[Congressional Record Volume 155, Number 100 (Tuesday, July 7, 2009)]
[Senate]
[Pages S7182-S7186]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                              HEALTH CARE

  Mr. WHITEHOUSE. Madam President, I have spoken many times on the 
floor of the Senate about the desperate need for reform of our broken 
health care system. Today the Congress stands at a moment of historic 
opportunity. The attention, hopes, and anxieties of the American people 
are focused on us like never before.
  We have seen over the course of the last 60 years constant lament 
over the

[[Page S7183]]

system's flaws and failure--failure when true opportunities for reform 
arise. President Obama has now challenged this Congress to reform our 
Nation's health care system, to expand access to insurance, to improve 
below-average results, and to bring down its costs. It is about this 
last challenge--the challenge of our unimaginable and grotesque health 
care costs--that I speak today.

  In his recent speech to the AMA, the President called escalating 
health care costs ``a threat to our economy . . . an escalating burden 
on our families and businesses . . . a ticking time-bomb for the 
federal budget, and . . . unsustainable for the United States of 
America.''
  I hope all of us share his sense of urgency. Our country's economic 
future may well depend on it.
  Over the past few weeks, I have been privileged to work with my HELP 
Committee colleagues to make long-awaited reforms and investments to 
control costs and wring savings from the system. In that process, much 
attention has been paid to the Congressional Budget Office's cost and 
savings estimates--estimates that, in many cases, have significant 
limitations.
  CBO, as we know, plays a vital role in our legislative branch by 
ensuring that we have objective, nonpartisan estimates of the likely 
costs and savings to the Federal budget of legislation. These estimates 
can help us make responsible and efficient use of the taxpayers' money, 
but we must recognize that in the particular context of health care 
reform, they are fundamentally limited by CBO's professional 
restrictions.
  CBO can only estimate health care costs and savings that have 
historic precedent. For example, since we have the experience of 
Medicaid and the Children's Health Insurance Program, CBO can estimate 
how much expanding coverage to all needy families will cost. These 
subsidies account for the vast majority of CBO's $600 billion estimate 
of the 10-year cost of the HELP Committee bill.
  On the cost savings side, however, CBO's capability is limited. We 
know our health care system is on an unsustainable course, and there is 
broad agreement on which of the broken pieces need fixing, but it is 
impossible to estimate cost savings with the degree of certainty CBO 
requires to provide what we call a score.
  CBO's Director has been refreshingly candid about this. In a recent 
letter to our budget chairman, Senator Conrad, he writes the following:

       Changes in government policy have the potential to yield 
     large reductions in both national health expenditures and 
     Federal health care spending without harming health.

  He continues:

       Moreover, many experts agree on some general directions in 
     which the government's health policies should move, typically 
     involving changes in the information and incentives that 
     doctors and patients have when making decisions about health 
     care. Yet many of the specific changes that might ultimately 
     prove most important cannot be foreseen today and could be 
     developed only over time through experimentation and 
     learning.

  CBO's professional discipline requires it to score legislation 
through a rearview mirror, looking back, and basing its calculations on 
what it can chronicle has happened in the past. But when we propose to 
take the country in a new direction, when there is a turn in the road, 
when we seek to fulfill President Obama's promise of true change in 
America, the rearview mirror doesn't help much. We have not been where 
we need to go.
  In addition, getting there will require leadership, creativity, and 
perseverance. It will require executive administration with constant 
adjustments and improvements as we work toward our goal. Those factors 
are beyond the capability of CBO to predict.
  I speak not to criticize the hard-working public servants of the 
Congressional Budget Office. They do an exemplary job with the tools at 
their disposal. Americans owe them a particular debt of gratitude now 
for how incredibly hard they have worked over these past weeks, but 
their tools come with their own limitations. The point of this reform 
is to turn around a system that is spiraling out of control. We spent 
18 percent of our gross domestic product on health care, the next 
highest spending Nation in the world--the next worst is Switzerland, at 
11 percent. Even if our success in this reform is limited to shaving a 
few percentage points off our national expenditure on health care, that 
change will be worth hundreds of billions of dollars a year. Yes, there 
will need to be an initial investment in health care reform, but the 
potential savings are multiples larger. CBO's inability to score those 
savings does not mean that those savings are not both real and 
substantial.
  One measure of the potential savings is the recent report of the 
President's Council of Economic Advisers, June 2009. I ask unanimous 
consent that the executive summary of this document be printed in the 
Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                The Economic Case For Health Care Reform


