Senate Health, Education, Labor, and Pensions (Murkowski): Business meeting to consider S.2355, to amend the Public Health Service Act to provide for hospital and insurer price transparency, S.4189, to reduce the price of insulin and provide for patient protections with respect to the cost of insulin, S.4974, to amend the Federal Food, Drug, and Cosmetic Act with respect to food safety, S.5026, to require warning labels on sugar-sweetened foods and beverages, foods and beverages containing high-intensity sweeteners, ultra-processed foods, and foods high in nutrients of concern, such as added sugar, saturated fat, or sodium, to restrict junk food advertising to children, S.1414, to amend the Public Health Service Act to provide that clinical studies required for licensure of biological products as biosimilar shall not be required to include the assessment of immunogenicity, pharmacodynamics, or comparative clinical efficacy, S.3788, to amend the Federal Food, Drug, and Cosmetic Act to require drug labeling to include original manufacturer and supply chain information, S.3794, to amend the Federal Food, Drug, and Cosmetic Act to further regulate compounding pharmacies and outsourcing facilities, S.494, to establish a national plan to coordinate research on epilepsy, S.4110, to revise and extend health workforce programs under title VII of the Public Health Service Act, S.1874, to amend the Public Health Service Act to reauthorize certain nursing workforce development programs, and S.380, to improve obstetric emergency care.

The Senate Committee on Health, Education, Labor, and Pensions will please come to order. I talk a lot about the high cost of healthcare, and I come to this issue not only as a senator, but as a doctor who has practiced medicine in a hospital for the uninsured and underinsured for over 25 years. We're seeing the inability to afford healthcare is impacting the ability of small businesses to provide health insurance for their employees. The cost of being insured has gone up. Premiums are climbing, particularly for the 62% of Americans getting their insurance from a small business.

And even those with insurance often have large deductibles before coverage truly kicks in. And so a family delays care or faces significant financial strain or puts it on the credit card, and somehow they're never able to pay off that credit card balance. We owe it to our fellow Americans to help. And let's put aside feckless partisan politics, do our job, pass— and pass legislation to make Americans' lives better. We are doing that today.

The bills we are voting on will help families access affordable, quality healthcare. The Patients Deserve Price Tags Act, championed by Senators Marshall and Hickenlooper, will make pricing information more easily available, empowering patients to compare prices and to pick the highest quality affordable option for care. So a mother, say for example Lafayette, Louisiana, has a child with an earache, pulls out her phone and says, search 'urgent care center near me, which one has the best price?' And then she could go to that one, she could go to that one and save her the money that can be quite substantial because we've made this information available. The bill also gives employers access to their data, allowing them to develop innovative plan designs driving down cost and benefiting employees. The legislation is so important and something I've been touting as part of my money and value for patients or the MVP agenda to lower costs for health insurance for families.

The Expedited Access to Biosimilars Act by Senator Paul increases market competition, lowers drug prices, and increases access to more life-saving treatments by eliminating costly and redundant clinical study requirements. The manager's amendment includes a policy from Senator Moody to eliminate government red tape that slows down FDA's review of biosimilars. The Insulin Act, sponsored by Senators Collins and Shaheen, caps how much patients pay for insulin, preserving access for the 40 million Americans with diabetes. And the National Plan for Epilepsy Act, led by Senators Schmidt and Klobuchar, will help the 3.4 million Americans living with epilepsy, improving research, diagnosis, care, and treatment. The Title VIII Nursing Workforce Reauthorization Act from Senators Collins and Merkley and the Empower for Health Act, Title VII, from Senators Murkowski and Reid strengthens the healthcare workforce, addressing shortages that limit families' access to care, especially in rural areas.

The Safe Drugs Act championed by Senators Banks and Heinrich and the Clear Labels Act from Senators Rick Scott and Gillibrand include common sense policies to help patients understand what is in their drugs, whether they are compounded by the pharmacy down the street or manufactured at a manufacturing plant, and help FDA and states better track when a problem occurs. The Making Families Food Safer Act from Senator Tuberville gives food safety regulators the ability to better respond to foodborne investigations. Quite topical given the recent cyclospora outbreak. Many of these bills were raised as priorities by members of this committee, but also by other senators at our Member Day hearings in March, where off-committee senators could come and present their priorities. Today's markup shows the success we can have when we work together on shared priorities.

In that spirit, we're also marking up Senator Sanders' Childhood Diabetes Reduction Act. This bill increases transparency for families around ultra-processed food and restricts targeting of junk food ads towards kids. I don't think it's a perfect bill, but it's a starting bill for bipartisan changes we need to make to how food is regulated and allows us to have a productive markup today. I'll continue to work on other initiatives in this space, including the need for a national uniform standard for food regulations than rather— rather than a patchwork of widely different state laws. And I appreciate the ranking member's bipartisan engagement.

Lastly, lastly, but most importantly, I acknowledge the unbelievable amount of staff work in this markup. In some cases, members of my staff have worked on a piece of legislation for over 6 months. These member priorities would not be moving forward without their expertise commitment, and sacrifice. So I publicly thank Kristen Chatinsky— I always have to work at that last name— Katherine Handler, Matthew Thomas, Romney Gripaldo, Dominic Travis, Carolyn Benson, and Liz Billick for their work in this markup.

Thank you, Senator Marshall. I appreciate my colleagues' efforts on these bills advancing a pro-patient, pro-family, and pro-worker agenda. I look forward to supporting them. With that, I recognize Senator Sanders. Mr. Chairman, thank you very much.

I want to applaud the staff on our side as well for their hard work, uh, and to tell you that I intend to be supporting all of the bills that are before us this morning. But I do want to say, in response to something that you I did say that at the end of the day, as a nation, we're going to have to ask ourselves one very simple question with regard to healthcare. Is healthcare a human right or is it not? And I would suggest, Mr. Chairman, that the overwhelming majority of the American people understand that healthcare is a human right, whether you're rich, whether you're poor, young or old. People have a right to get the healthcare that they need.

And I hope that the day will come sooner than later that the United States of America, our great country, the wealthiest nation on Earth, joins every other major country guaranteeing healthcare to every man, woman, and child. And by the way, despite the fact that 85 million Americans are uninsured or underinsured today, As the Chairman well knows, we are spending close to double what other nations are spending on healthcare. And the issue that we are ultimately going to have to deal with is the function of healthcare to make the insurance companies and the drug companies phenomenally rich, or do we provide quality care to all people as a human right? Mr. Chairman, let me focus my remarks now on one of the pieces of legislation that you met— that you mentioned piece that I introduced called the Childhood Diabetes Reduction Act. This legislation will require the FDA to put strong warning labels on ultra-processed foods that are high in sugar, salt, and saturated fats.

Importantly, it would also ban junk food ads targeted to children, similar to what Congress did to the tobacco industry nearly 30 years ago. Mr. Chairman, in America today we have an obesity epidemic and a diabetes epidemic. They are both directly related and they are both getting worse. More than 35 million Americans have type 2 diabetes, over 10% of our population. Diabetes is not only a serious illness unto itself, but is a contributing factor to heart disease, stroke, amputations, blindness, and kidney failure.

And the cost, the cost of treating that disease is staggering. According to the American Diabetes Association, the total cost of diabetes in the US is over $400 billion a year to treat diabetes. $400 Billion a year. It's an extraordinary amount of money. And when we talk about the type 2 diabetes epidemic and the huge increase in new cases, we must also talk about the epidemic of obesity in America.

About, about 90% of people with type 2 diabetes are overweight or obese. These two epidemics go hand in hand. The time is long overdue for us to pose some very simple questions. How did it happen that according to a CDC report in 2022, The rate of childhood obesity in America has tripled since the 1970s. Tripled since the 1970s.

And it's gotten so bad that 1 out of every 5 kids in America is now obese. How has it happened that over 40% of adults in our country today are obese? And in my view, the answers to these questions are not very complicated. For decades, Congress and the FDA have allowed large corporations to make huge profits By enticing children and adults to consume ultra-processed food and beverages loaded up with sugar, salt, and saturated fat. We can begin to turn that around today by passing this legislation.

There is growing evidence, including testimony before this committee a few years ago, that these foods are deliberately designed to be addictive, similar to cigarettes and alcohol, and lead to a higher risk of type to diabetes. Shockingly, according to a study published in the British Medical Journal in 2022, ultra-processed foods make up an incredible 73% of our nation's food supply. Bottom line, much of the food that we as Americans are now consuming are making us unhealthy and are contributing to the fact that our life expectancy is significantly lower than many other wealthy countries. None of this is happening by accident. The food and beverage industry is spending over $11 billion a year on advertising, pushing these unhealthy products onto the American consumer.

Even worse, nearly $2 billion of this money is spent to directly advertise these unhealthy products to our kids in order to get them hooked at an early age. According to the Rude Center for Food Policy and Obesity, children and teens view about 4,000 food and beverage ads on television each year and an average of 10 advertisements each day. Last year, for example, Coca-Cola spent over $5 billion on advertising while it raked in over $11 billion in profits. Not one of their ads will tell you that a 20-ounce bottle of Coke contains more than 15 teaspoons of sugar. 15 Teaspoons of sugar.

