belabor the point. what if they don't do it. what if they're not successful? >> that's a good point,@@@@@ rr money available have any anti-obesity programs at all operating in the states. 25% we know that's one of the major sources of chronic illnesses. >> correct me if i'm wrong, tom. i think obesity is the number one issue at cdc today. mr. chairman, my point is where is the effectiveness of the cdc if 25 states in america don't have obesity programs. there's funding there for them. >> mr. chairman -- >> senator burr, i don't know if it's the number one priority, but much of cdc is devoted always to dealing with -- to being reactive to difficult situations, whether it's an outbreak of e.coli at a county fair in ohio or north carolina, whether it's a flu virus, whether it's a whole lot of things. it's an agency that, because of its general, i think its general flat line funding for most of the years, it's an agency that has trouble focussing on an affirmative mission because it's playing defense so much. and that may be a question of management in part burke it's a question of what resources do we get them and where do we direct them. insenator harkin's efforts and the attention that prevention is getting in this legislation, the discussion that swirls around it as we move forward and this $10 billion or $8 billion a year or so will help them focus much better than they have on the big issues. i yield to the senator. >> my point was the numb befr one issue relative to the prevention side. clearly not to their response side. i think senator isakson might take objection to being flat lined fund he's their hero right now. >> we just adopted lamar alexander's amendment, which i thought was a good amendment. we're not talking about adding cost to the states. we only have 23 states that get any kind of funding from cdc for coordinated school-based programs. we do almost very lit until the cardiac area nationally. so we're trying to increase in these areas of prevention, which we know in those four areas. put aside the school-based stuff. we do almost nothing in oral health. so on matters that are in at least two of the chronic areas, not even half the states are getting the kind of support nationally without man dating that states have to raise their costs. >> i don't disagree with you. let me just pose this question. if we have obesity programs in 25 of the states you said, do those 25 states have an obesity program? and the answer is they probably do. >> here's the point. we're listening to anecdotal statements, rather than saying we're going to spend all this money on programs we don't know whosht they're effective. so why are we going to spend the money until we know -- why aren't we going back to say which programs do you got to work and which aren't? and why aren't we saying every program that's going to be out there we need to know whether it's working before we put money into it? instead we're throwing the money assuming they're all working. that's my whole problem with this. well, we are. we're saying we have an anecdotal evidence that oral health care works great in vermont. that's not science. that doesn't tell us a result. that's an observation that somebody is happy with one program. that has nothing to do with the science of whether it's eefktive prevention and whether it's effective wellness and whether or not you're going to really address chronic disease prevention. we're constituenting here taking a shotgun and we have a bunch of birds running by and we're going to take a gatlin gun with shotgun shol shels and shoot at it and most of the shells aren't going to hit anything. and it's a highly inefficient way. if we're going to spend this $8 billion a year, we ought to say before the first penny comes out, cdc has to demonstrate the effectiveness of its programs. and everybody else that does prevention in this country outside of cdc that is a federal government agency ought to have to, too. and then we compare what works and then fund it through one accountable structure so we can have them before us saying why isn't obesity going down in our young people in this country? why is adult hypertension still rising when we know what the cause is? why do we still have this tremendous rise in metabolic syndrome which is abdominal girth enlargement, which is the manifestation for future disease? we're not going about this scientifically. we're going about this saying, hope it hits something. so the point of the amendment is to call us back and say let's look at what we're doing. if we're going to fund these, then let's change this up, tom. let's make you common demonstrate that you have an effective program so we're not just throwing money because we have a program today. i agree with tom that sometimes certain good programs get shortchanged because they -- people don't perceive prevention as a viable list on the priorities so it doesn't net get the money and putting out acute fire like you have said several times is the one that gets it. but let's look at -- let's slow down here and let's -- if we're going to spend $8 billion, let's do it in a way that we actually get something for our grand kpids. '. >> we're disagreeing how we read this. i spent a lot of time drafting this stuff. i asked those questions. let's take the flock of bird. the way i read what we've done here is you have a flock of birds going by. we've asked what's the best gun and the best ammunition. that's why we put evaluations into every single part of this bill. >> i'm talking about before you spend the money, not after you spend it. >> but the idea is -- there are a lot of different things going