Bill Frist

Mr. FRIST

Mr. FRIST. Mr. President, I ask unanimous consent that when the Senate completes its business today, it stand in adjournment until 2 p.m., Monday, June 23. I further ask that following the prayer and pledge, the morning hour be deemed expired, the Journal of proceedings be approved to date, the time for the two leaders be reserved for their use later in the day, and the Senate then resume consideration of S. 1, the prescription drug benefits/Medicare bill.

Mr. FRIST

Mr. FRIST. Mr. President, I ask unanimous consent that the concurrent resolution be agreed to, and the motion to reconsider be laid upon the table, with no intervening action or debate.

Mr. FRIST. Mr. President, I ask unanimous consent that the Senate proceed to the immediate consideration of H. Con. Res. 139, which is at the desk.

Mr. FRIST

Mr. FRIST. Mr. President, I ask unanimous consent that the committee amendment be agreed to, the bill, as amended, be read the third time and passed, the motion to reconsider laid upon the table, and that any statements relating to the bill be printed in the Record.

Mr. FRIST. Mr. President, I ask unanimous consent that the Senate proceed to the immediate consideration of calendar No. 133, S. 686.

Mr. FRIST

Mr. FRIST. Mr. President, I ask unanimous consent that the bill be read the third time and passed, the motion to reconsider be laid upon the table, and that any statements relating to the bill be printed in the Record.

Mr. FRIST. Mr. President, I ask unanimous consent that the Senate proceed to the consideration of H.R. 2312.

Mr. FRIST

Mr. FRIST. Mr. President, for scheduling this afternoon, in 15 or 20 minutes I am going to speak for 20, 25 minutes, and then Senator Byrd is going to come over later as well. We have plenty of time, but if sometime in the next 30 minutes or so I may have the floor for 20 or 30 minutes, that will be helpful.

Mr. FRIST. Mr. President, I rise to oppose the Dorgan amendment on importation of foreign drugs. It is essential that my colleagues understand the gravity of what we are about to vote on today. My colleagues yesterday passed the Cochran second degree amendment by voice vote, ensuring that none of the provisions in the Dorgan amendment would become effective unless the Secretary of Health and Human Services certifies to Congress that the implementation of the Dorgan amendment would (1) pose no additional risk to public health and safety, and (2) result in a significant cost savings for Americans. While this safety and cost savings certification threshold determines whether the Dorgan importation language would ever become effective in the first place, I believe that in this era of increasing bioterrorist threats, now more than ever, we should not pass new drug importation legislation at all. Allowing the importation of drugs from Canada by pharmacists and wholesalers would simply encourage further proliferation of schemes to use Canada as a transshipment point for sending unapproved, expired, counterfeit or otherwise dangerous drugs to American consumers. The Assistant Deputy Minister of Health Canada clearly stated in a May 9 letter this year that, ``The Government of Canada has never stated that it would be responsible for the safety and quality of prescription drugs exported from Canada into the United States, or any other country for that matter.'' Allowing pharmacists and wholesalers to import drugs directly from sources outside the U.S. will further encourage the proliferation of purportedly ``Canadian'' Internet Pharmacies that are not from Canada. A 2003 Global Options report stated that 33 percent of so-called ``Canadian'' internet pharmacies are not from Canada. One was ``Canadarxfree.com'' and the actual country of origin was Mexico. Another, ``Trustedcanadianpharmacy.com'' had Barbados as the actual country of origin. Another troubling real-life example cited by Bill Hubbard, the Senior Associate Commissioner for Policy, Planning and Legislation at FDA during a June 12, 2003 hearing before the house Government Reform Subcommittee was, ``. . . we have an example of an 82-year-old gentleman who bought two drugs from a website.--[H]e was told on that website and when he made the phone call that he was getting a U.S. produced drug, sold in Canada and sold back to him. He got Indian drugs that are not approved, have no labeling, no information and he called the FDA and was outraged why are we letting this stuff in.'' The FDA determined the drugs were counterfeit. The so-called documentation requirements in the Dorgan amendment could easily be circumvented, forged and lack verification standards. In July 2002, the Department of HHS sent a letter to Senator Cochran that described the problems with allowing pharmacists and wholesalers and even individuals to import drugs from Canada, ``Since counterfeits can easily be commingled with authentic product, either by the case, by the bottle or by the pill, there is no sampling or testing protocol sufficient to protect against the grave public harm they pose.'' All of my concerns about importation and risks to the health and safety of Americans that I have expressed do not even include the reasons I believe this Dorgan amendment is truly unnecessary. We are in the midst of debating and passing a landmark Medicare prescription drug bill. Through this historic legislation we will provide our seniors with affordable access to medicines, without exposing them to the very real risks of counterfeit, subpotent, unapproved, adulterated, or misbranded drugs from importation. We have also gone a step further in addressing the affordability of medicines by overwhelmingly supporting the Gregg-Schumer amendment yesterday, which will allow generics to enter the market faster. Together with the President's recently issued final rule, this amended bill will save Americans money by improving access to more affordable generic drugs. I commend the President for proposing in this 2004 budget request, an unprecedented increase of $13 million in spending for FDA's generic drug programs. By increasing the program's size by almost one-third of its current size, FDA will be able to hire more generic drug application reviewers and approve generics faster. With all of the new information we now have about the dangers of importation and fraudulent websites, we owe it to our seniors to pass a meaningful, comprehensive Medicare drug benefit without exposing them to the very real risk of obtaining counterfeit imported medicines. I again urge my colleagues to vote ``no'' on the Dorgan amendment, even as modified by my second degree amendment.

