK; that we should stay where we are, maybe tinker with it a little bit but not change much. I think that is unacceptable. Too many people I run into, in Pennsylvania especially, have said to us: Please provide some protections for me. We are talking about individuals who have health care. Provide some consumer protections. Make sure the Medicare trust fund will always be there. Help me with this doughnut hole problem. This is the problem too many seniors run into when they cannot pay for prescription drugs at a certain point in the delivery of that benefit. I do not think the response of doing nothing or staying where we are is acceptable. That is one of the reasons why we have to make sure we focus on changes or debates about this bill, not going back to where we were in January or where we were 5 years ago and basically doing nothing year after year about health care and saying it is OK to stay where we are. We have a long way to go. But I think it is also important to point out this is not just a debate between Republicans and Democrats. We have had groups, across the board, that are neutral arbiters that weigh in on public policy but are not representing a Democratic point of view or a Republican point of view. The AARP said on November 20 of this year: Opponents of health reform won't rest. They are using myths and misinformation to distort the truth and wrongly suggest that Medicare will be harmed. After a lifetime of hard work, don't seniors deserve better? So says the AARP, just a couple of weeks ago--not even a couple of weeks ago, 10 days ago. The AARP also said on November 18, 2 days earlier: The new Senate bill makes improvements to the Medicare program by creating a new annual wellness benefit, providing preventive benefits, and most notably for AARP members, reducing drug costs for seniors who fall into the dreaded Medicare donut hole [that I spoke about earlier] a costly gap in prescription drug coverage. That is the AARP weighing in on not a concept, not a theory but the bill in front of us. The American Medical Association, on that same day, November 20, 2009: We are working to put the scare tactics to bed once and for all, and inform patients about the benefit of health care reform. I could go on from there, but we have ample evidence that there is strong support for the ways this bill will strengthen Medicare. I wish to move to the second topic I was going to cover today and that is the other end of Hubert Humphrey's test of government, what we do and what the test is of our Government as it relates to those in the dawn of life. I spoke of older citizens a moment ago. At the dawn of our life are children. It has been a topic and a focus of mine since the very beginning of this debate, which for me began last spring when I was working in the Health, Education, Labor, and Pensions Committee before our work this summer on the bill. The Patient Protection and Affordable Care Act, which is the bill before us today, deals with many aspects of our health care system. One of them is how we take care of our children. I have come back to this issue over and over. I have had just a basic test for this legislation. It is very simple. It is four words: No child worse off, especially and importantly, children who are low income and are particularly vulnerable, therefore, and children with special needs. So ``no child worse off'' should be the foundation of what we do in this bill for our children. That is particularly true for those who are vulnerable, as I said before; they are vulnerable or children with special needs. That is the foundation of what we should be doing, the foundation for a guiding philosophy. The way I look at this, every child in America, no matter who they are, no matter what circumstance, every child in America is born with a light inside them. For some, that light is boundless because of their circumstance, because of their ability, because of advantages they have. Their potential is unlimited and that light burns very brightly without any help from anyone else. That is some children. Then there are other children who have a light inside them and are deserving of our care and protection and advocacy. We have a lot of people around here who get besieged by lobbyists for different points of view, but very rarely do we have the same kind of lobbying power, the same kind of power in our system to stand for children. So we have to do that if an interest group will not. There are plenty who have advocated strongly for our children, but they don't get enough attention in my judgment. There are some children who are born with a light inside them that does not burn very brightly because of their own circumstances or limitations or because of particular vulnerabilities that they have. They are the ones for whom we have to fight the hardest. They are the ones we have to stand up to the special interests for because they cannot do it for themselves. They don't have a voice sometimes in this debate unless the Senate stands up for them. I believe no matter what the light is inside a child, no matter what the limit or whether it is unlimited potential, we have to make sure that potential is reached, the full potential--not most of it, not some of it, the full potential of every child, the full burning of that light inside them. There are two programs that work well to do that. They are Medicaid and the Children's Health Insurance Program. Thank goodness both these programs came along: Medicaid, some 40 years ago, and Children's Health Insurance Program less than the last 15 years. We have the opportunity to listen to people who come up to us on the street or who send us an e-mail or who send us a letter. It just so happens one of my constituents in Pennsylvania sent us a note the other day, literally 2 days ago, November 28. I will not give away her identity, but I will give you a general sense of what her challenge is. She wrote to us talking about her two children who are covered by the Children's Health Insurance Program in Pennsylvania. By the way, Pennsylvania is one of the first States that put into place this program, almost 20 years ago, back in 1992-1993. She wrote and said she was concerned that the House, in their bill, had made some changes that would adversely impact her situation. She said: We qualify for free Children's Health Insurance Program benefits in Pennsylvania but my husband's income is greater than the 150 percent of the Federal poverty level which means our children wouldn't qualify for the coverage under the House's proposed plan. Then she says: This has us terrified. She goes on to talk about what she and her husband are trying to do to make ends meet. She says: Our water bills will increase and we are nervously awaiting the annual increase in heating. I will not go through the whole letter, but suffice it to say we have a program in place now, the Children's Health Insurance Program, that works for families right now. Now we are engaged in a great debate on health care on the floor of the Senate and we deal with programs such as the Children's Health Insurance Program. What we have to make sure about is that we do nothing in this process to injure or harm or set limits on what we can do with a program that we know works. This is a program which is good for a child, to make sure he or she reaches the full potential of that light inside them. This is good for his or her family. Imagine the peace of mind that a mother or father has in the course of the day, whether they are going off to work or whether they are home, to know their child has health care. Yet we have some families, some parents, terrified even with the coverage they have, worried that coverage will not remain in effect for their children. So we have to make sure that rule is followed: No child worse off in America. We want to fix what is broken and build upon what works. I wish to make sure, as we go through this, we have a sense of what the difference is between these benefits and what can happen down the road. One of the things that will have an adverse impact on our health care system, generally, but in particular on a program such as the Children's Health Insurance Program, will be the skyrocketing cost of coverage. The share of household incomes spent on premiums is climbing. The New America Foundation reports that in 2008, household income spent--on the side, ``percent of median household income spent on health care''--is 26.3 percent. That is far too high as of 2008. With no action, if we stay where we are, go down the same road we are on, the status quo, don't change anything, let's start over and keep scratching our head about this, here is what is going to happen by 2016, 7 years away. That median household income dedicated to health care will skyrocket to 45 percent nationally. Unfortunately, in Pennsylvania, it goes up over 51 percent instead of 45 percent, so that is the ``do nothing'' path right now. Do nothing, and we can guarantee that those costs are going to keep going up and up. I said before we know the Children's Health Insurance Program works. By the way, when that bill passed and when it was reauthorized, we had help from both sides of the aisle--sometimes not enough help but we have had help supporting that program. We know this program works because we can see it from the results achieved by our children because of this program. Let's compare this to some other challenges in the economy. The national poverty rate. In 2007, a little more than 37 million Americans were in poverty, 12.5 percent of the population. In 2008, it was up to 13 percent. So the poverty rate went up from 2007 to 2008. The child poverty rate went from 18 percent to 19 percent, almost 1 million more kids in 1 year falling into poverty because of changes in the economy. People without health insurance, 2007 versus 2008, that has gone up. It may only be 15.3 to 15.4, but look at the overall number, from 45.7 to 46.3. Everything is going up. We would expect that, as tragic as that is, when times are bad. The national poverty rate is up, the child poverty rate up, and the uninsured rate is up. What has not gone up between 2007 and 2008 is the number of uninsured children: 8.1 million in 2007 were covered; 7.3 million kids covered in 2008. That is good news, that the number of uninsured children is actually going down from roughly 8 to 7 million. That is good news. Why is that happening? It is not magic. If we didn't have a Children's Health Insurance Program, that number would be going up just as the other numbers. Why is the uninsured number for children going down? One basic reason--and we could point to maybe a few others--is because we have a program called the Children's Health Insurance Program which works and which, fortunately, we reauthorized a couple of months ago. Thank goodness we did that, or more and more children would fall into poverty. We are on a path now to go from the number of children who are insured, to get that number that is now in the double figure millions, to get that to 14 million children, to have that uninsured number keep going down and cover more and more children. In a couple of years, we will have the opportunity to say that in America, we have 14 million kids covered. What we have to do is make sure we have a successful program that works for the child, for their family, and for our society. Because guess what. We are going to have a better economy because of the Children's Health Insurance Program. If we invest in a child early, they get health care, and they will learn better. When they learn better, they will be doing better in school and have a better job and have a higher skill level. This whole debate about children's health insurance isn't just a nice thing to do; it is how we compete around the world in a tough economy. It is how we build a skilled workforce in a tough economy. It is how we build strong families. This isn't just some nice program. This has real results for our economy, for gross national product growth, economic growth, for a skilled workforce. Fill in the blank. You could add 10 themes to that in terms of the impact of the legislation. But you have to be careful. In the midst of this health care reform debate, we have to make sure we don't do what some have urged which is to take the Children's Health Insurance Program, this program that we know works, and drop that into the health insurance exchange that will be created as a result of this bill. The exchange is a good idea to cover a lot of people. It just happens to be a bad idea when it comes to merging or putting the Children's Health Insurance Program in there. It needs to remain a stand-alone program. One of the reasons why we can say we are at that point where it is a stand-alone program still is because during the debate in the Finance Committee, Senator Rockefeller of West Virginia ensured that we kept the Children's Health Insurance Program out of the exchange and that the program would continue until 2019. Unfortunately, the House doesn't have the same provisions, and we want to make sure we do that by the end of the debate. I filed an amendment today to make sure that children are protected by health care reform, so we can truly say that no child is worse off as a result of our health care reform bill. In a nutshell, this amendment will strengthen and safeguard health care for children in CHIP from now until 2019 and beyond with whatever changes the future of health care reform brings. I will provide a couple of highlights. It continues funding through 2019. It ensures that children have access to the essential care they need. It streamlines and simplifies enrollment. The amendment also provides financial incentives for States to increase enrollment of eligible but uninsured children and calls for a study of children under the Children's Health Insurance Program compared to coverage of children under the so-called insurance exchange. These are just some highlights of my amendment. I will be talking more about it. I conclude with this thought. I know Senator Baucus was here a moment ago, chairman of the Finance Committee, who has worked very hard on this bill, this program, the Children's Health Insurance Program, and on the health care reform bill overall to protect our kids. I return to this letter I got 2 days ago from a mother, in essence commending the benefits of this program, that this program gives her peace of mind. What we have to do is make sure we keep the Children's Health Insurance Program intact and, if anything, strengthened over time so this mother doesn't have to worry again, so she doesn't have to be ``terrified'' of changes that will adversely impact her two children, especially in the midst of a bad economy but even if it were not. I thank the Chair and yield the floor.