on around the country. you mentioned el paso, he had vermont. i don't know if they're working or not. maybe they are. but let's get the experts out there and see if they really are working and if they are, then let's promote those and evaluate those. we evaluate everything in this bill. that's another reason we do annual appropriations so we can look at these things and evaluate them. third on this idea that we're -- we've got to put everything in one agency, that's why we set up this public council. because all the different departments, we're trying to get everybody involved in prevention and wellness across the spectrum from department of agriculture to the department of treasury and everybody else. that's why we set up a public council so that all of these departments are thinking about this. so we do -- so that's why we have annualappropriations. that's why we have evaluations so we can get the metrics. i agree with you. i think we ought to put more in public education. i think we should. hopefully we can begin to put more money out there. but again, the cdpc, the centers for disease and prevention, well, the swine flu and it's the same old story. what affects us right now, that's what we focus on and put money on. who's to say we shouldn't. we want to protect our people from flu virruseviruses. then the long-term stuff gets pushed aside. >> since cdc was so much of the conversation and monday of this past week i spoke at the tom harkin conference center at the center for disease control in atlanta, i thought i would change what senator brown said. all of us have perceptions of what's going on out there sometimes that aren't correct. cdc -- and this is a guess -- but i would say probably 75% of cdc's funding is not reactive but it is proactive. and i think one of the things senator coburn is saying so well, and i'm thinking about myself, we fund the nih and the cdc and we put a tremendous amount of money in dod because we have a controlled group of people upon which you can do research, making determinations all the time on best practices that somehow never get through this clearing hois to get promoted. they kind of get stirred around and we add more money to them. rather than think of this as a negative approach, it's kind of saying -- and i'll be the first to say i don't know all those best practices, either, but maybe it's time we look at what we know before we put more money to find out what we already do know and put incentives before pieing more money on top of the other. probably for every dollar spent in reaction, they spend $3 in proactive research in preventing things around the world. >> i find myself with both of these distinguished senators. when this bill came up, and i looked at it, i was very critical of it and still am. it was put together without much interchange with us. and frankly, it's very broad, very expensive. that's why i've been insisting we have scoring on this thing so that we at least know where we're going. and they not be just preliminary investments but they be investments that we can rely on. and this is just one example. i think the distinguished senator from oklahoma has done a singular very important job here on this committee by raising some of these issues. and there's nobody better to raise them. he's had a world of experience in the field of medicine. and by any measure, you can't ignore what he says. let me just give you an illustration here. let's face it, this bill is spending beyond belief. let me just give you a few examples in title three. the national prevention health promotion of public health council in section 30. cdc already does this. and i agree with the distinguished senator from georgia. cdc does a fairly decent job on these things. take the education and outreach campaign regarding benefits. that's section 304. cdc is marketing. its marketing division already does this. research on optimizing the delivery of public health services, section 331. that's cdc's current responsibilities. the health impact assessment, section 333 in this bill. again, cdc, centers for disease control provides states with technical assistance. give you another one. cdc and employer based wellness program, section 334 . they work with employers to have bring awareness to wellness issues. and why are we duplicating this bill when we know it's off the charts financially and we can't afford it. i think the senator has raised some very important issues here and i think if you go through this bill you'll find a lot more than this to criticize, such as big spending that isn't going to get us there, isn't going to help solve the problems. in the end, make us even less financially secure in this country an they are right now. frankly, i think you ought to get rid of senator from nok nok. >> look, i don't mean to be -- just find fault here, but my gosh, this is just over and over and over and over. it took senator kennedy and me two years to put through the c.h.i.p. bill. it didn't take us long to put through the drug bill. and here we are trying to put together the most important health care bill in list and it's got a lot of duplication in it. it's got a lot of expenses in it that aren't really justified. i mean, we're running our country into the ground under the guise that we're trying to do what's right. let me ask say that i've worked very closely from the distinguished senator of iowa. we're friends. and we both worked hard on the health and education act and gave the fda more authority than they've ever had before over dietary sup plems. and we can't have done it except together and i respect him and what he's trying to do here. but i