Mr. FRIST. I yield 2 minutes to the Senator from Mississippi.

Mr. FRIST. Mr. President, on my leader time, I rise to speak in opposition to the Dorgan amendment on the importation of foreign drugs. Before the vote, I want to let my colleagues know that I do believe this amendment has the potential for opening doors that would be dangerous in this day and time. I say this in spite of us passing by voice vote the Cochran amendment yesterday, which does two things. It says none of the provisions of the underlying Dorgan amendment would become effective unless the Secretary of Health and Human Services says it poses no additional risk to public health and safety and, two, results in significant cost savings for Americans. I supported that amendment. We all did; it was a voice vote. That is very important. It does change the threshold a bit, but I will vote against the Dorgan amendment because I believe in this era of increased bioterrorist threats, we, now more than ever, should not open the door and pass new drug importation legislation at all. The reason I say that, very quickly, is the Canadian Government has stated: The government of Canada has never stated that it would be responsible for the safety and quality of prescription drugs exported from Canada into the United States, or from any other country. If we open this door, Canada has the potential for--first of all, they cannot certify safety but, secondly, become a transshipment port for other countries if we open this door to Canada. There are a number of statements that have been made. The other concern I have is on the documentation requirements. I am afraid, in the Dorgan amendment, they could be forged or circumvented, and there is a lack of verification standards, I believe. Lastly, it is important we understand our underlying bill to which the Dorgan amendment is being applied has as its purpose to make drugs more affordable and lower that burden overall. I am hopeful we will accomplish that with the vote at the end of next week--drugs that are certified to be safe, that have gone through the FDA approval. I will be voting against the Dorgan amendment. I encourage my colleagues to do likewise.