Over twice the recommended daily limit for kids. Given this reality, which has been widely discussed by scientists and doctors for decades, the question then arises: What has the FDA done to address these epidemics which have impacted the health of millions of Americans and cost us hundreds of billions every year? And the answer is not much. So, uh, Mr. Chairman, uh, under the bill that we are now considering, the FDA would be required to put a warning label on sugary drinks that says Food and Drug Administration warning: drinking beverages with added sugar can contribute to obesity, type 2 diabetes, and tooth decay. Not recommended for children.

Similar warning labels we put on foods that are high in salt and saturated fats. This is not a radical idea. Chile implemented a similar law. Israel, Mexico, Peru also have similar laws. So, Mr. President, the time is now for us to do two things: to put strong labels on the products to protect our kids and to make sure that TV advertising does not hook kids on unhealthy foods.

Thank you, Senator Sanders. We'll now begin consideration of today's bill. For the awareness of all senators and staff, we intend to vote on amendments as they are raised but will hold the vote on final passage of both bills until the end of the session. We will keep members and staff updated on the timing of the vote on final passage. I'll ask colleagues to limit remarks to 2 minutes when discussing either of the bills or offering an amendment, as there are a lot of amendments to process.

As a reminder, when discussing an amendment, please identify which amendment you are discussing by its name and number. We were going to do the Price Tags Bill first, but Senator Marshall has had to leave, and so we're going to hold that until he returns. We'll begin now with consideration of S.1414, the Expedited Access to Biosimilars Act. I thank Senator Paul for his work on this legislation to improve access to affordable biosimilar medications. I thank Senator Moody, who championed, championed legislation incorporated into this bill via the manager's amendment.

At our April hearing on the biosimilar and generic drug market, we heard how biosimilars lack regulatory certainty. And have exorbitant development costs. In the 15 years since the biosimilar regulatory framework was created, we've learned a lot about how to ensure they are safe and work for patients, but laws have not kept up. This bill addresses these problems by reducing data required under law that in many cases is unnecessary, and it aligns with the FDA's common practice to provide clearer rules for biosimilar developers. It establishes a clear, consistent process for when FDA needs to require additional studies.

It also eliminates a redundant requirement that multiple FDA offices review each biosimilar before approved. I'm glad to see this legislation progress through committee. I encourage colleagues to support. We have a manager's amendment to S. 1414. I move to adopt the manager's amendment in the nature of a substitute and to have it considered original text for the purpose of further amendments.

All in favor say aye. Aye. Opposed, no. The ayes have it. The motion is agreed to.

Do any members wish to speak on the bill? Senator Paul. Prescription drug spending is mainly concentrated on biologic drugs like hormone therapy, cancer treatments, and monoclonal antibodies. Biologics are only 5% of prescriptions but account for 51% of spending. My bill seeks to reduce the cost of biologic drugs by removing the blanket requirement for for comparative efficacy trials in biosimilar development, which are often unnecessary.

These trials are like stage 3 trials that attempt to gauge whether biosimilar and the reference biologic are equally effective. But a review of over 600 studies published in the journal Pharmaceuticals found that no biosimilar with proven analytical similarity has ever failed a comparative efficacy study. The average cost of biosimilar development is 100 $300 million, and comparative efficacy studies generally cost $20 to $30 million. Removing these unnecessary studies, as they have already done in, uh, Europe and in England, would reduce, uh, development costs by 10%. Additionally, the studies can also take up to 3 years to complete, and biosimilar development can take up to 9 years.

Delaying treatments for the sake of conducting unnecessary studies harms the very people we intend to help.

The FDA has realized that these burdensome nature of these studies, and in its recent guidance, the agency waived comparative efficacy studies for therapeutic proteins like monoclonal antibodies. We've worked with the FDA on this bill because when a biosimilar is proven to be safe and effective, there's no reason to delay care to patients and regulatory certainty to manufacturers. I urge my colleagues to support my bill to significantly lower the cost and the time of biosimilar development. Does anyone else wish to speak?

The officer raises his hand, but I'm thinking that no, he's just checking his earpiece.

We'll now begin consideration of S.4189, the Insulin Act of 2026. I thank Senator Collins as well as her co-leads, Senators Shaheen, Kennedy, and Warnock, for their leadership on this piece of legislation. I appreciate their efforts to help make life-saving insulin more, more affordable. I recognize that this legislation may need more refinement and may encounter policy and procedural hurdles beyond this committee. I am pleased that we were able to advance it to the next stage of the legislative process.

We have a manager's amendment, S.4189. I move to adopt the manager's amendment in the nature of a substitute and have it considered original text for the purpose of further amendments. All in favor, please say aye. Aye. All opposed, say nay.

The ayes have it. The motion is agreed to. Do any members wish to speak on the bill? Senator Collins. Thank you, Mr. Chairman.

First, I want to thank Senator Shaheen for our longstanding partnership on this bill as co-chairs of the Senate Diabetes Caucus. Which I founded in 1997 to increase research funding and promote better healthcare for people with diabetes. I also want to thank Senators Kennedy and Warnock for their contributions. Beginning in 2015, I chaired 8 hearings on prescription drug prices when I chaired the Senate Aging Committee. We heard countless stories from Americans who are struggling to afford the medicine they needed, and the unaffordable cost of insulin was featured prominently at almost every single hearing.

The bill we're marking up today is the culmination of these efforts. While recent decisions by manufacturers to cut their list prices on insulin is encouraging, There is still more work to be done. Our bill would cap the cost of insulin at $35 a month for individuals who are on commercial insurance plans. According to the American Diabetes Association, nearly 40% of people with diabetes have rationed or skipped insulin doses due to the cost. One of my constituents, Beck Hosk— Bakins from Chelsea, Maine, skipped doses of insulin when she was unable to afford it and ended up in the emergency room.

The Insulin Act would help people like Bak afford the insulin that they need to survive. The bill not only caps out-of-pocket costs for patients but addresses perverse incentives in the market and the lack of biosimilar competition that contributes to high list price for insulin. Although, uh, the bill has some other issues in it that I'd like to go through, including, uh, citizen petitions which are largely backed by brand name manufacturers who were behind 86% of them, which is why FDA denied more than 9 out of 10 of them. I am mindful of the chairman's request that we keep our remarks brief. So I would like to end by thanking our committee co-sponsors on this— of this bill: Senators Murkowski, Tuberville, Banks, Baldwin, Kaine, Blunt-Rochester, Hickenlooper, and also Brooks.

I want to also thank all the patient groups that have endorsed our bill. Thank you. Senator, Senator Paul, I respect the intentions and motives of those who would like to see lower insulin prices in the bill, but historically price controls don't work. If you want to see examples of where we have extensive price controls, look to Venezuela, look to the Soviet Union. The old story in the Soviet Union was a guy goes into the store and he says, are you the store that doesn't have eggs?

'And the guy says, no, no, no, we're this— that's across the street. We're the store that doesn't have toilet paper.' Because they were so used to having shortages of things. You want people to have stuff. You want people to have the basics of life. You want to have food.

So, you know, do we have a right to food and healthcare, as the ranking member would say? Well, you know, you can say that, then you can set prices, but it doesn't work. What happens in capitalism is you have a freely fluctuating price. Now, are pharmaceuticals freely fluctuating prices? No, most of it's interrupted by an intermediary.

The government in over half the cases is the intermediary, and then insurance companies are the intermediaries and others obstructing the real true price. The only real true price of drugs in our country applies to about 3 or 4% of people that have absolutely no insurance. Not something I'm recommending, but they're the only people who really care. Almost all the prices are already set throughout the system. So while I think this is well-intentioned, I think the history of price controls is not a good one, and I will oppose it.

Senator Baldwin. Amendments? Does anybody else wish to speak on the bill? Okay. Do any members wish to offer an amendment?

Mr. Chairman. Senator Baldwin. I want to start by expressing how excited I am to have the Insulin Act on this markup today. This bill will make insulin more accessible for millions of Americans and significantly reduce the cost of insulin. Insulin.

No one should have to go without the medication they need to stay healthy. And that's why I introduced my amendment, Baldwin-Collins number 1. This bipartisan amendment would restore a pilot program for uninsured patients to access insulin for $35 a month and a resource center to help patients afford and access access affordable insulin. Both of these policies were in the original text of the Insulin Act, but unfortunately are not in the manager's amendment before us today. So I ask for the support of all of my colleagues on this amendment to ensure that patients without insurance are not left behind and that patients have access to resources to help them find information about access to insulin.

And Mr. Chairman, I ask for a vote on my amendment, Baldwin 1, to S.4189. Okay. I commend Senators Collins and Shaheen for their tireless work advocating on those who need insulin to survive. And partly, perhaps largely because of their efforts, most commercial insurance companies now voluntarily cover insulin for only $35 out of pocket. While I support the core policy of the Insulin Act, I cannot support creating new duplicative grant programs that exacerbate the problems in our healthcare system that drive healthcare costs.