just caution you, let's do it the right way and not duplicate programs that are already spending hundreds of millions if not billions of dollars. let's not fail to recognize the cdc does a terrific job. look, i'm very concerned about this process because, you know, there's such a desire to get a major health care bill through, i presume because the president is very popular and you might be able to do it on his watch. i don't blame you for that. he is popular and we all like it. rrá) aying that if what you have is a hammer, the problem looks like the nail. then senator coburn mentioned the bike paths and we already have bike path programs. and i think particularly every amendment has something behind it that i think is worthy of taking a look at. and i appreciate the way that you have taken a look at a number of our amendments. and this one particularly in the construction area, i think we've got a lot of those programs already being done. they're being done by agencies that know how to do them. and now we're going to turn some of them over to cdc to do and i don't know if that's the best mechanism to do them either. so i think there's something in this amendment that ought to get our attention. >> okay. i presume you want a role call vote on this? >> yes, i do. i want to make one more comment. if i was sitting outside of washington look at what we're doing, knowing we have $2.3 trillion we're spending on health care this year and we're talking about over the next ten years adding there between $1 trillion to $1.6 trillion to it, somewhere, wherever we end up with whatever you all write that cbo gives -- i don't know the number that you're going to get comfortable with, but president obama is talking about $1.3 trillion is what he said publicly, you're talking about increasing the cost of health care in this country 7. 2% to fix it. to fix it. we're going to increase the cost of health care, add $1.3 trillion over ten years, or $1.5 trillion over ten years to take something that's a $23 trillion to $25 trillion. so somewhere between 6% and 7% and we're going to increase the spending to say we fix it. if, in fact, we really do that and that's what we pass out of the senate and house, it better damn sure work. because we're belly up and sun burnt. >> couldn't agree more. that's the goal to get it done. that's the purpose. let's have a vote on the coburn amendment. senator dodd? >> no. >> senator harkin? >> no. >> senator mikulski? >> no. >> senator binghampton. >> no by proxy. >> senator murray? i'm sorry? senator reid? senator sanders? >> no by proxy. >> senator brown? senator casey? senator hagen? senator murkley? senator whitehouse? >> senator gregg? >> aye. >> senator also expander? >> aye by proxy. >> senator isakson? >> aye by proxy. >> senator mccain? >> aye by proxy. >> senator hatch. >> aye. >> senator roberts? >> aye by proxy. >> chairman kennedy? >> no by proxy. >> the vote is ten ayes, 13 nays. >> the amendment is defeated. senator murkley. >> thank you. i'm pleased to offer murkley amendment number one. this is po focussed on facilitating the ability of mothers to continue breast feeding after they go back to work. there are two fundamental reasons that this is very important. the first is that a very high percentage of mothers are working. and the second is breast feeding is of huge value to the health of our children. so let me address those points in just a little bit more detail. currently 72% of mothers work full time. the fastest growing segment of the u.s. workforce is women with children under 3 years of age. many women are in a situation where they need to return to work in a short period of time due to the finances of their family. often returning to work three to six weeks after delivery. and so it's simply an act of human decency to protect their right to continue breast feeding after they return to work to help meet their basic needs with regard to the care and nourishment of their children. now, let's look a little bit at the value of breast feeding to our children. we know that children who are breast fed have significantly lower infant mortality. we know that they have a much lower risk over their lifetime for many illnesses including asthma, diabetes, obesity and certain cancers. so when we look at all this, we have really just a huge win opportunity, a win opportunity for the strength of our families, breast feeding contributes a significant amount to bonding. certainly a win for the health of our children. it also is a win in term of many of the issues we're discussing in terms of prevention and in terms of cost of the health care system. usda study from 2001 found that if half the babies in the u.s. were breast fed for six months we would have savings of $37 6 billion on just three leading childhood illnesses. as many of you are aware, breast milk conveys some protection against certain viruss. it has some components within the milk which are very significant in terms of brain development. so it's a very, very important nutrient. this bill does two things. it lowers the hurdles that women face in continuing to pump milk when they return to work by asking employers provide flexible break time and asking them to proceed to provide privacy. those two issues are the simple things that can be enormously stressful for women returning to work. i can tell you the experience of my wife mary when our son jonathan was born 13 years ago. she was returning to work in a health care environment. she's a nurse. she was returning to a hospital, but she had to go to her employer and say to them, can i have permission to have flexible break time? can i have