                           Executive Summary

       The Council of Economic Advisers (CEA) has undertaken a 
     comprehensive analysis of the economic impacts of health care 
     reform. The report provides an overview of current economic 
     impacts of health care in the United States and a forecast of 
     where we are headed in the absence of reform; an analysis of 
     inefficiencies and market failures in the current health care 
     system; a discussion of the key components of health care 
     reform; and an analysis of the economic effects of slowing 
     health care cost growth and expanding coverage.
       The findings in the report point to large economic impacts 
     of genuine health care reform:
       We estimate that slowing the annual growth rate of health 
     care costs by 1.5 percentage points would increase real gross 
     domestic product (GDP), relative to the no-reform baseline, 
     by over 2 percent in 2020 and nearly 8 percent in 2030.
       For a typical family of four, this implies that income in 
     2020 would be approximately $2,600 higher than it would have 
     been without reform (in 2009 dollars), and that in 2030 it 
     would be almost $10,000 higher. Under more conservative 
     estimates of the reduction in the growth rate of health care 
     costs, the income gains are smaller, but still substantial.
       Slowing the growth rate of health care costs will prevent 
     disastrous increases in the Federal budget deficit.
       Slowing cost growth would lower the unemployment rate 
     consistent with steady inflation by approximately one-quarter 
     of a percentage point for a number of years. The beneficial 
     impact on employment in the short and medium run (relative to 
     the no-reform baseline) is estimated to be approximately 
     500,000 each year that the effect is felt.
       Expanding health insurance coverage to the uninsured would 
     increase net economic well-being by roughly $100 billion a 
     year, which is roughly two-thirds of a percent of GDP.
       Reform would likely increase labor supply, remove 
     unnecessary barriers to job mobility, and help to ``level the 
     playing field'' between large and small businesses.


                  WHERE WE ARE AND WHERE WE ARE HEADED

       Health care expenditures in the United States are currently 
     about 18 percent of GDP, and this share is projected to rise 
     sharply. If health care costs continue to grow at historical 
     rates, the share of GDP devoted to health care in the United 
     States is projected to reach 34 percent by 2040. For 
     households with employer-sponsored health insurance, this 
     trend implies that a progressively smaller fraction of their 
     total compensation will be in the form of take-home pay and a 
     progressively larger fraction will take the form of employer-
     provided health insurance.
       The rising share of health expenditures also has dire 
     implications for government budgets. Almost half of current 
     health care spending is covered by Federal, state, and local 
     governments. If health care costs continue to grow at 
     historical rates, Medicare and Medicaid spending (both 
     Federal and state) will rise to nearly 15 percent of GDP in 
     2040. Of this increase, roughly one-quarter is estimated to 
     be due to the aging of the population and other demographic 
     effects, and three-quarters is due to rising health care 
     costs.
       Perhaps the most visible sign of the need for health care 
     reform is the 46 million Americans currently without health 
     insurance. CEA projections suggest that this number will rise 
     to about 72 million in 2040 in the absence of reform. A key 
     factor driving this trend is the tendency of small firms not 
     to provide coverage due to the rising cost of health care.


  INEFFICIENCIES IN THE CURRENT SYSTEM AND KEY ELEMENTS OF SUCCESSFUL 
                           HEALTH CARE REFORM

       While the American health care system has many virtues, it 
     is also plagued by substantial inefficiencies and market 
     failures. Some of the strongest evidence of such 
     inefficiencies comes from the tremendous variation across 
     states in Medicare spending per enrollee, with no evidence of 
     corresponding variations in either medical needs or outcomes. 
     These large variations in spending suggest that up to 30 
     percent of health care costs (or about 5 percent of GDP) 
     could be saved without compromising health outcomes. 
     Likewise, the differences in health