Community health centers already provide deeply discounted insulin to patients regardless of insurance status or ability to pay. Community health centers and many others receive billions in both mandatory and discretionary funding to support their mission by participating in the 340B program. Any 340B provider is getting insulin for pennies on the dollar.

These savings are supposed to be passed on to the uninsured or low-income patients to pay for insulin and other treatments on a sliding fee scale. There are real transparency and oversight concerns that prevent 340B from translating to better access and lower cost for patients. So, Rather than holding covered entities accountable to ensure that existing resources are being used as Congress intended, this amendment creates another source of funding and enables diversion— further diversion of 340 revenue away from that which Congress originally intended. I will note that the Trump administration strongly opposes this provision. I acknowledge that members on both sides of the aisle may support the amendment.

And I share the goal, having practiced medicine in a hospital for the uninsured and the uninsured, um, to have affordable insulin. But I'll say the hospital where I practiced used 340B the way it was supposed to be used and actually gave the medicine for free to those who came in. And I would say that this amendment is giving cover for 340B entities which is not using the program the way that we intended it to. They're using it as a money grab. Now, I urge my colleagues to oppose this amendment and allow others to speak or make my motion.

Could I, Mr. Chairman? Senator Sanders. Thank you, Mr. Chairman. I strongly support capping the out-of-pocket cost for insulin at $35 for Americans. The underlying legislation, as we know, does that for Americans who have insurance.

Uh, but it does not do that for the uninsured. And that is what this amendment, uh, addresses. Uh, as I think we all know, several years ago, as part of the Inflation Reduction Act, we were able to make sure that people on Medicare— Medicare do not pay more than $35. We also had success in substantially lowering the cost of asthma and OCD inhalers. Bottom line, we are making success.

Having success in making insulin available to those who need it. This is an important amendment. Let's support it. Mr. Chairman. Senator Collins.

Mr. Chairman, I support this amendment and pleased to be the principal co-sponsor. The original bill that we reintroduced in this Congress had this provision in it in an attempt to move the bill along. We agreed to take it out and decide it at the committee level. But I think it's important that we not leave this population, the most vulnerable population, behind. Thank you.

Does anyone else wish to speak? I now make a motion to table the amendment. I shall be voting to table. The clerk should call the roll. Senator Paul.

Aye. Senator Collins? No. Senator Murkowski? Aye.

Senator Marshall? Aye. Senator Scott?

Senator Hawley? Senator Tupperville? Senator Banks? Senator Heastad? Senator Moody?

No. Senator Armstrong?

Senator Sanders? No. Senator Murray. No by proxy. Senator Baldwin.

No. Senator Murphy. No by proxy. Senator Kaine. No by proxy.

Senator Hassan. Yes. Senator Hickenlooper. No. Senator Markey.

No by proxy. Senator Kim. No by proxy. Senator Blunt Rochester. Yes.

Senator Ulster Brooks. No by proxy. Chairman Cassidy. Chairman Cassidy is a yes and notes that Senator Scott is yes by proxy. And Moody is a yes.

I thought we were voting on the amendment. I apologize. On the amendment? Yes. I thought, I thought we were voting on something else.

I'll change my vote. I apologize. And so you change it to yes. Yes. And Armstrong is a yes by proxy.

And Murkowski is not voting. Okay. I have 10 ayes, 12 nays.

The motion is not agreed to. Is not tabled. It is tabled.

The motion is not tabled, correct? Not tabled. I now move— I now move to vote on adopting the amendment. The clerk shall call the roll. I shall be voting no.

Senator Paul? No. Senator Collins? Aye. Senator Murkowski?

Not voting. Senator Marshall? Aye. Senator Scott?

Senator Hawley. No by proxy. Senator Hawley. Senator Toverill. Senator Banks.

For the amendment. Adoption of the amendment. Adoption of the amendment. It's not for the bill. It's for the adoption of the amendment.

Senator Houston. No. Senator Moody. Senator Armstrong. No by proxy.

Senator Sanders. Aye. Senator Murray. Aye by proxy. Senator Baldwin.

Aye. Senator Murphy. Aye by proxy. Senator Kaine. Aye by proxy.

Senator Hassan. Do you have these? Senator Hickenlooper. Senator Markey. Aye by proxy.

Senator Kim. Aye by proxy. Senator Blunt Rochester. Aye. Senator Ulster Brooks.

Aye by proxy. Chairman Cassidy.

No. Okay. And Senator Cassidy is a no.

I have 12 ayes, 10 nays. The, the amendment is adopted.

We will now begin with consideration of S. 2355, the Patients Deserve Price Tags Act. I thank Senator Marshall and his colleague, Senator Hickenlooper, for their efforts on this legislation aimed at increasing transparency in healthcare costs. This bill has undergone extensive bipartisan negotiations over, I think, 6 months. Stakeholder engagement, multiple rounds of technical feedback from the administration, from, I think, 3 to 4 agencies. I'm proud of the process this legislation has gone through and the bipartisan staff work that has gone along with it.

It is an example of the important work we can achieve in improving the U.S. healthcare system when we work together in a bipartisan fashion. We have a manager's amendment to S. 2355. I move to adopt the manager's amendment in the nature of a substitute and have it be considered original text for the purpose of further amendments. All those in favor, please say aye. Aye.

All opposed, say nay. The ayes have it. The motion is agreed to. Do any members wish to speak on the bill? Yeah, Mr. Chairman.

Senator Marshall. Yeah. Well, thank you, Mr. Chairman and Ranking Member Sanders as well. And to my colleagues, Senator Hickenlooper and all your teams who've worked so hard on this bill. 500 Comments we went through from HHS, Department of Labor, Treasury, 80 red lines.

But look, patients deserve price tags, not surprise billing. Once and for all will force transparency and competition into healthcare. Could you imagine going to the grocery store, standing in front of the meat locker, and you're living credit card to credit card, you're on Social Security, and you can't know what the price is between beef and chicken and pork. Could you imagine that? Can you imagine checking out and then still not knowing what the price was, and maybe 3 months later someone tells you what the the price is.

Health care is the only business in the world that's allowed this to go on. You know, this has been a really a 15-year journey for me to work on this concept, and then 8 years we've been working on it. Staff is working on it, making this bill better, better, and, and better. It's not perfect, but it's going to close so many loopholes. It's going to force health care providers to show you the price tag up front, not an estimate, It's gonna show you the price up front.

You know, think about this. You, you need an MRI of your knee. In one place it might be $300, another place it might be $3,000, and it's the same care given at both places. A hip replacement might cost $15,000 one location and $80,000 in another. When families have $5,000, $7,000 deductible, price tags matter.

So Again, I just can't say enough how hard our staff has worked on this and certainly just appreciate Senator Hickenlooper's efforts as well. And then all of our co-sponsors for bringing this across the finish line today. Thank you so much. Thank you, Senator Marshall. And also thank you for staying within 2 minutes.

I've had a light gavel to this date, Senator Collins, but I shall start trying to enforce the 2-minute rule. And starting, of course, with Hickenlooper.

Thank you, Mr. Chair, uh, and Ranking Member Sanders. Uh, for months we've been working alongside Senator Marshall and his staff, uh, Chairman Cassidy, Ranking Member Sanders, to push forward this Patients Deserve Price Tags Act. Uh, in 2025, Americans spent $5.7 trillion on healthcare. In the last 25 years, healthcare inflation has risen by 121% That's 40% more than the cost of living has gone up.

Too frequently, there's no way of knowing what you need to pay for medical care, what the cost is. Patients, often while sick or in severe pain, have the added mental anguish that comes from a totally dark, opaque system. Journal of American Medical Association has estimated that about 25% of our healthcare spend is on administrative processes, pricing failures, waste, inefficiency. I mean, even assuming 10% of that is legitimate administrative costs, it provides the opportunity for hundreds of billions of dollars of savings. The gaming and confusion in our healthcare system drives people crazy.

And we can put a stop to it. The lack of transparency in our healthcare system is the proverbial elephant in the room. It's almost unique among other services and goods that Americans pay for every day. No single company in this system is a monopoly, but without transparency, healthcare is an aggregated monopoly. This makes it almost impossible for people to make financially sound decisions about their healthcare.

It hurts the 180 million Americans whose health insurance are sponsored by their employers, who— they also don't have access to critical information. Even our nation's largest employers won't be able to see what they're paying for. 180 Million Americans have amazing purchasing power. Let's be clear. Preliminary nonpartisan economic consulting firms estimate $75 billion in additional tax revenue.

Savings and reduction of costs would be dramatically more than that. And we need to ensure that Americans can seek medical care without the risk of being bankrupt. I will yield, but only after I thank Colin Goldfinch, Romney Crippato, Lily Ryan, Max Seltzer, Patients' Rights Advocate, our own staffer Hannah Berner, for all their time and effort to get this bill in tip-top shape. We know that there's a better future for healthcare and sunlight is the best disinfectant. Amen.