Mr. CASEY

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

Mr. CASEY

Mr. CASEY. Thank you very much, Madam President. I rise this afternoon to speak about health care. We all have been concentrating on this issue for many months, and we are now into a period of time when we will be getting a bill very soon to the floor. That is our hope and our expectation. One of the parts of the Health, Education, Labor, and Pensions Committee bill that I voted on, as did the Presiding Officer this summer back in July when we passed our bill out of committee, one of the real priorities in that bill, and what I believe will continue to be a priority in the final legislation before the Senate, is children and what happens to children as a result of health care reform. We have a lot to be positive about in terms of legislation over the last decade or more as it relates to children, and I will speak about that. In terms of that guiding principle, I have a very strong belief--and I think it is the belief of a lot of people in this Chamber and across the country--that every child in America--every child in America--is born with a light inside them. For some children, that light is limited by circumstances or their own personal limitations, but no matter what that light is, we have to make sure the light for their potential burns as brightly as we can possibly ensure. For some children, of course, that light is almost boundless. You almost can't measure it because the child has advantages other children don't have or they have a family circumstance that allows them to grow and to develop and, therefore, to learn and to be very successful. But I believe every child in America is born with a light, and whatever the potential is for that child, we have to make sure he or she realizes it. We have a direct role to play. Those of us who are legislators, those of us who are working on the health care bill have an obligation, I believe, to make sure that light shines ever brightly. One of the other themes under this effort to expand health care for Americans is to focus on children who happen to be either poor or who have special needs. I believe the goal of this legislation, as it relates to those children, those who are poor or children with special needs, is four words: ``No child worse off.'' We need to ensure that a poor child isn't worse off at the end of this debate and enactment of health care reform and that a child with special needs is not worse off. I think that is the least we should do when it comes to protecting our children. There are at least two programs--one older than the other but both very important--that relate to our children. The older of the two programs is the Medicaid Program. It has been around for more than 40 years now. Medicaid, as it pertains to children, is a program we have come to rely upon to provide children with very good medical care, the best medical care, in some ways, that a child can have. We have to make sure we pay attention to how Medicaid is treated in this bill. We will talk a little bit more about that in a moment. In Pennsylvania, the State I represent, we have a 15-year experiment with the Children's Health Insurance Program or CHIP. The one thing we know about CHIP is it works. It works very well for children. As we know, in a general sense, the Children's Health Insurance Program is for children of low- and middle-income families in America who can't get coverage from their employer, for one reason or another, and don't have a family income that is low enough to qualify for Medicaid. So it fills a gap that had been there for years. We know, with regard to the Children's Health Insurance Program, today there are about 7.8 million children covered. That is wonderful. I am very proud and happy about that, but we are even happier and more positive about the future because the reauthorization of the Children's Health Insurance Program means that by 2013, 7.8 million children covered will rise to 14.1 million children. So an easy way to think about children's health insurance is 14 and 13: 14 million kids covered in the year 2013. That is a tremendous achievement--historic in American history. We have never had anything close to that, to have 14 million children covered in a good program such as CHIP. The caveat to that is we still have millions--by some estimates 8 million--of children who will not be covered even in 2013. One of the reasons we are debating health care reform is to make sure we are doing everything possible to strengthen the Children's Health Insurance Program and do not allow it to be weakened in any way. One way to weaken it--and fortunately the Senate Finance Committee did not do this in their final bill--is to take a stand-alone, successful, effective Children's Health Insurance Program and put it in the health insurance exchange. It may sound good--within one system-- but I believe, and many others believe, it would be very bad. The Finance Committee, led by Senator Rockefeller, worked very hard to make it possible to keep the Children's Health Insurance Program as a separate stand-alone program. I believe we have to do that. As we know, legislation passed recently in the House. The health care bill got through not just the committees but through the House itself. One of the problems with the House bill is it would end the Children's Health Insurance Program in 2013. We don't want to do that. We want to make sure, in the Senate, we do it differently than the House did. One component that is good about the House bill on this subject, however, is it does expand Medicaid. The House bill expands Medicaid for children to 150 percent of poverty for all States, and States would get assistance in paying for this expanded population. But then there is another caveat in terms of what I think has to be improved upon in the Senate. Children above 150 percent of poverty will go into a new exchange, which I think is, as I said before, the wrong way to go. We want to make sure, if something such as that were to happen, they would have cost-sharing protections and better benefits. Unfortunately, if they go into that exchange, they would not. This could have a direct impact on a State such as Pennsylvania. By one estimate, in Pennsylvania alone, this means that nearly 100,000 children who currently have children's health insurance coverage would lose it because of that change. So we want to make sure we don't go in the direction the House did as it relates to this issue of children's health insurance and the exchange--keeping it out of the exchange. We do need to expand Medicaid for children and we need to maintain CHIP as a stand-alone program. What are some of the numbers here? We are talking about nationally, in the Medicaid Program, 30 million children enrolled in Medicaid. As I said before, enrolled in CHIP are 7.8 million kids. Putting them together we have one-third of all children in America covered by those two programs. But as I said before, we still have plenty--millions and millions--of children who still are not covered by either program. We hear a lot of acronyms around here, but one important acronym for this debate, as it relates to children and to health care, is EPSDT: early pediatric screening diagnosis and treatment. The American Academy of Pediatrics has called EPSDT the ``gold standard'' for children's health care. This is essential that we keep that kind of standard in place. That means Medicaid, for example, covers all medically necessary treatment for children, including preventive care, primary care, dental, hearing, vision, and it goes down the list. Unfortunately, sometimes people say: Well, under commercial coverage you will get as much coverage for children of the same quality. Unfortunately, that is not true. There may be advantages to provider networks of commercial coverage for families who are wealthy enough, have the means to afford it and who can get out of the network and pay for something extra, but, of course, many families don't have that benefit. I wish to spend a couple moments on EPSDT. I will go to the first chart. The Commonwealth Fund and George Washington University did an excellent comparison of the benefits between commercial insurance and Medicaid. The first benefit we have on this chart is called developmental assessment. Some of these terms get a little long and there is a lot of policy jargon. One of the most important things for any child, especially very young children, is to have regular and high- quality developmental assessments, so we can catch anything that might be going wrong at an early enough age and give that child the benefit of early intervention and treatment in the dawn of their lives, in the early months and years of their lives. We can see, under Medicaid, for example, that this developmental assessment is covered. We can also see that under the Federal Employees Health Benefits Plan, there is a lot of verbiage there which I will not read, but suffice it to say it is limited. It is not covered to the extent it is in Medicaid. Another example is this phrase down here: ``Anticipatory guidance,'' another fancy term of policy, but it is this simple: It is helping parents understand what they should be expecting from their child physically, emotionally, and developmentally so they can get help, as I said before, early enough in the life of that child. This kind of guidance, again, is covered under Medicaid but not explicitly covered under the Federal Employees Health Benefit Program, which, as a beneficiary of that program, is a great health insurance program for Federal employees, but even something that significant, in terms of coverage and quality, would not be, in my judgment, good enough for poor children who should be covered in terms of developmental and anticipatory guidance with their parents under Medicaid. So Medicaid is better for poor children than even something as significantly good as the Federal employees plan. Let me go to the next chart. I know we are getting close to our time and I will be observing that. This chart shows EPSDT as it relates to physical, speech, and related therapies. We have heard horror stories from mothers of children with disabilities--either mild or severe. Physical therapy, speech therapy, and occupational therapy, these are all critical to a child who may have a disability. Sometimes early intervention can help a child recover to normal functioning and sometimes it is a disability that persists throughout a child's life. Under Medicaid, again, beyond the medically necessary threshold, basic therapies, such as physical, speech, and occupational therapy, are covered without limitation. I think it is vitally important we ensure that under Medicaid we continue to fortify that program so our children can get that kind of quality coverage. Let me conclude with a couple thoughts, very briefly. No. 1 is, at the end of this process of getting a health care bill enacted, I believe we have to live up to that basic standard of four words for poor kids: ``No child worse off'' at the end of the road. Dr. Judith Palfrey, a pediatrician, child advocate, and president-elect to the American Academy of Pediatrics, spoke at one of our hearings earlier this year, and here is what she said: Sometimes, we as child advocates find it hard to understand why children's needs are such an afterthought and why, because children are little, policymakers and insurers think that it should take less effort and resources to provide them with health care. I think that challenges all of us to make sure children are not second-class citizens when it comes to health care reform and what we do. Let me conclude with this thought: As I said before about that bright light inside every child who is born, we have to do everything possible to make sure that at the end of the road, at the end of this debate, and at the end of voting on this bill, we ensure that that light burns ever brightly, especially for children who happen to be poor or have special needs. With that, I yield the floor and note the absence of a quorum.