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

Mr. FRIST. Mr. President, on this Friday we have had a number of speakers come forward over the course of the morning and the afternoon on the topic of how best to improve Medicare, strengthen Medicare, preserve it, and build upon what we have learned in the past to bring it up to date and to give seniors the opportunity to receive the type of health care available today of which most people in the private sector are able to take advantage but to which, because of the structure of Medicare today, seniors simply do not have access in a way they really deserve: Things such as prescription drugs, which, as we heard debated 20 or 30 minutes ago by the distinguished Senator from Florida, are so absolutely critical to the health care toolbox, to the armamentarium out there today to take care of seniors and individuals with disabilities to prevent more serious illness for people on those pills that keep their blood pressure down at a reasonable level, that prevent debilitating strokes, prevent massive heart attacks; if they do not take that pill, those acute diseases that become chronic diseases occur, or episodic acute diseases occur. There is such a high barrier for prescription drugs that they are less likely to reach out and get the drugs. The whole purpose is to reverse the burden in a way that is sustainable over time. As politicians, we want to help people, we want to help them now. But if we do it in a shortsighted way, we can create bigger problems for people 3 years out, 5 years, 10, 15, 20 years out, or at this time we must think 30 years out. In the next few minutes, I will again step back and look at where we are in health care, what we are doing. Then we will be able to come back in next week and look at a lot of the individual amendments. They can be very technical. They involve a lot of terms that are unfamiliar to even a lot of Senators but also to the public at large. In the next few minutes, I want to take this big-picture look and introduce the demographic challenge that should be the backdrop for all of our discussions when we look at health care for seniors, for promises we are making today that we are writing into legislation to make sure we are doing it in a way that can be sustained over time. This is talking to seniors but, even probably more directly, to the near seniors and to the younger generation because it is their health care we are talking about. It is their money we are using, in large part, to pay for the health care security for seniors today. Thus, I think we have to look at it in this intergenerational way. In the big picture, the U.S. health expenditures for the dollars spent in 2001 and 2002 are similar, although this chart shows the most recent data for today of all health care dollars spent in the United States of America. The red on the chart is public expenditures, public programs--what is government--and the blue is the private sector. It is an interesting chart because it shows about half of the health care dollars run through government programs--Federal, State, and local--and half of the health care dollars are spent in the private sector. What we have the opportunity to do now is marry these two with public-private partnerships, to take care of one segment of these health care dollars, and that is this 17 percent, this bright red 17 percent--almost a quadrant--but 17 percent of the overall health care dollar which is spent on and for and by senior citizens and individuals with disabilities, about 40 million people. That is 17 percent. What we were concentrating on the last week, really the last several months, is this part of the pie. Medicaid, which is lower income, other Federal programs, other State and local programs are the other public programs--46 percent of the overall pie. What we are going to be doing is capturing the very best out of the private sector, in terms of health care delivery, technology, prescription drugs--which, remember, are not up in this red sector-- capture the best of the private sector with the best of the public sector, marry the two, and thereby give the seniors who fall into this sector here, this piece of the pie, better health care, better value that can be sustained over time. We are capturing the best of this section with the best of this section, marrying public and private. It is a new concept. Traditionally, Medicare has been command and control, Washington, DC-based: we dictate; we say what is in it, what is not in it. We dictate, micromanage the decisions. The problem with health care today, with the advances in health care delivery, with the new innovations, with the human genome project, with the new technology, it is not being adopted into this sector. To me, that is sort of the big picture I want to begin with. The challenge, if we are looking long term, if one of the goals of what we do now is we must be responsible for the future, we need to recognize what the demographic backdrop is. What does the future look like? The future looks different now, from a demographic standpoint-- demographic being numbers of people, ages of people, genders of people. That is what I am talking about when I am talking about demographics. That backdrop is changing more radically than ever, than at any time in the history of this country. I will tell you why shortly. It is changing in several ways. This chart is the number of Medicare beneficiaries. That 17 percent I just showed you was of the overall health care dollar, how many people fall in that section of that pie chart. Just look at two bars on this: This is the year 2000; this is in the year 2030. The important thing is there are 40 million beneficiaries--beneficiaries just means seniors, people who are in the program in the year 2000. You see it goes up, but just jump over and you can see it is 77 million in the year 2030. It seems like a long time from now, but it is not. That is not very long from now. But from this green bar to this green bar is a doubling in the number of seniors. Historically, we did not have that. I will show why we had this doubling that we have to face up to if we are responsible legislators. No. 1 is the baby boom. I love this chart because it is the way I view the baby boom. You see, it really is a baby boom. This, along this Y axis, is births per woman. You can see how it has changed over time. This is 1940, 1950, 1960, 1970, 1980, 1990, 2000--so we are about where this dotted line is now. You can see that we had this baby boom, this fertility curve, this increase in population right after 1945, up to about 1970, with the peak around 1959, 1960. You just add 60 or 65 years to this part of the chart and you quickly get out to 2010, 2015, 2020. That is what we need to look for. In other words, this fertility curve, this baby boom, this increase in the population has just moved right across this chart, and this baby boom is going to begin to hit us in about 2008--5, 6, 7 years from now. It just begins to hit, and then over the next 5, 10, 15 years it peaks and then goes back down. But it goes back down over a period of about 30 years. So we are talking 2010 out to 2040, 2050. The big thing is this anomaly is unprecedented in entitlement programs. This is what we have to prepare for. If this is the Medicare system here, and we are taking care of seniors, we are going to have a doubling in the number of seniors. One of the reasons is because of the baby boom. The other reason--and I am proud of this reason. I think we all are. I am, as a physician, because physicians focus their lives on health care and improving length of lives as well as quality of life. This is probably, to me, the easiest way of looking at the fact that people are living longer now than they did 10 or 15 years ago, and as we improve health care, as we do better with preventive care and better technology and get people to eat better and