Thank you. Senator Paul. I commend the authors for their intentions on this. I think that it mistakes the problem for being transparency, and the problem is actually the prices are fixed. So, if you're on Medicare, that's about half the people in the country, 40, 45% of people are on Medicare, and we tell you what the price is, and we make the hospital publish it everywhere, does your price change?

No, it's fixed. If you're on Medicaid, and we force the hospital to publish the prices and all these things, and we push it out there, is that gonna change the price of Medicaid? No, the price is fixed. If we force the hospitals to put the price of your insured care out there, and they do all the work, and it's labeled everywhere, Will the price of your insured care change? No, it's all fixed.

There's only a very small amount of this market that cares about this, and these people don't have insurance. Once again, that's the true marketplace. I'm not saying it's a great thing, but in the true marketplace, people care. There are apps and there are people beginning to ask that. I know at our local hospital, if you'll pay immediately towards either deductible or if you don't have insurance, you get a 25% discount.

So, I think people are aware of these problems. But I don't want people to think that this fixes the problem. When you mandate transparency on prices that are fixed, doesn't change the situation. The goal and what we need to try to strive to is where we have more patients that are in the situation where, where prices are fluctuating, where prices are fixed. Transparency won't help.

Would anyone else wish to speak? Okay. We will now move on to the S. 4974. Make the Making America's Food Safer Act. I thank Senator Tuberville for his work to advance food safety.

Given the Food and Drug Administration the tools to better inspect food facilities and to respond to foodborne illnesses is essential for Americans to have access to safe foods. This bill also gives FDA the ability to destroy unsafe food at ports of entry. We have numerous examples of unsafe products, including radioactive seafood and illegal e-cigarettes entering the market without the ability to seize and destroy. I also thank Senator Marshall for his work on ingredient safety. Ensuring that what goes into our food is safe is also important to improve our own health, and I look forward to working with him on this in the future.

We have a manager's amendment to S. 4974. I move to adopt the manager's amendment in the nature of a substitute and have it considered original text for the purpose of the amendments. All those in favor, please say aye. Aye. All opposed, say nay.

The ayes have it. The motion is agreed to. Do any members wish to speak on the bill? Thank you, Mr. Chairman. Senator Tuberville.

First, I'd like to thank Senator Kaine on this. This is— this is really important, especially those that have ports. You know, it's a common sense target approach. It modernizes our food safety system. It removes outdated statutory restrictions, allowing the FDA to leverage accredited third-party cert—.

Cert—. Certificate programs, data from both domestic and foreign facilities to prioritize inspections to help our supply chain. The bill grants FDA authority to immediately share vital, unredacted food safety data with state, local, and tribal and territorial health officials when public health is on the line. And finally, it grants the HHS Secretary authority to order the destruction of unsafe food imports that present a significant public health concern, preventing dangerous illegal products from simply turning around and reentering supply chains while preserving full due process rights for owners. This is a bipartisan step forward for public health, supply chain efficiencies, and American farmers.

Basically what this does is when it—. When bad food comes into our ports and it's turned around by our food inspectors, it goes right back out into the waters and goes to another port. And hopefully they get by with, with murder, so to speak. So we want to be able to destroy this food and not allow it into our country. So I urge my colleagues to support this bill.

I want to thank Senator Tuberville for roping me into working with him on this one. I very much appreciate this bill. I have a unique perspective that I share with Hickenlooper. In the history of the United States, only 30 people have been mayors, governors, and U.S. senators. And the reason that number is so small is that being mayor will kill you.

But, but this one part of this bill that's really good is the data sharing between state, local, state and federal health agencies with respect to this particular issue of food safety, because there's a lot of data that exists in silos, and when it doesn't get shared, then we can't do what we need to do to keep people safe. And so I really appreciate the portion of this that during tough times and when there are challenges, the data can be shared between the agencies at the local, state, and federal level. And I appreciate, uh, my colleague for bringing this forward and glad to support it. Anyone else wish to speak?

Okay. We shall now go to— do any members wish to offer an amendment? Senator Baldwin. Mr. Chairman, I would like to speak briefly to my amendment Baldwin 1 to S.4974. I will offer and withdraw and not ask for a vote on this.

This contains— this amendment contains the Codifying Useful Regulatory Definitions, or CURD Act. The CURD Act is a bipartisan bill with my colleague from Wisconsin, Senator Johnson, that would establish a definition of natural cheese for dairy processors and provide consumer clarity. While I will not be offering the bipartisan CURD Act amendment today, I want to thank the chairman and ranking member for committing to work with me and with Senator Johnson to find a path forward for this legislation. Thank you. Thank you, Senator Baldwin.

Thanks for offering the amendment. It's important that food labeling is accurate and does not mislead. I believe that the FDA currently has the regulatory ability to make the changes in this amendment and that Congress should not continuously weigh in on standards of identity. However, I commit to working with Senators Baldwin and Johnson on advancing this policy in other legislative vehicles later this year. Are there any other amendments?

Seeing no other amendments, did you have an amendment?

No. Let's move on. We'll now consider S.3788, the Clear Labels Act. Clear Labels Act. I thank Senator Rick Scott and his co-lead, Senator Gillibrand, for their work on this legislation.

I acknowledge Senators Tuberville, Moody, and Armstrong, who are cosponsors, for their contributions. As chair of the Aging Committee, Senator Rick Scott has brought increased attention to the vulnerabilities of our global supply chain. Congress must help address these challenges. Customs and Border Protection already requires pharmacies to provide drug country of origin information to patients, but pharmacies don't have this information, so they can't comply. This bill addresses that gap by requiring drug manufacturers to provide information about API suppliers and other key steps in the supply chain so that pharmacies know where the products they provide to patients come from.

Having this information provided through a drug label will also help fill gaps in FDA's information. Right now, FDA knows how much API gets imported every year, and it knows which suppliers a drug manufacturer uses. But FDA cannot tell you who manufactured the specific ingredients used in the pills that we take. This is common sense policy. I encourage colleagues to support the legislation.

We have manager's amendment to S.3788. I move to adopt the manager's amendment in the nature of a substitute and have it considered original text for the purpose of further amendments. All in favor say aye. Aye. Opposed say nay.

The ayes have it. The motion is agreed to. Do any members wish to speak on the bill? Senator Hassan. Well, thank you, Mr.

Chair. I share the goal of this legislation to increase the Food and Drug Administration's insight into our prescription drug supply chain. However, I do have concerns about the national security implications if we require companies to list publicly the exact location of each manufacturing facility that we rely on for life-saving medications. So I hope this committee will work to address those national security concerns. I think that's something we can do after this bill is reported out today.

But I just wanted to raise the concern. Thank you. Thank you. Senator Paul. I think labeling requirements are a cost which would increase the cost of drugs and not necessarily change things.

Most people are sort of directed where they're going to buy their drugs. Listing and having people list that it came from China, I don't think changes anything. I think it's also important to know that there's a lot that comes from China and there's a lot that comes from India., and the pharmaceutical chain sort of shifts, the supply chain shifts. Every time it shifts, if next year you find it's a little bit cheaper to get it from Vietnam than China, you gotta change your label again. I just don't think it changes the end choices that much on this, and so I'd be wary of adding more requirements that don't in the end probably shift what kind of decisions people make, because most people are directed by these decisions by the insurance they already have.

Does anyone else wish to speak? Mr. Chairman. Senator Collins. Mr. Chairman, mindful of the chairman's admonition, I would request unanimous consent to put my comments in the record. It is— it is given.

Do any members wish to offer amendments?

Okay. We'll now begin with consideration of S.3794, the Safe Drugs Act of 2026. I thank Senator Banks for his diligent work on this legislation and leadership to keep patients safe. Compounding pharmacies play a critically important role in our health care system. They help patients who cannot take oral pills and those who are allergic to certain ingredients patients access the medication that they need.

They also step in to help when supply disruptions create drug shortages. At the same time, we've seen examples of compounded drugs marketed as FDA-approved medications. This misleads patients who are looking for affordable options when the brand drug may be too expensive. And by the way, just like any medication, adverse events can occur with compounded drugs. But states and FDA don't consistently learn about these adverse events when they happen.

FDA has stepped in to address some of these problems, but sometimes states and FDA are not always sure who's first when a situation arises. This bill takes common sense approaches to begin addressing the challenges of compounding, which, by the way, I have great respect for compounders, which will in turn better support the compounding pharmacies that are doing good work in communities around the country. There is more to be done beyond the topics addressed in this bill, but it's a— we got to start someplace. It's a good first step. I encourage colleagues to support the legislation.

We have a manager's amendment to S.3794. I move to adopt the manager's amendment in the nature of a substitute and have it considered original text for the purpose of further amendments. All in favor, please say aye. Aye. Opposed, say nay.

The ayes have it. The motion is agreed to. Do any members wish to speak to the bill? Senator Banks. Thank you, Mr. Chairman.

My Safe Drugs Act puts in place reasonable safety guardrails for compounding pharmacies. The compounding industry has grown a lot over the last few years because of the telehealth industry, but there are still gaps in the law that some companies are exploiting. We all represent compounding pharmacists and value the work that they do, Mr. Chairman, as you said, and our constituents obviously rely on them. But investigative journalists have exposed terrible conditions and dangerous products at some compounding facilities. Patients need to be better protected.