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     care expenditures as a share of GDP across countries, without 
     corresponding differences in outcomes, also suggest that 
     health care expenditures in the United States could be 
     lowered by about 5 percent of GDP by reducing inefficiency in 
     the current system.
       The sources of inefficiency in the U.S. health care system 
     include payment systems that reward medical inputs rather 
     than outcomes, high administrative costs, and inadequate 
     focus on disease prevention. Market imperfections in the 
     health insurance market create incentives for socially 
     inefficient levels of coverage. For example, asymmetric 
     information causes adverse selection in the insurance market, 
     making it difficult for healthy people to receive actuarially 
     reasonable rates.
       CEA's findings on the state of the current system lead to a 
     natural focus on two key components of successful health care 
     reform: (1) a genuine containment of the growth rate of 
     health care costs, and (2) the expansion of insurance 
     coverage. Because slowing the growth rate of health care 
     costs is a complex and difficult process, we describe it in 
     general terms and give specific examples of the types of 
     reforms that could help to accomplish the necessary outcomes.


         THE ECONOMIC IMPACT OF SLOWING HEALTH CARE COST GROWTH

       The central finding of this report is that genuine health 
     care reform has substantial benefits. CEA estimates that 
     slowing the growth of health care costs would have the 
     following key effects:
       1. It would raise standards of living by improving 
     efficiency. Slowing the growth rate of health care costs by 
     increasing efficiency raises standards of living by freeing 
     up resources that can be used to produce other desired goods 
     and services. The effects are roughly proportional to the 
     degree of cost containment.
       2. It would prevent disastrous budgetary consequences and 
     raise national saving. Because the Federal government pays 
     for a large fraction of health care, lowering the growth rate 
     of health care costs causes the budget deficit to be much 
     lower than it otherwise would have been (assuming that the 
     savings are dedicated to deficit reduction). The resulting 
     rise in national saving increases capital formation.
       Together, these effects suggest that properly measured GDP 
     could be more than 2 percent higher in 2020 than it would 
     have been without reform and almost 8 percent higher in 2030. 
     The real income of the typical family of four could be $2,600 
     higher in 2020 than it otherwise would have been and $10,000 
     higher in 2030. And, the government budget deficit could be 
     reduced by 3 percent of GDP relative to the no-reform 
     baseline in 2030.
       3. It would lower unemployment and raise employment in the 
     short and medium runs. When health care costs are rising more 
     slowly, the economy can operate at a lower level of 
     unemployment without triggering inflation. Our estimates 
     suggest that the unemployment rate may be lower by about one-
     quarter of a percentage point for an extended period of time 
     as a result of serious cost growth containment.


               THE ECONOMIC IMPACT OF EXPANDING COVERAGE

       The report identifies three important impacts of expanding 
     health care coverage:
       1. It would increase the economic well-being of the 
     uninsured by substantially more than the costs of insuring 
     them. A comparison of the total benefits of coverage to the 
     uninsured, including such benefits as longer life expectancy 
     and reduced financial risk, and the total costs of insuring 
     them (including both the public and private costs), suggests 
     net gains in economic well-being of about two-thirds of a 
     percent of GDP per year.
       2. It would likely increase labor supply. Increased 
     insurance coverage and, hence, improved health care, is 
     likely to increase labor supply by reducing disability and 
     absenteeism in the work place. This increase in labor supply 
     would tend to increase GDP and reduce the budget deficit.
       3. It would improve the functioning of the labor market. 
     Coverage expansion that eliminates restrictions on pre-
     existing conditions improves the efficiency of labor markets 
     by removing an important limitation on job-switching. 
     Creating a well-functioning insurance market also prevents an 
     inefficient allocation of labor away from small firms by 
     leveling the playing field among firms of all sizes in 
     competing for talented workers in the labor market.
       The CEA report makes clear that the total benefits of 
     health care reform could be very large if the reform includes 
     a substantial reduction in the growth rate of health care 
     costs. This level of reduction will require hard choices and 
     the cooperation of policymakers, providers, insurers, and the 
     public. While there is no guarantee that the policy process 
     will generate this degree of change, the benefits of 
     achieving successful reform would be substantial to American 
     households, businesses, and the economy as a whole.