exercise more, we are going to continue to have these seniors-- which are already doubling in number--live longer. Let's just take an example. This is what it was like in 1940, 1950, 1960. What this means is-- let's say I am 65 years old. If I am 65 years old, in the year 2000 I would be predicted to live another 20 years. This is years of life remaining at age 65. That is pretty good. Let's say if it were for me, 60 years old, I would be 65 plus 15 is 80.2 years of age. If I were a woman, I would be able to say I am 65 years of age, and I am going to live 20 more years. That is pretty interesting. But the good news is that when Medicare started, when you were 65, say, back in 1965, if I was 65 years of age, they would say I am only going to live 13 more years. But because health care has gotten better now, I am going to live 15 more years, and if I am out in 2030, I am going to live 17 more years. You have not only more seniors but each one of those seniors is living longer. Thus they are going to be in the Medicare system for a longer period of time than what we would have thought or predicted back, either in 1965, the year 2000, or 2030. If we are good, which I think we are in terms of science, technology, health care, this is going to increase more and more. I don't know where it is going to stop. Nobody really knows, in terms of how long people will live. But it is interesting, doubling the number of seniors because of the fertility curve, and each one of those seniors will live longer, of which we are all proud. As an aside, this differential between women and men is pretty remarkable. If I am talking to a woman 65 years of age, I say you are going to live 20 more years. If I am talking to a man, you are only going to live 15 years. Why is that? There are a lot of hypotheses, and we don't fully know why the difference, why it is. But the point is they both are going to live longer. This is sort of a summary chart. In 1970, we had 20 million people. Now we have 40 million people. You are going to see this line break. In 2030, we are going to have 77 million people. Again, the summary chart: A lot more people coming out of the system. That is one component. Let's say this is the Medicare system. We say trust fund but it is not really a trust fund like in a bank or the way you envision money accumulating and then paying it out. That is just not the way it happens. It is a pay-go system, which means for every senior over here taking out for health care, you have workers--that is most of the people who are probably listening to me right now, people who have been working--who have to support it. The moneys they pay on April 15, or whenever they pay their taxes, go out to support these seniors. The money we are spending is not money seniors paid in in the past; it is a pay-go system. That is why this trust fund is not really a trust fund. What is interesting there, not only do we have a doubling of the number of seniors, but we have fewer workers paying into the system, which the very next day are paying out to support an increasing number of seniors. This is fascinating because it, too, is a part of that fertility curve, in the 1940s and 1950s. You will see in 1970 there were 7 of these individuals, 7.3 to be exact--paying taxes to support every senior in the system. What is interesting is that in the year 2000 that has come way down. Instead of having 7 people over here working to support each senior, you have 3.9--say 4. You have these 4 working. So, therefore, they are having to work twice as hard or pay twice as much for taxes, or work twice as many hours a day than they were working in the past because you have fewer of them supporting each worker--for health care. Again, with the fertility boom, as it comes through, this is going to fall, by 2030, to only 2 or 2.4 workers, and they are going to have to work that much harder to support whatever we promise and whatever health care we give to seniors. All of sudden, we saw a huge challenge. We can promise so many things right now. We can promise to improve their benefit. We can promise to give them whatever they ask for and what they want. But in doing so, if we fulfill our obligation to both this generation and also the next generation, we need to do so in a way that can be sustained. We have a doubling of the number of seniors with fewer people paying in, which compounds the challenge of technology and adding benefits and the challenge of looking at chronic care. The product of that is, if we didn't change the law at all--if we just kept the Medicare law as it is, which is not realistic because it will change no matter what--we are spending about $226 billion a year now. In 2030--not with this bill--we are going to be spending $448 billion and fewer people are going to be paying into that system to expend the $448 billion that we have today. That is why you will hear again and again from Members such as the Senator from Oklahoma, Mr. Nickles, and also the Senator from New Hampshire, Mr. Gregg. They will again and again remind me and our colleagues in our caucus that whatever we do, we need to do it in a way that can be sustained over time. We can't be making promises that cannot be in any way upheld or fulfilled in the future by putting an unnecessary and unfair burden on that next generation. This is a chart which I almost hesitate showing. This summarizes and puts things in perspective why we have to address Medicare now. No. 1, because seniors deserve better health care security. It is just too obvious to me that without prescription drugs, and without preventive care and disease management within Medicare today, they are not getting what they deserve. The second issue is as important as Social Security. At some point we need to come back and address Social Security as well as the cost of the demographic shift because of our responsibility to seniors and that next generation. But if we look--this is the financial challenge--at the unfunded promises over the next 75 years--I am not going any further out than 75 years, but it is important having gone out 30 years to mention the next 75 years--if you add up all of the unfunded promises, promises that are made, mandates that are in the law but we haven't determined how to best pay for them; as comparison, the debt held by the public of $3.6 trillion, just for comparison purposes--if we look over the next 75 years for Social Security, what is the shortfall there? That is why we have to come back and address it at some point, and I am not sure when it will be. But it is $3.6 trillion, and somebody is going to pay for it. We are going to have to address that. But Medicare and health care for our seniors--this is not the bill on the floor; this is today, the current law as it exists--there is a $13.3 trillion Medicare shortfall over the next 75 years. That is one of the reasons I think it is important for us to address Medicare now, relatively early in this Congress, why we should not delay, why we do need to finish the bill next week, and have the House do the same, have the President sign it as soon as possible, but also stress the point that we have to get this thing right. We have to do it responsibly because what we are doing as a product of modernizing Medicare is making sure we get the very best value, that it is an efficient system, that it is adding a brandnew benefit of prescription drugs which even isn't calculated in this. This $13.3 trillion is Medicare as we have it today. One of the things we are going to do is add the $400 billion benefit over a 10-year period--not 75 but a 10-year period on top of this already $13.3 trillion Medicare shortfall. We are going to add a benefit on top of that. That is why we can't just add a benefit on top without addressing Medicare overall. That is why you heard the President from day 1 say yes, we have to have prescription drugs; yes, we have to improve the