And that's what this bill does by making all compounding pharmacies report serious adverse events and label their products, and also require some compounding pharmacies that do significant business across state lines to report how much they are compounding. This is a bipartisan compromise. I want to thank the pharmacy associations and drug safety organizations for working with me on, on this, as well as you, Mr. Chairman. We had to exclude several issues and leave them unresolved for now, but we will continue working on them. I appreciate everyone's support.

With that, I yield back. Does anyone else wish to speak?

Senator Hustad, you want to wait for your amendment or you have to speak for amendment? Okay. Seeing no others, do any members wish to offer amendments? Senator Hustad. Thank you, Mr. Chairman.

I call up Houston Amendment Number 1 to S.3794. And the reason that I'm doing this is because countless Americans have to go see a doctor every time they want a prescription. But many of those prescriptions could be more efficiently offered by allowing those drugs to become over-the-counter. My amendment creates an expedited approval pathway for these products, allows sponsors to get early informal FDA feedback before filing, and directs FDA to weigh the full public health benefit of over-the-counter drugs. Every time we spend a dollar on an over-the-counter drug, that saves— every dollar spent on over-the-counter products saves the healthcare system $7.33 and delivers those savings at the convenience for patients and should be a priority.

For this committee. It helps reduce the cost of people getting access to healthcare. The current prescription OTC switch process at the FDA isn't working, and sponsors need to be— have more predictability and less friction. You want something to happen in the world, create less friction. It's more likely to happen, it's more likely to be efficient, and this will improve healthcare and improve access and cost.

So I'm not asking for a vote today, Mr. Chairman, but I look forward to continuing to work this— work on this delivery for patients. And I offer but withdraw my amendment. Thank you. Thanks, Senator Husted, for his work. I think this is actually a wise piece of legislation.

Over-the-counter products are a critical piece of this puzzle. I will note that Benadryl, Tagamet, Prilosec, and a lot of nonsteroidals have previously been prescription only, and now we just go into the counter and get them. FDA has created a new category of products called ACNU, pronounced ACNU, that would allow drugs that are otherwise prescription to be accessed OTC by using standardized safety tools to ensure the drug is appropriate for the patient before getting the drug. But they just haven't approved any, and the reforms that we authorized last year are still being implemented. I agree that we should look at all options to improve access to safe and affordable medications.

Next year, the Prescription User Fee Program is being reauthorized. That is the time to consider this policy. I appreciate that Senator Husted is withdrawing this amendment so that we can continue that process.

Let's now move to S.494, the National Plan for Epilepsy Act. I thank Senator Schmidt and his co-lead Senator Klobuchar for their leadership in this important bipartisan legislation which brings federal agencies, researchers, and the epilepsy community together to identify gaps and improve research, diagnosis, care, and treatment. The legislation creates a clear path to help deliver better outcomes for people living with epilepsy and their families. I urge colleagues to support it. There is a manager's amendment to S-4 494.

I move to adopt in the nature of a substitute and have it considered original text for the purpose of further amendments. All in favor say aye. Aye. Opposed, nay. The ayes have it.

The motion is agreed to. Do any members wish to speak to the bill? Mr. Chair, Senator Hassan. I just want to thank Senator Schmidt and Klobuchar, and I think Senators Collins and Kaine are also on this bill.

As somebody who has family members who live with epilepsy, It's just critically important that we make more progress on this disease. It is treatable. It can also be truly debilitating. And I think that it's time for a really concerted strategic effort to improve treatment and, and better lives. Thanks.

Anyone else? We shall now move to S. 1874, the Title VIII Nursing Workforce Reauthorization Act of 2025. I thank Senators Collins and co-lead Senator Merkley for their work. This legislation reauthorizes and updates the nursing workforce programs under Title VIII, which addresses nurse staffing shortages, especially in rural areas. And I urge colleagues to support.

We have a manager's amendment. I move to adopt in the nature of a substitute and have it considered original text for purposes of further amendments. All in favor, please say aye. Aye. Opposed?

Nay. Ayes have it. Motion's agreed to. Do any members wish to speak? Senator Collins.

Thank you, Mr. Chairman. Maine continues to face a serious shortage of nurses, particularly in our rural communities where hospitals struggle to recruit and retain staff. This shortage is driven by a severe— a severe shortage of nursing faculty. Our bill would help to strengthen the nursing workforce by reauthorizing critical programs that support nursing education, expand access to clinical training, and help schools prepare more students for careers in nursing. These programs are essential to addressing the workforce shortage facing hospitals in rural areas across our country.

I have a letter of support for this bill from the Nursing Community Coalition, which represents 65 nursing groups. I ask all of my colleagues to support this legislation, and I'm yielding back the remainder of my time, even though I want to talk further.

On average, you're still over time. Oh, oh, cruel. Do any—. Does anyone else wish to speak? Senator Blunt Rochester.

Thank you, Mr. Chairman. And thank you to the ranking member for this bipartisan markup and to Senators Merkley and Collins for your important work on the underlying bill. I also want to acknowledge my co-leads on work in this space, Senators Tillis, Merkley, and Kramer, for their support of the National Nursing Workforce Center Act. Just a second, Senator Blunt-Roddy. I think you're going to your bill, correct?

Yes. And then I have—. That's—. Senator, it's part of the first. Does anybody else wish to speak on the bill which we're currently considering?

And do any members wish to offer an amendment? Yeah, I'd like to call up Blunt-Rochester Amendment 1. Got it. Okay. Thanks.

And again, I'm looking at the clock. Okay. Okay. Go. Ready?

Yes, ma'am. All right. Thank you, Chair Cassidy and Ranking Member Sanders. And again, thank you to Senators Tillis, Merkley, and Kramer for their support on the National Nursing Workforce Center Act, on which my amendment are based. And I, I will say this, we all know that nursing is the largest healthcare profession in our country and it touches everyone from birth with nursing midwives to palliative care.

And so the work that we are trying to do to strengthen our nursing workforce is important. When nurses feel distressed, patients feel it, and shortages show up in patient care from delayed treatments to closed hospital departments to longer hospital stays to worse outcomes. And there's an economic toll as well. Burnout related to turnover alone costs an estimated $9 billion a year. And so we appreciate the support of our amendment.

Uh, my amendment to Title VIII creates a 3-year pilot program to support state nursing workforce centers and establish a formal relationship with HRSA. There are 46 states currently that have nursing workforce centers, and these centers help states understand whether they have the right nurses in the right places doing the right things, and also helps with workforce planning. My amendment also, again, our— this is bipartisan, it's bicameral, it's endorsed by over two dozen organizations from nurses to hospitals to AARP. And I also want to thank all of the members and staff who helped us, particularly Senator Sanders' staff and Senator Cassidy's staff, for your help and your support on this. And I am within my time, and I am so proud on behalf of nurses.

Let's support our nurses. And I yield back. Thank you. And I ask for a yes vote from my colleagues. You almost took the landing, then you just trembled at the end.

But we can do it. We can do it as a voice. Mr. Chairman, Senator Marshall would like to speak to the bill and the amendment, if I could, in favor of them. Have I ever mentioned my wife is a nurse? Yes.

Good. You know, nurses make or break healthcare. Nurses stand in the gap. If you're a newly diagnosed diabetic and you can't get into the nutritionist, the nurse is standing in the gap. A patient in a mental health crisis, we can't get them into the mental health specialist.

The nurses stand in the gap. The nurses are the ones that solve the problems. They're the boots on the ground that make a difference. And Senator Collins is absolutely right. The challenge is we don't have enough educators, nurse educators.

And, you know, we literally, talking to my community colleges, tech colleges, we have 2x, twice the number of qualified applicants as we can take into the system. They're not going to replace doctors. But they can sure, like I said, stand in the gap and quickly change the delivery of healthcare, meeting patients where they are. And just want to thank all my colleagues for working on promoting nurses. We, we just can't have too many of them.

AI is not going to replace them, by the way. So thank you, Mr. Chairman.

I appreciate Senator Blunt Rochester's goal to improve nursing workforce data collection. This amendment uses existing funding to support public-private partnerships operating state or regional nursing workforce centers. Centers.

The amendment addresses deficiencies in gathering information about the nursing workforce and improves capacity. For that reason, I support the amendment. I move to vote on adopting the amendment. In the interest of time, I would ask that all who are in favor say aye. But before that, if someone wishes to vote no, they can be recorded no even through a voice— even through a voice vote.

All in favor, please say aye. Aye. Opposed, say nay. Senator Paul wishes to be recorded as a nay. The ayes have it.

The amendment is adopted. We will now begin. Anyone else wish to—. Does anyone else wish to offer an amendment? Senator Rochester.