  Mr. WHITEHOUSE. This report compares the share of America's gross 
domestic product spent on health care to the share spent by our 
international industrialized competitors. It also looks to the wide 
variation in health care expense and quality, region to region, within 
the United States of America. From each of these measures, the report 
comes to the same conclusion: They estimate excess health care 
expenditures of about 5 percent of GDP, which translates to $700 
billion per year. Former Treasury Secretary O'Neill has written 
recently that the target is $1 trillion per year. Whether $700 billion 
or $1 trillion, that is a savings target that is worth an enormous 
expenditure of executive and legislative effort to achieve, 
particularly when all the evidence suggests that achieving it will 
actually improve health care outcomes for the American people.
  Perfect examples of the savings that await us are in quality of care. 
I have spoken before about the Keystone Project up in Michigan which 
reformed care in a significant number of Michigan's intensive care 
units. It reduced infections, respiratory complications, and other 
medical errors. Between March 2004 and June 2005, just a little over a 
year, the project is documented to have saved 1,578 lives, 81,020 days 
patients otherwise would have spent in the hospital, and over 165 
million health care dollars--just in a little over a year, just in 
intensive care units, just in one State, and not even all of the 
intensive care units in that State.
  In my home State, the Rhode Island Quality Institute has taken this 
model statewide with every hospital participating, and we are already 
seeing hospital-acquired infections and costs declining.
  Why aren't these quality reforms happening spontaneously all over the 
country? Because government and private insurers haven't set up the 
right rules for the game. When we began our intensive care unit reform 
in Rhode Island, the Hospital Association of Rhode Island estimated a 
$400,000 cost for a potential $8 million savings from the ICU reform 
program. That is a 20-to-1 return on investment. Super deal, right? Who 
wouldn't take that? Well, the hospitals pointed out that all the 
savings--the $8 million--went to the payers--to Medicare, to the 
insurance companies--and all the costs and all the trouble and all the 
risk came out of their own pockets. The savings actually cut hospital 
revenues. So with a lot of business experience around this Chamber, do 
we know a lot of businesses that would spend $400,000 in cash in order 
to lose $8 million in revenues? That is not a good economic 
proposition. We have made the rules such that it is not a good economic 
proposition for hospitals to invest that way.
  That is why the HELP Committee bill changes payment incentives and 
invests in grant programs so it begins to make economic sense for 
doctors and hospitals to invest in lifesaving and cost-saving quality 
improvements. If we can make it an economic win for providers to 
improve quality this way, think of the torrent of American ingenuity 
that will unleash. Now we are stuck. We are stuck in a bog of market 
failure, with the connection between risk and reward--the fundamental 
connection between risk and reward that is the basic engine of American 
capitalism--interrupted and disabled. But CBO can't score that 
innovation because we haven't been down this road before. There is 
nothing in the rearview mirror for CBO professionals to work with to 
determine what those savings will be.
  There is a similar problem in disease prevention. A study by the 
Trust for America's Health found that investing $10 per person per year 
in proven community-based programs to increase physical activity, 
improve nutrition, and prevent tobacco use could save the country more 
than $16 billion annually within 5 years. Out of the $16 billion in 
savings, Medicare could save more than $5 billion, Medicaid could save 
more than $1.9 billion, and private payers could save more than $9 
billion, but those program providers don't get funded. That is why the 
HELP Committee bill establishes a prevention and public health 
investment fund to provide expanded and sustained nationwide investment 
in preventing illness. Well run, the savings could be enormous. But CBO 
can't score it because we haven't been down this road before, and there 
is nothing in the rearview mirror for CBO professionals to work with.
  A third area for significant efficiencies and savings is the 
contentious, inefficient billing and approval process.

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Right now, doctors and insurance companies are locked in an arms race. 
Private insurers delay claims and deny claims for reimbursement and 
throw up barriers to payment, and the providers, in turn, staff up and 
hire consultants and add people to fight back. This battle creates a 
colossal burden on the system, consuming perhaps 10 to 15 percent of 
all private insurance expenditure and then creating a reciprocal and 
probably actually greater cost shadow out in the provider community 
from having to fight back against that 10- to 15-percent expenditure. 
It all adds no overall health care value--none. It is pure 
administrative cost shifting. Even the insurance industry estimates 
that $30 billion per year could be saved through simplification of that 
process. That is why the HELP Committee bill has strong administrative 
simplification requirements. But again, CBO can't score it because this 
is another new road. Again, there is nothing in the rearview mirror for 
CBO to work with.