Mr. CASEY

Mr. CASEY. Madam President, I would like to commend and congratulate my colleague Senator Robert Byrd on the momentous accomplishment of becoming the longest serving Member of Congress. Senator Byrd has spent 56 years and 320 days serving the people of West Virginia, in that time casting more than 18,500 votes. He is a fierce advocate for his home State of West Virginia, a mentor and disciplinarian with new Senators. And he possesses an encyclopedic knowledge of Senate history, rules, and procedure. The current President pro tempore of the Senate, he has held more leadership positions than anyone in Senate history. I am honored to have worked alongside a man who will go down in history as a great American public servant, and I look forward to working with Senator Byrd for years to come.

Mr. CASEY

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

Mr. CASEY

Mr. CASEY. Mr. President, I rise today to talk about the aftermath of the elections debacle in Afghanistan. President Hamid Karzai's first term was characterized by a cloud of corruption and mismanagement. In his speech on Tuesday, President Karzai promised to battle corruption and to build a government that includes elements of his political opposition. Our President, President Obama, said that Mr. Karzai's performance should be measured not in words but deeds. I believe this to be true, and I wish to offer some thoughts on how President Karzai can rebuild the confidence of the Afghan people as well as the international community. I am afraid the time window for this new government will be very short, so President Karzai needs to move quickly and with resolve. We might ask, what are the markers by which we should measure the progress of this new Afghan Government? I believe there are at least five areas to review. First: President Karzai intends to build a better legislative framework to combat corruption. This is good. But he has also said that corruption cannot be solved by replacing high-ranking officials. I could not disagree more with that assessment. With a host of government officials accused of corruption, we will not see a significant break with the past. A large part of battling corruption is removing the perception of corruption. Keeping these officials in place will only serve to fuel a commonly held perception that Mr. Karzai refuses to resolutely deal with this issue of corruption. I echo President Obama's call for strengthening the country's anticorruption commission. The establishment of such a body is long overdue and could play a key role in rebuilding Afghanistan's trust in the legitimacy of the Karzai government. The CIA should not--should not--be cooperating with Wali Karzai. If we are serious about corruption, we should also be judged by our deeds and not our words. There are ministries in Afghanistan that are in need of serious reform. The Interior Ministry, which oversees the police, must confront the corruption practiced by police officers on a daily basis. The Agriculture, Energy, and Private Development Ministries also require substantial reforms. A second area to examine: President Karzai should move quickly to publicly distance himself from some of the more unsavory characters from his election campaign. GEN Abdul Rashid Dostum, the Uzbek warlord, has been accused of terrible human rights violations for his role in detaining thousands of Taliban fighters who were suffocated in shipping containers. Mr. Karzai's Vice Presidential partner, Mr. Fahim, has been accused of drug trafficking. I fully acknowledge and I think everyone in this body fully acknowledges that President Karzai has a difficult job of balancing a wide variety of Afghan power centers and ethnic groups. We know that. But building a foundation for his country on such dubious grounds not only calls into question his judgment but seriously endangers the prospects for sustainable reform. Third: Karzai should keep in place those who have competently fulfilled their responsibilities. Most noteworthy, perhaps, is the Governor of Helmand Province, Governor Mangal, who continues to struggle on the front lines against the Taliban. I had the opportunity this past August to meet Governor Mangal and to spend some time with him. He is very brave, and he is very competent. I think President Karzai should understand that the American people expect Governors to be strengthened and not undermined. Mr. Karzai should empower provincial Governors and local leaders who have proven their ability to lead. At the national level, the Health Minister has also done a commendable job, and the Education Ministry has made some important strides. We cannot tell Karzai whom to retain or dismiss in his new government, but these personnel decisions send a very strong signal to the Afghan people and the international community of where he intends to lead the country in the short term. Fourth: President Karzai needs to take steps to improve the election process in Afghanistan. Systemic and widespread fraud marred the 2009 election. President Karzai should call for an inquiry into the 2009 electoral process led by experts from Afghanistan and the international community. Parliamentary elections are scheduled for next year. Without a serious investigation and an effort to address the shortcomings of the electoral system, the elections in 2010 and in the future are at risk. Without clean electoral processes in place, the Afghan people will continue to question the legitimacy of their elected leaders. Fifth and finally: The viability and legitimacy of this new Karzai government will be determined in large part by whom he decides to incorporate from the opposition. While his main opponent, Abdullah, has said he will not join a unity government, there are competent people from his team who can play a constructive role in Afghanistan. We want and need President Karzai as a reliable partner. I hope his reelection will provide the opportunity for a fresh start in Afghanistan, a start that is characterized by a commitment to good governance, political inclusion, and a realization that Afghanistan's future must be based upon the rule of law. When I saw President Karzai in August just after the election, I implored him to confront these pressing issues and explained that the patience of the American people was not infinite--in fact, it grows shorter by the day. The next few weeks will be pivotal. President Karzai can do so much to rebuild the confidence of the international community and the Afghan people in this short period of time. As President Obama determines our troop commitment to the Afghan theater, it must be done with a confidence in Afghanistan's decisionmakers--a confidence that frequently does not often exist today. President Karzai cannot let his golden hour pass. It is too important to the future of Afghanistan. It is too important to the Afghan people. Finally and most critically, it is too important for the American families who have lost loved ones in Afghanistan and have relatives currently serving in Afghanistan. The sacrifice made by U.S. troops and civilians working to bring stability and a democratic future to the country cannot be overstated or undervalued. This should be the starting point for any discussion with President Karzai. I believe he has a solemn obligation to get this right, just as we have an obligation here in the Congress to get our strategy in Afghanistan right. There won't be just one way to do that. We will get it right only by vigorous debate, only by an honest dialog of the challenges we face. But one of the most significant challenges, in addition to the obvious security challenge as well as the developmental challenges, is this central concern we have about governance. Governance in Afghanistan starts with President Karzai. He has an opportunity to demonstrate he is committed to these reforms on corruption, on the better delivery of services to his people, but he has not done very well in a lot of those measures in the recent past. He has to prove himself first and foremost to his own people that he is serious about these reforms, but I think he also has an obligation to our government and to the international community to demonstrate that he wants to get this right. Mr. President, I yield the floor and note the absence of a quorum.