a room with some privacy? and just the daunting aspect of returning to work is hard enough when you're newly -- you' ere a new mother and you haven't had a lot of sleep. it's hard enough to return to work, but in addition to have to make a special request to your employer and wondering how far you should push in asking for those two simple things, flexible break times and privacy. many states have gone down this path and have found that it works well. to change the presumption, to change the presumption from the individual mother carries the burden of having to go and raise these issues, to changing it to an understanding that this is a reasonable request, very important and valuable to the health of our children. so with that, i would ask for your support for this amendment. thank you, mr. chair. >> thank you very mump, senator. i think it's very interesting you gave us a rundown of what our respective states do in this area, which was a very creative idea. tom? >> first of all, i want to congratulate the senator on his amendment. i think it's an important amendment. probably the most important thing that we know about breast feeding is that it remarkedly increases iq. whether that's nurture, we don't know exactly why. but the fact is this is a positive amendment. it's -- i'm hardly ever wanting the government to interfere with parents suckling their children in a way that pumping -- you know, pumping and feeding is just as nutritious for the children. so whether they're actually having a baby at their breast or whether they're feeding them their breast milk it still is nutritious. it's also much better for moms. that's the other thing you didn't mention. is the health of the women who are in post partum state are markedly improved and their health all the time that they breast feed is markedly improved as well. so good amendment. i plan on supporting it. >> very helpful. constructive comments as well. >> i have just a couple of questions. i think like everyone on the committee, i appreciate the intent of this amendment and fully support mothers everywhere who need to have time for lactation and all that sbentail. my wife breast fed two children and now my grand kids are going through the process. i know a few things about it but probably don't know much and probably don't want to learn a whole lot more. for instance, learning there's a plug-in in the car for breast pumps. i'm trying to imagine driving down the highway with that. but my question is, you're amending the fair labor standards act with this. and what -- you're importing the fmla employer exemptions into the fair labor standards act. is that really where you want to put it? is that the most effective place to put it? we're kind of combining two different processes here. >> thank you for your question. there are times when i can say i am not a lawyer and that i've dmended upon the expertise of our committee staff and team to find the most appropriate way to frame this particular piece. and so other than to say i've relied on their expertise -- it's the first time the question has been raised and i thank you for raising it. >> one reason i raise it is because congresswoman karen maloney has offered the same thing. if you haven't talked to her i was hoping you would talk to her so there might be some mechanism for keeping the two acts separate. >> i can comment on that. she and i held a press conference supporting an identical bill in the house and the senate. i was very pleased to be a lead sponsor here in the senate. her bill, or this combined bill, it goes further. it gets into things such as tax credits and so on and so forth. we tried to take care of the simplest elements, and i think this is a foundation we can build on in the future, but to take the simplest elements of flexible break time, break time that is not expected to be paid, it's unpaid break time. most states have pursued in that manner, and simple privacy. those two concepts would go a great long way in this effort. >> i think we accept that amendment. but i would appreciate it if you would at least check and see about this interweaving the mfla with state fairness act. >> i don't know the answer myself on that. i think there's a lot of unanimity about this amendment, and i would recommend having done that, we still go, mike, and take a look at this thing and work it out in a way that will satisfy everyone in terms of where the law would be worked. >> okay. i'm absolutely happy to have my staff work with your team on technical amendments and and lot whether that's the best frame. >> that's a real help. kay? >> thank you, mr. chairman. i want to applaud senator merkley for bringing this forward. i look forward to supporting the amendment. >> thanks very much. >> want a roll call vote or just a -- >> as the chair would desire. >> voice vote. i think there's a lot of unanimity. all those in favor say aye. >> aye. >> those opposed nay. senator, thank you. and thank senator coburn. i think his comments were tremendously helpful as well. and very worthwhile. and the statistics are pretty amazing about childhood development and the like. so congratulations. >> thank you very much, mr. chair. i do extend an appreciation to mr. coburn. >> oren, you're up next. >> we've got hatch -- we accept this amendment, will you be for the bill now? will you do that? leave the microphone on. >> orren, i don't think your mike is on there. >> there it is. there it is. let me call up amendment number 94. >> hatch number 94? >> it's enzi's amendment with 94 with his permission. >> oh, senator enzi number 94. senator enzi. but it's with his permission. and only with his