Thank you, Mr. Chairman. I'd also like to call up Murkowski Amendment Number 1 to S.1874. Okay. Senator Murkowski was unable to be here this morning, but she She knows also how important Title VIII programs are and that more needs to be done to address our nursing workforce shortages. Low compensation and inadequate pay, not to mention burnout and heavy workloads, push nurses away from teaching, making faculty roles, as Senator Marshall mentioned, less attractive than clinical jobs that often pay significantly more.

According to the American Association of College of Nursing, U.S. nursing schools turn away 92,672 qualified applicants from their nursing programs. The primary reason cited was faculty shortages. Every vacant nurse educator seat means fewer nursing students can be trained, worsening the nationwide shortage. That is why Senator Murkowski and Senator Durbin worked together to introduce the Nursing Faculty Shortage Reduction Act, which the Murkowski Amendment Number 1 is based on. This demonstration program is designed to address the critical shortage of qualified nursing educators in the United States by providing grants to schools of nursing to supplement faculty salaries.

This covers the gap between clinical nursing and factual nursing pay, ensuring that we have sufficient nurses to teach our next generation. With that, I encourage my colleagues to support this amendment and ask for a vote. Is a voice vote okay when we get there? Then we will ask for a voice vote in the interest of time. And I turn—.

I thank Senator Murkowski. Thank you. I ask— I thank Senator Murkowski for her strong support of the nursing workforce. This amendment provides financial support to offset pay gap between clinical nursing practice and teaching the next generation of nurses. The amendment exposes problems in how universities recruit and retain faculty from key professions like nursing.

I also want to acknowledge Senator Murkowski's good faith efforts to work with my staff to improve the legislation. The amendment we are considering today is a substantial improvement over what was offered at the last markup. I appreciate Senator Murkowski's work on this issue and will support the issue. Does anybody else wish to speak to the amendment? I now move to vote again as last.

We'll have a voice vote, but if anybody wishes to be recorded as a nay, we shall do so. All in favor, please say aye. Aye. All opposed, say nay. Senator, record Senator Paul as a nay.

And then I have by proxy I have Armstrong as a no. And that's it.

Okay, we'll now go to the, um, uh, S.4110, Empower for Health Act. I thank Senators Murkowski and co-lead Reid for their work. This legislation reauthorizes and updates the workforce programs under Title VII, Strengthening the Health Care Pipeline. It helps improve recruitment, training, and retention of health workers, especially in underserved areas. I urge colleagues to We have a manager's amendment.

I move to adopt the manager's amendment in the nature of a substitute and have it considered original text for the purpose of further amendments. All in favor say aye. Aye. Opposed, nay. The ayes have it.

The motion's agreed to. Do any members wish to speak to the bill? Mr. Chairman. Senator Collins. Mr. Chairman, I just want to point out the Empower for Health Act includes the geriatrics Workforce Improvement Act, which Senator Kaine and I have introduced.

It would reauthorize the Geriatrics Workforce Enhancement Program and Geriatrics Academic Career Awards Program. These programs operate in 37 states, including Maine. Maine's population is the oldest state by median age. In the country, and yet there is a very significant shortfall of healthcare providers who specialize in geriatrics. Reauthorizing these programs will help ensure that older Americans will be cared for by a healthcare workforce specifically trained to meet their unique and complex health needs.

So I appreciate the work that Senator Kaine and I have done on this bill. The act also includes the Biopreparedness Workforce Pilot Program Reauthorization Act, a bill that I worked on with Senator Baldwin. Thank you, Mr. Chair. Does anyone else wish to speak?

Okay. Do any members wish to offer an amendment? Senator Blunt-Rochester. Thank you, Chairman Cassidy and Ranking Member Sanders. And also thank you to Senators Reid and Murkowski for their important work on the underlying bill.

Again, thank you to my colleagues who have worked with us on this legislation. I've been working on this bill since we were in the House, and it stemmed from what we saw during the pandemic and just the impact on our nurses, our nurses. And so To be able to see us move forward with this is, is a great day for nurses in this country. My amendment to Title VII is a common-sense fix that would give HRSA the clear authority to establish a federal nursing-focused research center, something they are currently prohibited from doing. This would ensure consistent federal data collection on the nursing workforce, data which will help policymakers and healthcare leaders create strategies for alleviating the nursing workforce shortage.

As I said before, we have bipartisan, bicameral support and support from others across our country. And again, the nurse supply and demand in the United States has always moved in cycles, but we haven't been able to see the changes coming. And what we want to do with this amendment is fix that. And so again, thank you so much for the support of my colleagues. And again, we salute our nurses in this country.

Thank you. And I yield back. Does anyone wish to speak? I'm sorry. Does anyone wish to speak on the amendment?

I'm going to ask for—. I thank Senator Blunt Rochester's goal of improving nursing workforce data collection. The amendment helps states and regions collect, analyze, and report data on health workforce programs, including nursing workforce programs. And better data helps policymakers make informed decisions about education, recruitment, and retention of nurse nurses and other health providers. I urge colleagues to support the amendment.

I move now to adopt the amendment, and again, by voice vote. All those in favor, please say aye. Aye. Those which be recorded as nay. Do we have any proxies?

Okay, the ayes have it. The amendment is adopted.

Now, we have any more amendments on this bill? Okay. Let's move to the S.380 Rural Obstetrics Readiness Act. I thank Senators Collins and Hassan for their leadership in this legislation. The bill aims to help rural practitioners prepare for and manage obstetric emergencies.

This legislation further facilitates access to care for mothers residing in rural communities. By supporting the improved delivery of emergency obstetric services during pregnancy, labor, delivery, or the postpartum period in areas without dedicated obstetric units. We have a manager's amendment to S.380, a move to adopt in the nature of a substitute and have considered original text for the purpose of further amendments. All in favor, please say aye. Aye.

Those opposed say nay. The ayes have it. The motion is agreed to. Do any— do any members wish to to speak on the bill. Surprise, surprise, hasanddoes.

I want to thank you, Mr. Chairman, and Ranking Member Sanders, not only for this markup but for the work that your teams helped us do on Senate Bill 380, the Rural Obstetrics Readiness Act. I want to thank Senator Collins as well for her leadership. Across our country, we are seeing maternal healthcare deserts as more rural hospitals are struggling to keep their labor and delivery units open. This bill would provide targeted support to help ensure that small rural hospitals, especially those without labor and delivery units or specialists, have the training that they need to respond to an obstetric emergency such as labor and delivery. I appreciate the committee's work on this bill, and while we weren't able to include the purchase of equipment as an allowable activity under today's agreement, I look forward to working with the committee in the future to add that critical use of funds.

This is the kind of equipment that some of our hospitals simply cannot afford to purchase at this time. I urge my colleagues today to support this legislation. Thank you. Anyone else? Mr. Chairman, thank you.

Mr. Chairman, first let me salute Senator Hatson for her leadership on this bipartisan legislation. Our bill will help prepare rural healthcare facilities that do not have a designated labor and delivery unit to respond to obstetric emergencies. Nationwide, more than 2 million women live in a county without a provider offering obstetric care. In Maine, about half of our rural hospitals do not have dedicated labor and delivery units. We're trying to recruit Senator Marshall to come to Maine to help with that.

Rural Mainers have to drive more than 45 minutes to the nearest birthing hospital on average. The bill that we're marking up today will ensure that rural hospitals will be better prepared to handle women experiencing an emergency with their pregnancy, even if that hospital does not have dedicated labor and delivery staff. The grants and training opportunities created by this bill are sorely needed. It seems like every month we learn of another rural hospital in Maine that is giving up its obstetrics unit because of a lack of providers. I ask all of our colleagues to support passage of this legislation.

Thank you. Uh, Senator Hustad. I thank Mr. Chairman. This bill is necessary for a variety of reasons, but one of the challenges we have in America is with declining birth rates. Uh, in, in general, since 2000, we've had 11% reduction in this country in births.

And in many states it's higher than 25%. And it's acute in rural areas because there are just fewer people having babies. And the economics and the challenges that these hospitals are having are, are legitimate concerns. And so I just commend the sponsors for bringing this legislation forward. Thank you.

Does anyone else wish to speak? Okay. We will now consider 50— S. 5026, the Childhood Diabetes Reduction Act. I thank Senator Sanders for his work on this legislation. Providing transparency to consumers about the food they eat is important to giving them the tools to make their own health decisions.

I have long called on the NIH to increase focus on nutrition and obesity, including in my 2024 NIH Modernization White Paper. In Louisiana, the Pennington Biomedical Research Center is doing cutting-edge work to improve our understanding of how nutrition affects health. The NIH provisions of the bill strengthens research on food and dietary patterns and the relationship between diet and chronic disease. I'm glad we're able to come to a bipartisan agreement on these issues. While other areas of the bill raise policy and jurisdictional concerns, in the spirit of bipartisanship, I will support it to advance a priority of the ranking member.

We have a manager's amendment, S. 5026. I move to adopt the manager's amendment in the nature of a substitute and have it considered original text for the purpose of further amendments. All in favor, please say aye. Aye. Opposed, say nay.

Ayes have it. Motion agreed to. Do any members wish to speak to the bill? Senator Sanders.