Mr. CASEY

Mr. CASEY. If there is no further business to come before the Senate, I ask unanimous consent that it adjourn under the previous order.

Mr. CASEY

Mr. CASEY. There will be no rollcall votes during Friday's session of the Senate. As previously announced, the next vote will occur at approximately 5:30 p.m. Monday.

Mr. CASEY

Mr. CASEY. Mr. President, I ask unanimous consent that the resolution be agreed to, the preamble be agreed to, the motions to reconsider be laid upon the table, with no intervening action or debate, and any statements be printed in the Record.

Mr. CASEY. Mr. President, I ask unanimous consent that the Senate proceed to the immediate consideration of S. Res. 342, submitted earlier today.

Mr. CASEY

Mr. CASEY. Mr. President, I ask unanimous consent the bill be read a third time, and passed, the motion to reconsider be laid upon the table, with no intervening action or debate, and any statements be printed in the Record.

Mr. CASEY. Mr. President, I ask unanimous consent the Senate proceed to the immediate consideration of Calendar No. 197, S. 1860.

Mr. CASEY

Mr. CASEY. I ask unanimous consent the committee substitute amendment be withdrawn; that an Akaka-Voinovich substitute amendment be agreed to; the bill, as amended, be read a third time and passed; the motions to reconsider be laid upon the table, with no intervening action or debate and any statements be printed in the Record.

Mr. CASEY. Mr. President, I ask unanimous consent that the Senate proceed to the immediate consideration of Calendar No. 164, S. 806.