nature of the benefits; but at the same time we have to address reform because not to do so would be irresponsible as the leader of the United States of America. And the same thing goes on in this body today. That is why the bill we have brought to the floor is not just a Medicare package and not just a bill that says let us promise pills to seniors, but says, yes, those medicines are critical and vital, but at the same time we have to address the overall integrated delivery of health care which, I would argue, allows us to have a more efficient system, a system that has more value, and a system that allows us to address, as we look out to the future, this huge unfunded promise we have made in the past. When we are in the middle of talking about each of these individual amendments and the technical nature of materials, it is hard to back up and look at some of these principles that underlie doing this thing right--doing it in a bipartisan way, allowing ample time, as we have had all week, to fully debate the amendment process. This is the issue Senator Dorgan talks about a lot, and he talks about the Finance Committee a lot. And we are beginning to talk about it a lot on the floor. I don't want to get into the debate, but it will be a backdrop for much of the discussion next week. If you look at Medicare beneficiaries and a pie chart of 40 million people, all of those 40 million people are not very expensive in what they actually expend in terms of health care expenditures. Over here, these are all the beneficiaries. This is 100 percent of the 40 million people. Over here is health care expenditures. The point of this is, if you just focus on the orange, 6 percent of all Medicare beneficiaries, about one in two--if this whole body were filled right now, there would be only about five or six of them in the whole body, just six desks, who would be responsible for 50 percent of all the money we put in Medicare. Of that $220 billion which we put in, only six desks--you probably see these six desks around me--would be responsible for half of that money. Why? Because they are sicker; they have more chronic diseases. Right now, I think as we say in approaching a program that is sustainable that gives very good care, wouldn't it be great to be able to identify this 6 percent which accounts for 50 percent of these expenditures--or it could be the top 15 percent or 14 percent--this 6 percent, and the 8 percent which accounts for 76 percent--wouldn't it be great if we made absolutely sure that in that population we gave them the very best care possible in terms of prevention, in terms of management, in terms of coordination, in terms of an integrated way of taking care of their health care problems and making sure they are treated and cared for? I am absolutely convinced--and I say this having taken care of thousands of Medicare patients, which I was blessed to be able to do before coming here--if we had the data system to be able to identify who they are and had them in the appropriate system to manage their care, they would be better cared for with a better value for the dollar. But this is a fascinating chart on which very few people have focused. We will get back to it I think in the debates next week. I mentioned Senator Dorgan. He and I have been discussing the same charts many times. This chart is very similar to the prescription drug expenditures as well. We can focus on certain populations. This is an extension of Senator Dorgan's conversation, and my conversation with him. These ``CCs'' are ``chronic conditions.'' A chronic condition is something such as congestive heart failure. Congestive heart failure is when the heart gets big, it just does not pump quite as well. It is like water behind a dam; it begins to fill up in the body. It fills up in your lungs. You get short of breath and swelling in your feet. If you see people who are a little short of breath, typically it is an element of congestive heart failure, if they have heart disease at all. But what is interesting is, if you look at Medicare expenditures, for people who only have one chronic condition such as heart failure, they account for about 4 percent of expenditures. If they have two chronic conditions--say, heart failure and diabetes--they would account for an additional 7 percent of expenditures. If they have three or four or five chronic conditions, they account for about 65 percent of expenditures. What I am suggesting is, if you could identify people with five chronic conditions or four chronic conditions--and right now, it is amazing, because in Medicare, in our data base, you really cannot do that, but in a newer system, an up-to-date system, if you could identify these people and then manage them better, to make sure you had integrated care, coordinated care--maybe it would be a phone call from a nurse once a week, to say: Have you weighed yourself today to see if you picked up any weight? If you have picked up weight, you better come in and see us because your lungs are filling up with water. But in a newer system we could catch it before they are hospitalized, and all of a sudden you have saved the hospitalization or maybe someone's life. That sort of integrated care is just not a part of Medicare today, and it should be. Thus, if we better manage these people--and ``management'' is not a great word. If we better treat them, if we better care for them, we would cut overall costs and improve the quality of care. We simply cannot do that in the Medicare program today. Thus--and this comes to what this bill is all about--how do you address some of those issues? The bill on the floor allows us to address each of the issues I have mentioned. In 2006, seniors, after having had access to a prescription drug card--and every senior could have a drug card in about 9 months from now. If we can pass this bill next week, get it through conference, have the President sign it, probably 6 to 8 months after that every senior could have a prescription drug card that would give them some benefit in terms of lowering the cost of their prescription drugs. That is a pretty good, immediate response, if we can get this bill through on time. In the year 2006, though, the prescription drug card begins to be replaced by three options an individual senior would have. They could keep what they have today--traditional Medicare--and with that they could have access to an insurance drug package; No. 2, they could take advantage of Medicare+Choice, which is a coordinated care, integrated care type program; or, No. 3, they could take advantage of a PPO, which is an integrated health care, coordinated health care delivery system that includes prescription drugs, preventative care, and that chronic disease management. Thus, as we look ahead in designing this program--and this, as shown on the chart, is sort of the general outlay of the bill itself--you will hear about a lot of amendments over the next week, and those amendments will talk about, for example: Well, what about the size of the drug package in each? A decision in the bill was made to have this same drug benefit under traditional Medicare and Medicare+Choice, which, by the way, has 5 million people in it. And this other program has 35 million people in it today. This prescription drug benefit is the same. Some people might say: Well, we ought to change the benefit. Some people will say: Let's make sure this is a truly competitive model that takes advantage of what we know in the private sector works, which has more market-based principles--yes, that is highly regulated by the Government--to make sure those benefits are delivered; and those benefits have to be a part of each PPO that comes forth and bids, but let's make this more competitive. And Monday and Tuesday and Wednesday we are going to hear a lot about how to make this a really up-to-date system and as competitive as possible, which would improve quality