  Finally, multiple studies show that the private insurance market is 
plagued by inefficiency and waste. While administrative costs for 
Medicare run about 3 to 5 percent, overhead for private insurers is an 
astounding 20 to 27 percent--charges that consumers pay for higher 
premiums. A Commonwealth Fund report indicates that private insurer 
administrative costs increased 109 percent--they more than doubled--
private insurer administrative costs more than doubled from 2000 to 
2006, just in 6 years. The McKinsey Global Institute and a leading 
health economist indicate that Americans spend roughly $128 billion 
annually on ``excess administrative overhead''--that is, $128 billion 
on excess administrative overhead--in the private health insurance 
market.
  That is why the HELP Committee bill establishes a strong nonprofit 
public health insurance option that would compete on even terms with 
private insurance companies, bringing down premiums, negotiating more 
efficient provider payments, and increasing consumer access--all 
through the power of free market competition. All this is done through 
the power of free market competition. But, again, CBO cannot score it 
because we have not been down that road before. There is, again, 
nothing in the rearview mirror for CBO professionals to work with.
  In the 1930s, Franklin Delano Roosevelt's proposal for an innovative 
program called the Tennessee Valley Authority faced this dour 
prediction from a Member of the House of Representatives:

       Mr. Speaker, I think I can accurately predict no one in 
     this generation will see materialize the industrial empire 
     dream of the Tennessee Valley.

  Another Member remarked:

       The development of power in that particular locality of the 
     Nation . . . can be of no general good.''

  Had FDR been cowed and discouraged by such pessimism, by the 
difficulty and uncertainty and novelty of his task, the TVA would never 
have brought electricity, jobs, and prosperity to millions of 
Americans.
  Likewise, today, it is precisely because our reforms are innovative 
and because they will take energy, commitment, and leadership to 
achieve that they are unscorable. That should be an inspiration to us, 
not a discouragement. Through this reform bill, we must challenge 
ourselves and the Obama administration to do that which economists and 
commentators cannot specifically score and analyze. With strong 
leadership and dedication, we can not only bend the cost curve, we can 
break it.
  Let's set a hard target, say, $500 billion in annual savings, and see 
how fast we can get there. Let's make this the Apollo project of our 
generation. The stakes are high enough to justify that effort.
  I thank the Chair and yield the floor.
  The PRESIDING OFFICER. The Senator from Wyoming is recognized.
  Mr. BARRASSO. Madam President, I ask unanimous consent to speak for 
up to 10 minutes in morning business and that Senator Sessions be 
recognized when I have finished.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BARRASSO. Madam President, most everybody knows I am an 
orthopedic surgeon. In Wyoming, many refer to me as ``Wyoming's 
doctor.'' That is because for over two decades folks have invited me 
into their home with statewide television and radio health reports, 
where I gave people information on how they can stay healthy and how to 
keep down the cost of their medical care. I ended each report by 
saying: ``Here in Wyoming, I'm Dr. John Barrasso, helping you care for 
yourself.''
  That is also my philosophy for government--helping people help 
themselves. As medical director of the Wyoming Health Fairs, I worked 
to give people around the Cowboy State access to lifesaving preventive 
tests and low-cost medical screenings.
  My goal was always to encourage families to eat right, exercise, 
manage chronic diseases, and stop smoking because prevention is one of 
the keys to a long and happy and healthy life.
  As I travel home every weekend, I hear the concerns people have about 
health care and the cost of their medical care. They are concerned 
about the specific cost of their medical care and how it affects them 
and their family budgets. Many families across Wyoming and in this 
country worry that they will lose the health care coverage they 
currently have. Others cannot afford insurance today. That is what is 
wrong with our current health care system. That is what we need to fix.
  I know from firsthand experience that doing nothing is simply not an 
option. We must be careful, thoughtful, and deliberate about the 
changes we make. Health care is a very complex and an intensely 
personal issue. It deserves a national debate--a serious, open, and 
transparent national debate.
  I welcome the opportunity to talk about the concerns of people living 
longer and needing more care and more advanced care. The concerns are 
affordable care, access to care, and high-quality care.
  In the midst of this debate, we cannot stand for rural Americans to 
be left behind. They need access to high-quality, affordable health 
care like everybody else.
  When I first came to the Senate, I promised the people of Wyoming I 
would fight each and every day to protect and modernize our rural 
health care delivery system. I committed to do my part to strengthen 
our rural hospitals, rural health clinics, and community health 
centers. I committed to do my part to increase rural America's access 
to primary health care services and to aid in the successful 
recruitment and retention of nurses, nurse practitioners, doctors, and 
physician assistants all across rural and frontier America.
  There are obstacles faced by our hospitals, clinics, and our 
providers--obstacles they have to overcome to deliver quality care to 
all the families in rural America. They end up having to do it in an 
environment of markedly limited resources. The Federal Government needs 
to recognize these important differences and then respond with 
appropriate policy.
  The people of Wyoming know I am here not just as their Senator but 
also as a rural doctor who has practiced medicine, fighting on their 
behalf.
  Recently, I joined three of my colleagues to introduce S. 1157, the 
Craig Thomas Rural Hospital and Provider Equity Act.
  Today, I rise to talk about a different bill that I have introduced 
alongside my colleague from Oregon, Senator Ron Wyden. It is called the 
Rural Health Clinic Patient Access and Improvement Act.
  This legislation is a great example of what true bipartisanship can 
produce. I thank Senator Wyden and his staff for working so hard to 
collaborate with me on this very important bill. I commend him for his 
dedication to helping rural Americans have equal access to the high-
quality medical care they deserve.
  This legislation strengthens America's 3,500 rural health clinics 
that serve rural and frontier communities.
  Rural health clinics are a highly valued medical provider in 
communities all across this country. In Wyoming, we have rural health 
clinics located in communities that many people have never heard of, 
such as Baggs, Glenrock, Hulett, Lovell, Medicine Bow, Saratoga, and my 
wife Bobbie's hometown of Thermopolis. These clinics make sure people 
have access to primary care as close to home as possible. That is not 
easy to.
  To give you a snapshot of Wyoming's health care landscape, we have 
only 26