Mr. CASEY

Mr. CASEY. Mr. President, I rise tonight to speak about the health insurance reform bill that will eventually come before the Congress. We have a process underway in the Senate that is still playing out. We don't have a bill, but I think we are cognizant of the fact that we need to talk about the challenge we face with regard to health care, as well as talk about some good ideas to confront this challenge. I commend my colleague from Ohio, Senator Brown, who has led the fight on making sure the public option is a priority. From day one, he not only has led this fight, but also from day one, way back in the summer when we were actually working on language in the Health, Education, Labor,and Pensions Committee, he and others sat down to actually rewrite that section. We are grateful for his leadership and for his ability to relate to us what a public option means to real people--not the concept, not only the policy of it, but what it means to real people and real families. I commend him for that great work. One of the areas I have tried to spend as much time as possible on is the question of what happens with regard to our children. Will children at the end of this process be better off or worse off, especially in the context of children who happen to be vulnerable because of income? We are concerned about poor children and children with special needs in particular. I believe one of the principles--or maybe the better word is a goal-- that we must meet at the end of the road, when we have a bill that gets through both Houses of Congress and goes to the President, when a bill gets to the President of the United States, President Obama, for his signature--and I believe we will get there; it is going to take some time and we are going to be continuing to work very hard in the next couple of weeks to get that done. But when that bill gets to President Obama, I believe we have to make sure in this process over these many months of work--and for some people, many years--we have to make sure that bill ensures that no child, especially those who are vulnerable, is worse off. I believe we can get there. I believe we must get there. I believe we have an obligation, especially when it comes to vulnerable children, poor children, and those with special needs. To set forth a foundation for that, I submitted a resolution several months ago, resolution 170. I won't read it or review it tonight, but it was a resolution that focused on that basic goal of making sure no child was worse off. I was joined in that resolution by Senator Dodd, then-chairman of our health care reform hearings, this summer. Senator Rockefeller also was a cosponsor of this resolution, someone who has led on not just health care issues in the Finance Committee but also in a very particular way he stood up for children, as has Senator Dodd-- both Senators in their many years in the Senate. We just heard from Senator Brown. He was a cosponsor of this joint resolution for children, as well as Senator Sanders from the State of Vermont and Senator Whitehouse from Rhode Island. Those five Senators joined with me in this resolution which I believe is the foundation for what we have to do with regard to children. The chart on my left is a summation of some of the things we just talked about. First of all, this first point with regard to our children, children are not small adults. It seems like a simple statement. It seems very much self-evident, but, unfortunately, we forget that. I think we forget it once we become adults. But even in the context of health care reform, we cannot just say this is a health care strategy or program or manner of delivering care or a treatment option or a way to cover more Americans with regard to health care, so if it applies to an adult it will work for children. Unfortunately, because they are not simply small adults, we have to have different strategies for children that differ from the way we approach the challenge in providing health care for adults. The second bullet: Children have different health care needs than do adults. I think that is a basic fundamental principle; that children have to be approached in a different way. The treatment is different, the prevention strategies are different, and sometimes the outcome of a health care treatment or strategy is different. It is also critical that all children, particularly those who are most disadvantaged, get the highest quality care throughout childhood. And that is the foundation of that resolution. When it comes to health care reform generally, but in particular with regard to our children, we have to get this right. We can't just say: Well, we tried, and we tinkered with some details or some programs, and we did our best. When it comes to health care for children, not only for that child or his or her family or the community they live in--and we tend to forget this--but also our long-term economic strength is predicated in large measure, in my judgment, on how we care for our children, and especially the kind of health care our children will receive. So we have to get this right for our kids, for their families, and for our economy long term. Fortunately, we have made great strides over the last 15 years. Really even less, maybe the last 12 years we have made great strides on children's health insurance. President Clinton signed a law passed by Congress in 1997 creating a nationwide Children's Health Insurance Program--the so-called CHIP program. In that case, we had something that had its origin in the States. My home State of Pennsylvania started one of the largest, if not the largest, children's health insurance efforts in the Nation, and that was built upon by way of Federal legislation so that we now have had a program in existence since about 1997 nationally where millions of children have health care because we made them a priority. In Pennsylvania, for example, we have had, fortunately, a diminution, a decreasing number of children who are uninsured, to the point where last year, when there was a survey done for the State of Pennsylvania, the uninsured rate for children was 5 percent. That is still too high, but it is lower than it used to be. We want to bring that, obviously, to zero, but we have a 5-percent rate of uninsured children in Pennsylvania and 12 percent uninsured for people between the ages of 19 and 64. For children and for citizens over the age of 64--65 and up--we have had strategies for both those age groups; children more recently, with regard to children's health insurance, as well as Medicaid for low- income children, and also, we have had Medicare for our older citizens. But the problem is that age category in the middle, that vast middle age group of 19 to 64. We haven't had a strategy recently, or over many decades, and that is one of the many reasons we are talking about health insurance reform for everyone but especially for those who are in that age category. With regard to children, we have to make sure what we know works stays in place. We have plenty of data to show that children with health care coverage do better than children without health care coverage. That is irrefutable. It is absolutely indisputable now. I don't think anyone would dispute that as a matter of public policy. Children with insurance are more likely to have access to preventive care. A major part of our reform effort--and the major part of the HELP bill we passed this summer--is all about prevention. Children in public programs are 1\1/2\ times more likely to obtain well-child care than uninsured children. What does that mean? Well, it is simple. The experts tell us children enrolled in the CHIP program--or SCHIP, as we sometimes call it--in their first year of life have six well-child visits to the doctor. That is fundamentally important. It can alter in a positive sense that child's destiny. Their future can be determined in the first couple of weeks and months, and certainly the first year of life. It is good for that child in the first year of life to go to the doctor at least six times for a well-child visit, as they do in the CHIP program. It is important that we have prevention strategies in place for that child in the very early months of that child's life, but certainly in the first year. Here is another chilling statistic. Uninsured children are 10 times more likely to have an unmet health care need than insured children-- not double or triple but 10 times more likely to have an unmet health care need. We hear some people in this debate say: Well, that is about someone else. That is about some other family, someone else's child. That is not our problem. Well, it actually is your problem. Even if you have no compassion, even if someone out there says: Well, that is not my problem; that is someone else's problem. It is your problem because for every child who has no insurance, and as a result has no well-child visits to the doctor or does not get to the dentist or does not get preventive care, there is, in some way, an adverse impact on our economy. Think about it long term. If you are running a company, who do you think will be a stronger employee for you or a more productive employee, someone who got good health care in the dawn of their life--as Hubert Humphrey used to say--or someone who didn't get that kind of health care or nutrition or early learning? All these things we talk about have ramifications for our long-term economy because of our workforce. To have a high-skilled workforce, you have to have access to health care. So that number of 10 times more likely to have an unmet health care need for the uninsured child versus the child with insurance is chilling. It is one of those numbers that alone should compel us, should motivate us to pass this bill. Insured children are better equipped to do well in school. Uninsured children, with poorly controlled chronic diseases, such as asthma, can suffer poor academic performance if their health care condition causes them to miss many days of school. We know that. This is not news, but, unfortunately, we have allowed conditions to persist in our system where a child doesn't get the kind of care they need, and that allows their asthma or other condition to be made worse. Insurance improves children's access to the medications and treatments they need to control chronic diseases, allowing them to miss fewer days of school. We know that is the case. The chart on my left gives a brief overview of a Johns Hopkins University study published in the New York Times on October 30, just a few days ago, which states that hospitalized children without insurance are more likely to die. So this isn't just about a child getting a slower start in life because they didn't have health care or a child not having a B average in school because they didn't get health care or missing days from school. All of that is terrible for that child and for that family, but this is a lot worse than that. This is literally about the life and death of a child, according to this study and others as well. Mr. President, I ask unanimous consent to have printed in the Record an article dated October 30, 2009, in the New York Times with the headline: ``Hospitalized Children Without Insurance Are More Likely to Die, a Study Finds.''