and improve the value of each dollar put into the system. So you will hear about market-based competition. It will be maximized in this area, as shown on this part of the chart. Again, people will be able to keep exactly what they have today. So I say to seniors who are listening, you do not have to worry about things being taken away from you or the question: What is Government going to do? Are they going to come in and take away benefits you already have? No. You are going to get access to additional benefits, even if you stay in traditional Medicare. You will be able to take advantage, like 5 million people do, of an HMO. People start running when they hear that word HMO, but let me tell you, 5 million people who are in these HMOs are pretty pleased because they have access to prescription drugs today or people can choose this PPO model, which is the model that works best in the private sector today. It is the model most people who have employer-sponsored insurance today have. It definitely is the model of the future because of this continuity of care delivered in a seamless way as we look to the future. Mr. President, I am going to cover just one more little bit different concept as a preface to what we will be talking about next week in the Medicare debate, and that is on what is called the donut. Now I am coming back down from 35,000 feet to about 5,000 feet to look at what will be one of the hot topics and an issue that will be debated in terms of what is called a gap or a donut. I guess those are the two words that are used mainly. The concept is that people will get a lot of assistance, especially if you are under the poverty level or under 160 percent of the poverty level. There is no donut for 44 percent of all seniors. There is no gap. There is no donut. I will come back and talk a little about what the donut is. If you are under 160 percent of poverty--that is about $16,000, $17,000, if you are married, of income every year as a senior--there is no donut, there is no gap. This chart I show you deals with those individuals who are below 100 percent of the Federal poverty level. What this chart shows, in the blue, is the percent of your total expenses in a year that is paid for by the plan. The green is the amount that is paid for by the beneficiary. So if you have $1,000 of drug expenses a year, and you are below the poverty level, you will have almost 98 percent of all of your drug expenses paid for by the plan, and you will pay $25--very little. It is a very generous benefit. I will have one more chart that goes above the poverty level to 160 percent of the poverty level. If you have $2,000 of expenditures in drugs a year, again, if you are below the poverty level, the plan pays for 98 percent of all your drug expenses. If you have $3,000 of expenditures a year, again, the plan pays for about 95 or 98 percent of all your drug expenses. You can see that goes up. If you have $7,000 of drug expenditures a year, again, the plan pays about 98 percent of that. And this is one of the beauties. Remember, none of these people get prescription drug coverage through Medicare today. I do not know what it is below the poverty level, how some of them get it through other plans. In fact, if you look at all seniors, about two-thirds do get some element of prescription drug coverage somewhere. And we have to be very careful because we do not want to have everybody coming to a Government program. But the point I want to make is, if you are under the poverty level or indeed at 160 percent of the poverty level, the plan itself is very generous. We are going to hear on the floor next week the question: Is that too generous? Or maybe it is not generous enough. It is hard to argue it is not generous enough, given the fact that 44 percent of all seniors are going to have no donut and get a very generous benefit, and everybody is going to get a benefit. Referring to the same chart again, for example, this shows, for an individual who has $1,000 of drug expenses or $2,000 of drug expenses, how much they are going to pay for those prescription drugs. So whoever is listening to me right now, they would be able to know how much they could spend on drugs every day and know where they are going to fall. For example, if you were a heart transplant patient of Bill Frist 10 years ago, you would have probably had about $7,000 in drug expenses every year. Every time I transplanted a heart or a lung, the patient would have anywhere from $5,000 to $7,000 of drug expenses every year. Drugs are expensive and can take your life savings. For every patient I had who had a heart or a lung transplant, they did not go through that procedure without expending $6,000 to $7,000 on prescription drugs every year. Most of them are seniors. That is one of the reasons why this plan means so much to me. I have a personal interest in that these are people whose faces I have looked into and eyes I have looked into over the years. Let me go above 160 percent and you see it looks different. What I want to focus on, of the 40 million people out there, of the seniors, the 50 percent richest, 50 percent highest income people. They still get a lot of help. Just graphically look at it. Remember in blue and gray here is the percent paid by the plan. This is 100 percent at the top. So you can see it is anywhere from 30 to 50 percent coming all the way through. This chart, you can look at it all sorts of different ways, but the point I want to make, in the bill, when we talk about gap, it doesn't mean you will be left out. If you fall into what is called a donut or gap, you benefit all the way up until that level, and then through that gap you pay for your prescription drugs. But then at the other side of the gap you are picked up again. Thus, at the end of a year, what happens? The gap is right about $4,500 to about $5,800. I am looking to my staff member because the figures have changed a little bit as we tried to narrow the gap over the last several weeks. But that means the gap is somewhere right around $4,500 to this bar here, this is $6,000. But, remember, if you are an individual and you are listening to me and you have $4,500 in expenditures, still about 45 percent of all your expenditures are paid for by the plan. And if you are in the gap, the so-called donut, it is little bit less, it is a couple percentage points less, but still right at 42 percent, at $5,000. And then if you are into $6,000, you are back up around 40 percent, $6,000, $7,000, $8000, coming up. The reason why I show this chart is because I have seniors calling me now and saying: What about if I am in the hole of that donut? What about if I am in that gap? Does that mean the Government excludes me, doesn't help me? The answer is absolutely no. You just pick where you are on here and graphically you can see that these are for the wealthiest seniors, and the bar graph I showed you for the poor. I am showing you the two ends, the two extremes. But above 160 percent of poverty, this is the gap right here. So still you are getting huge assistance at the end of the year. Again, probably the best example, because the gap is between $4,500 and $5,800, would be the $6,000 that at the end of the year you are in the gap between $5 and $6,000, and you are still getting about 40 percent of your drugs paid for. Some people say it should be higher; some people say lower. The point is, on the gap itself, it doesn't mean you are left out in the cold. Over time we tried to minimize it and keep it as small as possible. We will come back to that later. It is a concept that takes a little bit of time to explain. Depending on who is arguing which side in terms of the gap, there will be some, as you try to make the point, who make that gap sound real bad. Others might minimize it. The reality is, you will be helped wherever you are, even if you are in the gap. You will get huge help as you go forward.