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hospitals and 18 rural health clinics spread over nearly 100,000 square 
miles, which is a remarkably large distance. With vast distances, 
complex medical cases, and increased demand for technologically 
advanced medical care, the rural health care system is certainly not 
one size fits all.

  Let me explain what this Rural Health Clinic Patient Access and 
Improvement Act actually does.
  First, the rural health clinics currently receive an all-inclusive 
payment rate that is capped at $76. That payment has not been 
adjusted--except for inflation--since 1988. We all know that medical 
inflation has gone up at a much greater rate than regular inflation.
  This bill addresses this problem by raising the rural health clinic 
cap from $76 to $92. Rural health clinics are a key component of the 
rural health care delivery system, and we need to make sure there is 
fair pay for patients who are taken care of in those facilities.
  We also need to give them enough flexibility to meet their 
community's health care needs.
  Additionally, this measure would establish a new quality reporting 
program for rural health clinics.
  Three years ago, Congress required the Centers for Medicare and 
Medicaid to create a physician quality reporting system. This program 
offers bonus payments to doctors who report quality measures on 
Medicare services.
  The quality incentive program is linked to the Medicare physician fee 
schedule. Rural health clinics, though, are not paid using the 
physician fee schedule. If Congress wants to pay doctors based not on 
volume but on the quality of care, then it is important to remember 
that the one-size-fits-all approach will not work here.
  That is why this bill ensures that a comparable quality incentive is 
available to rural health care providers.
  Third, the Rural Health Clinic Patient Access and Improvement Act 
would create a provider retention demonstration project. It is a five-
State project that will study the extent to which a medical 
professional can be encouraged and enticed to practice in an 
underserved rural and frontier area.
  The States would be given grants to help physicians, physician 
assistants, nurse practitioners, and certified nurse midwives to help 
them pay a small portion of their medical liability costs.
  I believe these incentives will help draw more providers--especially 
those who deliver babies--to work in an underserved area because their 
malpractice insurance is the same whether they deliver 1 baby or 100. 
In these small areas, there aren't that many babies being born each 
year, so the cost, while it is the same for malpractice insurance, has 
to be distributed over a fewer number of patients. This will encourage 
them to practice in underserved areas.
  Wyoming has too few primary care providers for the population we must 
serve. My State is not alone. This bill that Senator Wyden and I have 
introduced reflects our commitment to ensure rural Americans have 
access to high-quality health care services.
  I strongly encourage all my colleagues with an interest in rural 
health to cosponsor this bipartisan piece of legislation.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Alabama is recognized.

                          ____________________