Mr. CASEY. This is what the article says: Researchers at Johns Hopkins Children's Center analyzed data from more than 23 million children's hospitalizations in 37 states from 1988 to 2005. This wasn't a quick survey, Mr. President. This was a detailed study of millions of records over that long a time period. Continuing the quote: Compared with insured children, uninsured children faced a 60 percent increased risk of dying, the researchers found. So this research showed a 60-percent increased risk of dying. That is what we are talking about. This isn't theoretical. This isn't some public policy argument we have pulled down from a public policy report. This is about life and death for children. We are either going to stay on the course we have been on with regard to children, making improvements, strengthening a program like CHIP, or we are not. I think it is vitally important that we continue to make progress as it relates to children's health insurance. So this is fundamental to this discussion about health care reform, and sometimes a study or a chart or a public policy report doesn't tell us nearly enough. Sometimes the life of a person says it best. Senator Brown has been highlighting letters that he has received from people in the State of Ohio, and people in Pennsylvania have written to me or sent an e-mail or appeared in my office and relayed their own stories. In this case, when it comes to real families and real children, it is especially important to highlight them. I just have one example to share tonight. I received a letter from a Pennsylvania resident named Denise Lewis. Denise has four children who are now older, but when she contacted us, she was recalling what she went through with her four children in terms of health care. All through their childhood, Denise and her husband struggled with being either uninsured or underinsured. What health insurance they have had has always been employer-based but often was limited and only covered hospitalizations. Her family couldn't afford the premiums on more expensive coverage, and much of this, unfortunately, was before the Children's Health Insurance Program was in effect. Her family never qualified for any other kind of assistance. She said she would work a second job part time as a waitress so they could afford food and to pay off medical bills. Today, even though her youngest is 19 years old--her youngest child of the four is 19 years old today--she is still sending monthly checks to her pediatrician to pay for all the care her children received. Imagine that, all these years later, because of the system we have. Goodness knows there are great parts to our system that we should celebrate and be proud of, but there are a lot of parts of our health care system which simply don't work for too many Americans and is hurting families, hurting businesses, and killing our ability to grow our economy long term, and this is one example. Why should Denise Lewis or anyone have to worry like this, have to choose between food and getting medical care or paying for a hospital visit? Why should anyone have to pay off medical bills years and years later for children who are already grown? At times, Denise said the medical care her children needed would actually determine what food the family ate that week. They managed to make ends meet but never had any money for extras of any kind. Listen to this in terms of what Denise said, and these are her words: Wondering whether you should go to the doctor is completely different from wondering whether your kids should go to the doctor. That is the nightmare that too many families are living through. There are those who say: Well, let's just think about it for another 6 months. Some are saying: Let's not pass a bill. Let's slow it down. It's too complicated. We can't do this. For those who are saying that, I would ask them if they have ever had to face that decision--the question of what kind of care their child would get. Had they ever faced the dilemma of how much your family can eat in a particular week or can you pay for a doctor's visit? Denise Lewis, one of her children had frequent ear infections as a baby, and more than once she would call the pediatrician and ask if she could get a prescription without coming to the office so she wouldn't have to pay for the office visit. Why have we tolerated this, year after year and decade after decade, of people telling stories such as this? The Congress of the United States, year after year, has said we will get to that later; it is too complicated. Why should any parent, mother or father, single parent-- why should any parent have to make those choices or say to a pediatrician can I get a prescription without coming to the office because I can't afford the office visit? We are the greatest country in the world. We have all the benefits of the wonders of technology and great doctors and dedicated and skilled nurses, great hospitals and hospital systems, all this brainpower and talent and ability--ability to cure disease. Yet on the other side of our system we tell people you have to pay more for a doctor visit for your child. Why did we allow this to happen? Year after year, we have just allowed the problem to persist. Our system has said to women, you should engage in some preventive strategy. With regard to breast cancer, you should get a mammogram. Then we say you have to pay for all or most of it. Why do we do that? Why should we allow that to continue? I want to move to two more charts. I know I am over my time a little bit. Let me go to the next chart. I really believe, when we describe some of these challenges, we are talking about, really, a national tragedy, that the children in our country should be reduced to having the emergency room as their primary care physician or their doctor's office. When we were growing up, we knew what it was like to go to the doctor, but for too many children the emergency room is the doctor's office. That is not good for the child because that usually means they are further down the road for a condition or problem; they are sicker and have more complications. It is also bad for how we pay for health care. We also know the emergency room care by uninsured Americans with no place to go but an emergency room is one of the biggest drivers of the out-of- control costs we often see in our system. That is why we need health care reform now. We now cover about 7 million children in CHIP. Thankfully, fortunately, we reauthorized it in 2009. It kind of went by people pretty quickly, but that was a major achievement. That bill went through and the President, President Obama, signed it into law. By virtue of that one signature and the work that led up to that, those 7 million who are covered now by CHIP will double by 2013 to 14 million children who will be covered by that program. But even with that reauthorization, there are still things that will challenge us with regard to the Children's Health Insurance Program. One of them is a failure that could take place over time where we do not strengthen the Children's Health Insurance Program. I meant to highlight this chart as well: ``Uninsured low-income children are four times as likely to rely on an emergency department or have no regular source of care.'' That is the point I wanted to make about emergency room visits. Finally, let me move to the fourth chart. Not only is this program, the Children's Health Insurance Program, a major success across the country, but it has reduced the rate of uninsured children by more than one-third. As we can see by this chart on my left, insuring children is something people across America strongly support. Prior to the amendments and the markup process in the Finance Committee this fall, there was a proposal to move the Children's Health Insurance Program into the health insurance exchange as part of the Finance Committee bill. Many members of that committee, and others like me and others, didn't think that was a good idea. Senator Jay Rockefeller was another and, fortunately, he was on the Finance Committee. His amendment in that committee fortunately removed the Children's Health Insurance Program from the exchange. Why was that