Mr. FRIST

Mr. FRIST. I ask unanimous consent that the Senate proceed to the measure and I object to further proceeding.

Mr. FRIST. Mr. President, I understand that H.R. 8 is at the desk and is due for a second reading.

Mr. FRIST

Mr. FRIST. Mr. President, in a moment the Senate will have a short period for debate and closing remarks in relation to S. 504, the American history and civics education bill. The vote on passage of the bill will begin promptly at 9:15 this morning. Following that vote, the Senate will resume the prescription drug bill and proceed to a vote in relation to the pending Dorgan amendment on drug reimportation. Following those votes, Members are encouraged to remain and offer their amendments. The chairman and ranking member will be here throughout the day to process as many of the amendments as possible. Later today, I will have more to say on the schedule for next week. I might add that we will be voting late Monday afternoon, but we will have more on that a little bit later this morning.

Mr. FRIST

Mr. FRIST. People are going to begin saying the same thing about me, that laughter coming as we are here on Friday afternoon. I say I am going to speak briefly, and I go on for 45 minutes. I have a feeling I am following in Senator Byrd's footsteps.

Mr. FRIST. If the Senator from West Virginia will yield.

Mr. FRIST. Mr. President, if there is no further business to come before the Senate, I ask unanimous consent that the Senate stand in adjournment under the previous order following the remarks of Senator Byrd for up to 60 minutes.

Mr. FRIST

Mr. FRIST. Mr. President, as I mentioned earlier, we have had a productive week. We have moved forward and we have debated and we have amended the prescription drug Medicare bill. We have discussed such issues as asset testing, generic drugs, and appropriate premiums. Yesterday we discussed drug reimportation and the issue surrounding pharmacies and mail order prescriptions. We have made good progress over the last 5 days on this legislation. I want to express my sincere appreciation to my colleagues for their attention and for their very diligent participation. If we look back over the last several days, we see some other things we have been able to accomplish at the same time we have been on this bill. Indeed, the Senate has had H.R. 389, which will help increase public access to defibrillation in schools. We passed a series of bills reported by Chairman Domenici and the Energy Committee relating to historic sites and trails to watershed studies and to recreation areas. We passed S. 1276, which strengthens the AmeriCorps program and allows our national volunteer program to be more efficient. This week we were able to adopt a conference report to accompany S. 342, the Keeping Children and Families Safe Act. This bill will assist in the dissemination of information of child abuse programs and the availability of psychological services for child victims. The Senate also agreed to conference with the House on the child tax credit legislation, allowing that bill to move forward and differences between this body and the House to be worked out. Lastly--this reminds me that on tomorrow, summer begins officially-- with the approach of summer, I would be remiss if I did not mention that the Senate passed S. 1015, the Mosquito Abatement for Safety and Health Act. This legislation authorizes grants for mosquito control programs to prevent mosquito-borne diseases. This morning--again, I have great delight because it was on behalf and at the instigation of and with the leadership of my colleague from the great State of Tennessee, Senator Alexander, who brought forth the bill--the American History and Civics Education Act passed unanimously on a rollcall vote. Next week we will resume the prescription drug/Medicare bill, and hopefully we will pass that--not hopefully, I am confident we will pass that bill prior to the beginning of the July 4 recess. I thank all of my colleagues.

Mr. FRIST

Mr. FRIST. Mr. President, an issue outside of Medicare but one that has been in the news, one that deserves more attention, is an issue that is changing a little bit, like the demographics I just went to, in an unprecedented way. That is childhood obesity. This is flipping from Medicare, where we are talking about seniors, all the way to the other end of the spectrum as we look at an epidemic occurring in children that we have never seen before. It is a medical issue. It is an issue I first became aware of as a physician, but it has gotten worse. Many of us saw the release by the Centers for Disease Control and Prevention from this past weekend which led me to want to restate the importance of addressing this issue. Historically childhood obesity was thought of in moral terms, there was an unfair stigma to obesity. But what we have become aware of in medical science only recently, and that is childhood obesity is a serious condition that has implications not just to the child as a child or as an adolescent but has grave lifelong complications. The kids, are not just at risk for developing bad habits but now we know they are at risk of adult diseases, of developing evolving adult diseases because of that childhood obesity, because of that inactivity. It was last weekend, Friday or Saturday, that the CDC released statistics which were alarming even to me. I have been studying this and writing legislation on it. It has to do with a type of diabetes called type 2, adult onset diabetes. What this new research showed is that one in three Americans born right now--the date was from the year 2000, but one in three Americans who are born in the year 2000 will develop diabetes in their lifetime. That is higher than any estimate we have known to date in medical literature. In fact, the American Diabetes Association had an estimate which was generally accepted broadly, based on good data. This is three times that. One in three Americans born right now will develop diabetes. The good news is that doesn't have to be the case. Things can be done that can reverse that. I am very interested and will continue to focus on health disparities between gender, men, women, between ethnicity, between race. And if you look at this data in terms of African Americans and Hispanic children, nearly half will develop diabetes. Women are at higher risk than men, and the disease is striking at younger ages. It used to be a little bit older. Now it is younger and younger that this type of type 2 diabetes strikes. The number of diagnosed cases among the population as a whole has jumped 50 percent in the last 10 years hitting over 11 million in the year 2000. That figure will skyrocket to 165 percent by 2050, putting the number of Americans with type 2 diabetes at 29 million. The implications of this are severe. Diabetes leads to a whole host of chronic illnesses. It is the leading cause of kidney disease, heart disease, amputations, and blindness. The good news is these high rates of diabetes are not inevitable. Type 2 diabetes can be prevented. That is because the leading cause of type 2 diabetes is obesity and lack of exercise. Walking for 30 minutes a day, losing a few pounds can literally cut a persons's risk by more than half. You don't have to be a marathon runner, an iron man participant, but following that mantra of moderate exercise and moderate, even minimal weight loss can make a huge difference. You can reap huge health rewards. That is why Senator Bingaman, Senator Dodd, and I and many others on both sides of the aisle introduced a piece of legislation called the INPACT Act, the Improved Nutrition and Physical Activity Act, with obesity rates double what they were 30 years ago. And we are learning a lot about obesity disease scientifically almost every day. Americans need, more than ever, to be able to make and be encouraged to make healthy decisions about nutrition and physical activity. On the House side, I am pleased that Representatives Mary Bono and Kay Granger, along with other cosponsors, introduced companion legislation earlier this year. I will not go into the legislation now. I encourage my colleagues who are not cosponsors to look at it so we can pass that in the future. It is a multifaceted approach. It emphasizes youth education to jump-start healthy habits early on, to prevent a future struggle with weight. It funds demonstration projects to find innovative, creative ways of improving eating and developing good exercise habits. It includes rigorous evaluations so we can learn what works best. What it does not do is outlaw certain ``bad'' foods in any way. It doesn't attempt to micromanage or regulate what Americans eat or drink. It does have a modest price tag, consistent with what the appropriate role of the Federal Government should be. It doesn't attempt to replicate a billion dollar diet industry or the fitness industry that is out there. I know--we all know--there is no single solution to this growing epidemic of obesity. We know it is an epidemic. We know it is getting worse. We do know that leadership on our part can make a difference, can increase awareness of the serious medical consequences, in particular for children. As the adults in this situation, we can and indeed we must show our determination to keep them safe by keeping them fit.