Thank you, Mr. Chairman. I won't repeat what I said at the beginning of the markup. I think everybody understands We have a horrendous diabetes crisis in this country, uh, and that is related to the crisis we have with obesity. Maybe there are a lot of factors involved as to why. Certainly one of them is that the food industry, uh, produces a lot of junk food targeted to our kids, resulting in many of our children being overweight, laying the groundwork for diabetes.

So what we do here is two things. We require a warning label on sugary drinks that says, quote, "Food and Drug Administration warning: Drinking beverages with added sugar can contribute to obesity, type 2 diabetes, and tooth decay. Not recommended for children," end of quote. Not a radical idea. It's being done by countries all over the world.

And secondly, we ban junk food advertising targeted to kids. Also not a radical idea done throughout the world. Thank you, Mr. Chairman. Senator Paul, I have an amendment. Are you ready?

No, no. Anybody else wish to speak to the amendment? Yes, this is the bill. Senator Collins. Thank you, Mr. Chairman.

Well, I appreciate the intent of the ranking member to reduce the incidence of diabetes, particularly for our nation's children. I am concerned that his bill will not truly combat diabetes. That's why the diabetes advocacy groups have not taken a position on this bill. But it will have the unintended consequence of making food more expensive for Americans. In addition, I have had many conversations with school nutrition directors who have expressed concerns that when we start getting into mandates that you can only— you cannot have full-fat milk in schools or chocolate milk or strawberry milk, that it leads to food waste and it deprives children of the opportunity to have the calcium that they need.

I think that this bill would end up labeling worthwhile foods like yogurts, cheeses, potatoes, smoothies, and other products as somehow being detrimental to health and therefore will set the effort back. In order to truly tackle the long-term challenges with appropriate child nutrition, I've long supported programs at the CDC and NIH that seek to tackle the issue of obesity in youth, as well as the study of ultra-processed foods, which I support. Therefore, I will oppose this bill. Mr. Chairman, if I might. Senator Sanders.

Well, let me be very clear. The definition of ultra-processed food in this bill excludes products that meet FDA's definition of healthy which must include a key food group recommended by the Dietary Guidelines. This includes dairy, vegetables, fruits, whole grains, and proteins. This legislation does not require warning labels on dairy products like natural cheese or milk. We're willing to, uh, continue working with offices to improve this definition, uh, but that is the simple reality of what's in this bill.

Mr. Chairman. Senator Marshall. Yeah, thank you, Mr. Chairman.

Desperate times call for desperate measures, and I feel desperate. This childhood obesity epidemic is for real. I was trying to look up the numbers. I couldn't find them off the top of my head, but America's on this seafood diet. Seafood and eat it.

Generally speaking, I'd like to do less rather than more when it comes from regulatory process, but I'm going to support Senator Sanders' bill here. It's not perfect, but sometimes you have to— we just have to do something. And this is the most significant something I can see. Senator Sanders mentions we spend 2, 3, 4 times more than other countries do. Well, one of the reasons is we're sick.

We have a very sick country, and it starts with this childhood epidemic that we have, and sugary drinks are a big part of the calorie intake as well. I think that this is a great— it's a good first step, and we have more work to do. We have to take care of the grass loopholes and several other things that just aren't quite ready for prime time, but I think this is a step in the right direction, and we're going to support Senator Sanders' bill. Thank you. Would anybody else like to make a comment before we go to amendments?

Okay, do any members wish to offer an amendment? Senator Paul. This is Paul, Amendment 2. You know, I applaud the attentions and intentions of those who are concerned about childhood obesity and diabetes. It absolutely is a problem, sort of an ironic problem, that the problem in a capitalist society is too much food, but that's a problem we have and too much of the wrong food.

I don't know that labeling will do anything. I share sort of the desperation that we should do something, but there actually is something we could do. We subsidize the wrong food. We give people food stamps. A significant percentage of our country gets food stamps, and the number one item on food stamps is Coca-Cola, Pepsi, soft drinks.

Number four on the list is bagged snacks. Number 11 is candy. Believe it or not, you cannot just get an individual candy bar, you can get a bag bag of candy on food stamps. Cookies are on the top 20 list. Ding Dongs, Twinkies.

And so if we were really serious about this, we just wouldn't subsidize bad food. My amendment wouldn't change the amount. We'd still have the same amount of food stamp money. Not one person would get less money. They'd have more money for healthy food.

My amendment would simply say that there'll be a formulary and candy won't be on the formulary anymore. Sugared, uh, soda won't be on the formulary anymore. This is not unprecedented. WIC program already does this. We looked at using the WIC formula, but we didn't think it was expansive enough with protein and things like that.

I don't know why they decided pregnant women didn't need protein, but they don't. I think meat is not on the WIC program. But anyway, food stamps, there'd still be thousands of items that could be— people could buy, and inevitably they would be shifted. And I think you'd see a real change in childhood obesity within a year or two view of this. I really think it can be a bipartisan issue.

It hasn't been so far, but I hope both sides of the aisle will consider this. This has real teeth in it, doesn't reduce food stamps. All it does is said the unhealthy foods that have been referred to so far would not be paid for by the taxpayer. Senator Sanders, uh, I do understand where Senator Paul is coming from, but I disagree with them. Uh, obviously our goal is to encourage folks in our country to eat better.

And that is why we're having these warning labels, because I suspect that many parents may not know just how much sugar there is in the various products their kids eat. The problem, I think, with Senator Paul's amendment is, you know, you got a low-income kid, he's with his friends, and suddenly we're saying to that kid, because you're poor and you're on food stamps, You know, you can't do what your other friends are doing. We're stigmatizing these kids. So the goal, of course, Senator Paul, is to get people on food stamps and every American to try to eat better, to educate people about what's in the process, in the foods that they eat. But I think this is simply stigmatizing low-income folks who are on food stamps.

So I would oppose this amendment. Mr. Chair, both arguments are really good arguments, and I've really grappled with this one, and I've tended to be on Senator Sanders' side of this.. But I'm going to go with Senator Marshall. Desperate times require that we push this farther.

Senator Paul has been advocating for this for some time, and I think the time has come to take that step. And I view that step as consistent with the, with the legislation that I'm going to support. Anyone else wish to comment on the amendment? Mr. Chairman, so just really quickly. So I agree with both, both the senators, and it's a— it is a tough call.

It's absolutely a tough call on what to do here. But I am proud of what else we've done up here. We've tried to reward good behavior with food stamps. We've tried to double— we call double up bucks if you're making good healthy choices, working with grocery stores, and trying to reward good behavior. Eventually we need to figure a way to incorporate Senator Paul's goal here as well.

But I am concerned that it would would strike. I don't think we'd have the votes to get the big bill, Senator Sanders' bill, across the finish line if it passes. So I'm truly torn on what to do here. Thank you. Anyone else wish to speak to this?

This amendment would add a policy to the bill that falls outside of our committee's jurisdiction. By the way, I agree with the concept. And I agree desperate times call for desperate measures. And I actually spoke to this when I was in the Ag Committee when I was in the House of Representatives. But before proceeding on this amendment, we need to consult with the Ag Committee to understand their equities and receive technical feedback.

Therefore, I'll be supporting a motion to table this policy, although again, I agree with Paul. But nonetheless, for jurisdictional issues, I will make a motion to table the amendment. The clerk shall call the the roll. Mr. Chairman, one more thing I forgot. I believe states have the ability to do this already.

Thank you. The clerk should call the roll. Senator Paul? No. Senator Collins?

I'm sorry. No is to oppose tabling. Yes is to table on the Paul Amendment.

Aye. Okay. And then Murkowski is not voting. Senator Marshall. Aye.

Senator Scott. Senator Hawley. Aye. Senator Tuberville. Senator Banks.

Senator Houston. No. Can I interrupt for a second? Banks is— I'm sorry, Tuberville is a no by proxy. No by proxy.

And Tim Scott is a yes by proxy.

Proxy. Okay. Senator Moody.

Senator Armstrong. Yes, by proxy.

Senator Sanders. Yes. Senator Murray. Aye. Senator Baldwin.

Aye, by proxy. Senator Murphy. Aye. Senator Kaine. No.

Senator Hassan. No. Senator Hickenlooper. Yes. Senator Markey.

Senator Kim. Oh, yes. Okay. Senator Kim. Senator Blunt Rochester.

Senator Alston Brooks. Chairman Cassidy. Yes.

Was it 16-6? I have 16 ayes, 6 nays. What is it? 16 Ayes, 6 nays. The amendment is tabled.

Do we have another amendment? Senator Hustead. Thank you, Mr. Chairman. I call up Hustead Amendment Number 1. I share the concerns about health of children in this country and what they're eating.

I also care about the cost of food, and I do not want the cost of compliance with this bill to fall on working families. Furthermore, I understand we need to understand what ultra process means in this bill. It's not a term of art with a settled boundary. It is a list of ingredients that show up on the foods that most families buy and can afford as they try to make ends meet. And so my amendment's simple.

It requires that before the bill goes into effect, it is confirmed that it will not raise the cost of food for families. And I will ask for a recorded vote, and I encourage my colleagues to vote yes. Do any members wish to speak on the amendment? Yes. Senator Sanders.