important? The data is overwhelming that placing families that are covered by the Children's Health Insurance Program into that newly created insurance exchange would, in fact, increase their costs and decrease their benefits. There was a debate about it, but I think the Finance Committee did the right thing. By keeping the Children's Health Insurance Program as a stand-alone program that we know works--all the data shows it. It is not an experiment. It is not a new program. We have had more than a decade of evidence that shows that it works. We have to keep that in the final bill. We have to keep that as a stand-alone program, and we have some work to do to make sure that happens. When you see the numbers here, an overwhelming three to one majority, 62 percent to 21 percent of Americans, would oppose the elimination of the Children's Health Insurance Program if they learned that a new health insurance exchange ``may be more costly for families and provide fewer benefits for children.'' We have to make sure when we get to the point of having a final bill worked out that we keep that in mind. We know for now that we have a stand-alone program. Thank goodness that change was made. We know it works. But we have to do everything we can to strengthen the Children's Health Insurance Program, because in the coming years there will be recommendations to change it. There will be others who will make suggestions about how the Children's Health Insurance Program fits into our health care system, and we have to be very careful about how we do that. But for now I want to emphasize two points and I will conclude. A commitment to that basic goal that no child at the end of this is worse off, especially vulnerable children who happen to be poor or have one or more special needs--we have to make sure that happens. We also have to reaffirm what I think is self-evident and irrefutable. The Children's Health Insurance Program works. We have to keep it as a stand-alone program, and we have to continue to strengthen it because there are some changes we can make to strengthen it. I look forward to working with our colleagues in the Senate to meet those goals. I know the Presiding Officer has a concern about this as well. He has been a great leader on health care in his first year in the Senate. I thank him for his work. I will conclude with this. In the Scriptures it tells us ``A faithful friend is a sturdy shelter.'' We have heard that line from Scripture. We have heard it other places as well. We think of a friendship as a kind of shelter when things get difficult, when life gets difficult. One of the questions we have to ask ourselves in this debate is, Will the Congress of the United States really be a friend to children? Will we be that faithful friend who acts as a sturdy shelter? Because children can't do it on their own; we have to help them. I believe by getting this right we can be that faithful friend and we can be that sturdy shelter for our children. Let it be said of us many years from now, when people reflect upon how this debate took place and what we passed, in terms of health care reform--let it be said of us, when our work is done, that we, all of us as Members of the Senate and Members of the Congress overall, that we created at this time, at this place, a sturdy shelter for our children and that we can say that with confidence and with integrity. [From the New York Times, Oct. 30, 2009] Exhibit 1. Hospitalized Children Without Insurance Are More Likely To Die, a Study Finds (By Roni Caryn Rabin) Nicole Bengiveno/The New York Times Researchers analyzed data from more than 23 million children's hospitalizations from 1988 to 2005. Uninsured children who wind up in the hospital are much more likely to die than children covered by either private or government insurance plans, according to one of the first studies to assess the impact of insurance coverage on hospitalized children. Researchers at Johns Hopkins Children's Center analyzed data from more than 23 million children's hospitalizations in 37 states from 1988 to 2005. Compared with insured children, uninsured children faced a 60 percent increased risk of dying, the researchers found. The authors estimated that at least 1,000 hospitalized children died each year simply because they lacked insurance, accounting for 16,787 of some 38,649 children's deaths nationwide during the period analyzed. ``If you take two kids from the same demographic background--the same race, same gender, same neighborhood income level and same number of co-morbidities or other illnesses--the kid without insurance is 60 percent more likely to die in the hospital than the kid in the bed right next to him or her who is insured,'' said David C. Chang, co- director of the pediatric surgery outcomes group at the children's center and an author of the study, which appeared today in The Journal of Public Health. Although the research was not set up to identify why uninsured children were more likely to die, it found that they were more likely to gain access to care through the emergency room, suggesting they might have more advanced disease by the time they were hospitalized. In addition, uninsured children were in the hospital, on average, for less than a day when they died, compared with a full day for insured children. Children without insurance incurred lower hospital charges--$8,058 on average, compared with $20,951 for insured children. In children who survived hospitalization, the length of stay and charges did not vary with insurance status. The paper's lead author, Dr. Fizan Abdullah, assistant professor of surgery at Johns Hopkins, dismissed the possibility that providers gave less care or denied procedures to the uninsured. ``The children who were uninsured literally died before the hospital could provide them more care,'' Dr. Abdullah said. Furthermore, Dr. Abdullah said, indications are that the uninsured children ``are further along in their course of illness.'' The results are all the more striking because children's deaths are so rare that they could be examined only by a very large study, said Dr. Peter J. Pronovost, a professor of surgery at Johns Hopkins and an author of the new study. ``The striking thing is that children don't often die,'' Dr. Pronovost said. ``This study provides further evidence that the need to insure everyone is a moral issue, not just an economic one.'' An estimated seven million children are uninsured in the United States, despite recent efforts to extend coverage under the federal Children's Health Insurance Program. Advocates for children said they were saddened by the findings but not surprised. ``We know from studies of adults that lack of insurance contributes to worse outcomes, and this study provides evidence that there are similar consequences for children,'' said Alison Buist, director of child health at the Children's Defense Fund, a nonprofit advocacy organization. ``If you wait until a child gets care at a hospital, you have missed an opportunity to get them the types of screening and preventive services that prevent them from getting to that level of severity to begin with.'' The most common reasons for children being hospitalized were complications from birth, pneumonia and asthma. The study found that the reasons did not differ depending on insurance status. Earlier studies have found that uninsured children are more likely than insured children to have unmet medical needs, like untreated asthma or diabetes, and are more likely to go for two years without seeing a doctor. Following a recent expansion, 14 million children will be covered by the CHIP program by 2013, according to the Congressional Budget Office. Advocates for children are concerned that efforts to overhaul the health care system may actually reverse the progress made toward covering more children if CHIP is phased out and many families remain unable to afford health insurance. ``You can't just dump 14 million vulnerable children into a new system without evidence that the benefits and the affordability provisions are better than they are now,'' Dr. Buist said. ``That's not health reform.'' Mr. CASEY. I suggest the absence of a quorum.