Mr. FRIST

Mr. FRIST. Mr. President, I ask unanimous consent that there now be a period of morning business with Senators speaking for up to 10 minutes each.

Mr. FRIST. Mr. President, I see the Senator from West Virginia. I have about 10 more minutes. I know he has been around all afternoon. These Friday afternoons give an opportunity for people like you and me to make some points where you are not rushed and it is real pleasant to be able to stand back and look at issues that are terribly important. When you have so much going on during the day, it is a little bit harder to do. Let me take a couple more minutes and then we will be happy to yield the floor to the Senator from West Virginia.

Mr. FRIST

Mr. FRIST. Mr. President, I send a second-degree amendment to the desk and ask for its immediate consideration.

Mr. FRIST

Mr. FRIST. That is correct. In response to the distinguished Senator from New Mexico, he is exactly right. We are talking about health care security for individuals, and 35 million seniors who are choosing this particular plan today do not have access. They have no choice. Even if they wanted it through Medicare, they cannot get it. That is the benefit--the prescription drug card--that we are initially going to reach out with to help every single senior. People with low incomes will get a lot more help than wealthy people. Every senior will have access to the prescription drug card. On the last chart, we will show what happens 2\1/2\ years from now. This will be Medicare in 2006. This is exciting. Seniors, after using the prescription drug card about 2 years, will stop using that because, by then, we will have designed a system that does the following: Those people, just as the distinguished Senator from New Mexico said, who chose traditional Medicare can keep it. They can keep exactly what they had, but they will have access to a new prescription drug insurance plan. They don't have this now. We are going to add that. Some people say they don't want all these choices. ``I am fine, Dr. Frist, Senator Frist. Let me keep what I have. I am 80 years old and I just want exactly what I have. I am doing fine.'' We are going to be able to tell them they can keep what they have, but if they would like, they can have access to prescription drugs. The green here represents prescription drugs. Medicare+Choice, which is mainly HMOs, already has prescription drugs--almost all of them. The value is about $600 today, if you choose this. Only 5 million people chose this, and 35 million are in that. We will really double the value. If you want to stay in Medicare+Choice, the actuarial value--I really hate using these words--you are going to get this much benefit, and you are going to have this much benefit. Or--this is the exciting part--we have the entities that build upon all the rapid advances of the last 20 to 30 years that is state of the art. That is why it is so important to get the best Democrats have to offer, the best Republicans have to offer, the best of the private sector, the best of the administration to make sure this is designed well with state-of-the-art technology, the most modern, the fairest, the most equitable--this is where a lot of the debate is going to be. People can stay in traditional Medicare, choose Medicare+Choice, or choose these new PPOs. The PPOs will have prescription drug insurance as part of integrated health care and coordinated care where they have teams of doctors and chronic disease management, with nurses who are integrated into a team who may call a patient once a week to make sure they have not picked up too much weight. When you pick up weight, that means you are retaining water, and you could develop congestive heart failure. They actually will have chronic disease management and preventive care. Remember, there is no preventive care in Medicare. There is no coordination in Medicare. If you have chest pain, it may be esophagitis or indigestion, and you might go see Bill Frist, the heart surgeon, because it is in your chest. That is what you do in Medicare. You go to Bill Frist, the heart surgeon. I know a lot about heart surgery and fixing a heart, but I do not know that much, to be honest with you, about indigestion. Yet people will come see me when I practice. That coordination is fragmented, it is disjointed, and that is what we will give away by giving this option of the PPOs. That is pretty much it. The debate is how many people will move from traditional Medicare to Medicare+Choice or PPOs. Should there be incentives for people to move since we know PPOs are a higher quality of care in terms of objective management? It only makes sense, if you coordinate people's care, you have preventive medicine built into it and chronic disease management. It is going to be hard to argue that the care is not there. But what sort of incentives? That is where much of the debate will be. Initially, the debate was maybe the prescription drug package over here should be more available than this one and people will gravitate. The underlying bill does not have that happen. This Medicare benefit for drugs is the same as the Medicare+Choice benefit and the same as the PPO benefit. That is the way I look at this issue. It keeps it simple, which I need as we go through this debate. Now we are down to filling in the details to make this system work. I am very optimistic that this will be what seniors have access to in 2006, but it will not happen unless we do our work over the next 10 days.