This amendment, unfortunately, is a poison pill intended to further delay warning labels on ultra-processed food. We've been talking about labels year after year after year. We understand what exists now is inadequate. The time is now to do it.

For more than 30 years, the food and beverage industry has been required to put nutritional labeling on their products. These labels are totally inadequate. I think most of us know that putting warning labels on ultra-processed foods will not, not lead to higher overall grocery prices. We've seen that in other countries around the world. There are a lot of reasons why food prices are going up, but it ain't labels.

Thank you, Mr. Chairman.

I thank Senator Husted for offering this amendment. I agree with his concerns that the risk of— about making the risk of food prices more expensive for consumers. But I will oppose this amendment. But while I do so, I commit to working with the senator to ensure this policy that we're— the underlying bill does not harm consumers as we continue to diligence the bill. I shall now make a motion to table the amendment.

I ask for unanimous consent to voice vote the motion to table. Any objection? I want to be recorded.

Okay, so a voice vote, please. All in favor to table? So an aye is to table the amendment. All in favor, please say aye. Aye.

All opposed, say nay. No. So I think it's Collins and Hawley are recorded as no. Is there— and Husted is recorded as no. And a Moody is a no and a Banks is a no.

Okay. Okay. And I think we say that Murkowski is not voting and Murkowski is not voting. Okay.

Are there any other amendments to offer? Okay, in the interest of time, without objection, we're going to batch vote on final passage, uh, for some of the bills. Batch number 1, we will now move to final passage of the following bills as amended and move that they be favorably reported. By the way, none of these have amendments. This would be S.1414, the Expedited Access to Biosimilars Act.

So we are voting on the bills that we have already considered. I'm sorry, I may have missed— as amended. So we're going to do the 1414 Expedited Access to Biosimilars Act, the Making America's Food Safer Act, the National Plan for Epilepsy Act. And this will be for final passage. If there's no objection, we shall batch.

The clerk shall call the roll. I shall be voting yes. Senator Paul. Yes, by proxy. Senator Collins.

Aye. Senator Murkowski. Not voting. Senator Marshall. Aye.

Senator Scott. Yes, by proxy. Senator Hawley. Senator Tupperville. Yes, by proxy.

Senator Banks. Aye. Senator Hustad. Aye. Senator Moody.

Aye. Senator Armstrong. Yes, by proxy. Senator Sanders. Aye.

Senator Murray. Aye. Senator Baldwin. Aye, by proxy. Senator Murphy.

Aye. Senator Kaine. Aye. Senator Hassan. Aye.

Senator Hickenlooper. Aye. Senator Markey. Aye. Senator Kim.

Aye. Senator Blunt Rochester. Senator Alzerbrooks. Everyone's going to be a yes on this. Chairman Cassidy.

Aye. I have 22 ayes, 0 nays. Okay, that's good. Batch number 2. We'll now move to final passage of the following bills as amended and move that they be favorably reported.

S. 2355, Patients Deserve Price Tags Act.

S. 3788, Clear Labels Act.

S.4110, Empower for Health Act. S.1874, the Title VIII Nursing Workforce Reauthorization Act of 2025. S.380, the Rural Obstetrics Readiness Act. And before the clerk calls the roll, I would like to say it has been a long morning. But when people say that Congress is not functioning well, this committee had a long morning because we are functioning well.

And we've taken stuff from people who are off committee and on committee and in a considered way brought good things that make our country's life better. So I thank you all for participating. Once more, staff.

So the clerk shall call the roll. I shall be voting yes. Senator Paul? No by proxy. Senator Collins?

Aye. Senator Murkowski? Senator—. Not voting. Senator Marshall.

Senator Scott. Yes, by proxy. Senator Hawley. Senator Tupperville. Yes, by proxy.

Senator Banks. Senator Houston. Senator Moody. Senator Armstrong. Yes, by proxy.

Senator Sanders. Aye. Senator Murray. Senator Baldwin. Aye, by proxy.

Senator Murphy. Sarah Cain. Senator Hassan. Senator Hickenlooper. Senator Markey.

Senator Kim. Senator Blunt Rochester. Senator Ulster Brooks. Chairman Cassidy. Yes.

I have 21 ayes, 1 nay.

We shall now vote the final. So the— so the— it passes. These—. These bills pass as a batch. We'll now move to final passage of S.3794 as amended.

I move to favor— this is— I move to favorably report S.3794. The clerk shall call the roll. Senator Paul.

Do I have his proxy here?

No, by proxy. Senator Collins. Aye. Senator Murkowski. Not voting.

Senator Marshall. Aye. Senator Scott. No. No by proxy.

Senator Hawley. Aye. Senator Tuberville.

Come back to that. Senator Banks. Yes. Senator Houston. Yes.

Senator Moody. Armstrong. Senator Armstrong. Yes by proxy. And Tim Scott's yes by proxy.

Tim Scott's yes. Yes. By proxy. Senator Tuberville. Yes.

Yes. By proxy. 8, 9. Senator Sanders.

Aye. Senator Murray. Aye. Senator Baldwin. No.

Senator Murphy. Aye. Senator Kaine. Senator Hassan. No.

Senator Hickenlooper. No. Senator Markey. Aye. Senator Kim.

Aye. Senator Blunt Rochester. No. Senator Alsobrooks. Yes.

Chairman Cassidy.

Aye. I have 17 ayes. Wait, I'm sorry. And Senator Paul wishes to be recorded as a yes on this vote. Okay, so 18.

So that's, uh, 1, 2, 3, 4. So I have 18 ayes, 4 nays. The bill is favorably reported.

Now we'll vote on final passage for 4189 as amended. I move to favorably report 4189. The clerk shall call As amended, the clerk shall call the roll.

Senator Paul. No by proxy. This is the insulin bill. The Collins insulin bill. Senator Collins.

Aye. Senator Murkowski. Not voting. Senator Marshall. Senator Scott.

No by proxy. Senator Hawley. Senator Tovaril. Yes by proxy. Senator Banks.

Aye. Senator Husted. No. Senator Moody. Aye.

Senator Armstrong. No by proxy. Senator Sanders. Aye. Senator Murray.

Aye. Senator Baldwin. Aye. Senator Murphy. Aye.

Senator Kaine. Aye. Senator Hassan. Aye. Senator Hickenlooper.

Aye. Senator Markey. Aye. Senator Kim. Aye.

Senator Blunt Rochester. Aye. Senator Alston Brooks.

Chairman Cassidy. No. I have 18 ayes, 4 nays. Okay. The ayes have it.

The bill is favorably reported. We now go final passage on S. 5026. I move to favorably report as amended. The clerk shall call the roll. Senator Paul.

No by proxy. Sarah Collins. No. Senator Murkowski, not voting. Senator Marshall, yes.

Senator Scott, no by proxy. Senator Hawley. Senator Tupperville, no by proxy. Senator Banks. Senator Houston.

Senator Moody, no. I'm sorry, you said no. Okay. Senator Moody is no.

Senator Armstrong? No by proxy. Senator Sanders? Aye. Senator Murray?

Aye. Senator Baldwin? No. Senator Murphy? Aye.

Senator Kaine? Senator Hassan? Aye. Senator Hickenlooper? Aye.

Senator Markey? Aye. Senator Kim. Senator Blunt Rochester. Senator Alsobrooks.

Chairman Cassidy.

Aye. I have 12 ayes, 10 nays.

I now move to author— the ayes have it. The clerk has favored— the bill is favorably reported. I now move to authorize staff to make any required technical and conforming changes when preparing S. 2355, S. 4189, S4974, S1414, S3788, S3794, S494, S4110, S1874, S380, and S5026. All those in favor say aye. Aye.

All opposed say nay. The ayes have it. The motion is agreed to. And now I think Senator Baldwin has some comments. Mr. Chairman, I have comments, but I also have a unanimous I be recorded as present for the on-block votes that I missed due to jockeying between Commerce Committee markup and this.

Granted. Thank you. My comments relate to the Childhood Diabetes Reduction Act. I strongly support the legislation's goal for reducing childhood obesity and diabetes, and I have long fought fought for greater investments in diabetes treatment, research, uh, prevention. I've also fought to ensure that our nation's children have access to healthy food that helps them grow.

My concern is not with the bill's objective, it is with how it would be implemented. As drafted, the legislation could require many dairy products, including milk, cheese, and yogurt to carry an FDA warning label unless the FDA chooses to exempt them through its regulatory authority. This places tremendous weight on agency discretion rather than providing a clear direction in statute. Unfortunately, FDA leadership under Republican and Democratic administrations have long refused to enforce proper nutritional labeling standards that already exist for dairy products. I oppose this bill today because I think we have more work to do to get this right.

This legislation must include provisions to support the accurate labeling of dairy products, and I look forward to working with the committee to address these concerns. Thank you, Mr. Chairman. Thank you, Senator Baldwin. Senator Collins, okay. Um, okay, good job everyone.

The committee stands adjourned.