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

Mr. CASEY

Mr. CASEY. Mr. President, I ask unanimous consent the Senate proceed to executive session to consider en bloc Calendar Nos. 314, 495, 496, 502, 503, 515, 516, 517, 518, 523, 524, 525, 528, and 529; that the nominations be confirmed; that the motions to reconsider be laid on the table en bloc; that no further motions be in order; that any statements relating to the nominations be printed in the Record; that the President be immediately notified of the Senate's action, and that the Senate resume legislative session.

Mr. CASEY

Mr. CASEY. Mr. President, I ask unanimous consent that the Senate proceed to a period of morning business, with Senators permitted to speak for up to 10 minutes each.

Mr. CASEY

Mr. CASEY. Mr. President, as in executive session, I ask unanimous consent that at 4:30 p.m. on Monday, November 9, the Senate proceed to executive session to consider Calendar No. 185, the nomination of Andre M. Davis to be a U.S. Circuit Judge for the Fourth Circuit; that there be 60 minutes of debate with respect to the nominations, with the time equally divided and controlled between Senators Leahy and Sessions or their designees; that at 5:30 p.m. the Senate proceed to vote on confirmation of the nomination; that upon confirmation, the motion to reconsider be made and laid on the table, the President be immediately notified of the Senate's action, and the Senate then resume legislative session.

Mr. CASEY. For the information of the Senate, if Members wish to speak with respect to this nomination on Friday, they are encouraged to do so.

Mr. CASEY

Mr. CASEY. Mr. President, I ask unanimous consent that when the Senate completes its business today, it adjourn until 9:30 a.m., Friday, November 6; that following the prayer and pledge, the Journal of proceedings be approved to date, the morning hour be deemed expired, the time for the two leaders be reserved for their use later in the day, and the Senate resume consideration of H.R. 3082, the Military Construction and Veterans Affairs appropriations bill.

Mr. CASEY

Mr. CASEY. Mr. President, following morning business, there will be 40 minutes for debate prior to a cloture vote on the committee-reported substitute amendment to H.R. 2847. Therefore, Senators should expect the first vote of the day to begin around 12:15 p.m.

Mr. CASEY

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

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