Senate Health, Education, Labor, and Pensions (Murkowski): Business meeting to consider S.1782, to prohibit discrimination on the basis of mental or physical disability in cases of organ transplants, S.3799, to amend the Public Health Service Act to reauthorize the Healthy Start Initiative, S.4109, to reauthorize the Stem Cell Therapeutic and Research Act of 2005, S.2339, to reauthorize the Young Women's Breast Health Education and Awareness Requires Learning Young Act of 2009, S.4472, to amend the Accelerating Access to Critical Therapies for ALS Act to reauthorize the provisions of such Act through fiscal year 2031, S.2658, to require sponsors of drug applications and holders of approved applications to provide certain submissions and communications to the Food and Drug Administration and the United States Patent and Trademark Office, S.3014, to amend the Federal Food, Drug, and Cosmetic Act with respect to citizen petitions, and S.1954, to improve the requirements for making a determination of interchangeability of a biological product and its reference product.

This Senate Committee on Health, Education, Labor, and Pensions will please come to order.

I joke sometimes my pillow talk with my wife is about healthcare. And so how do you lower cost, how do you improve innovation, how do you improve care? She's a doc, so it's not as strange as it might seem. But I say that because actually Americans expect us to find answers. And too often they see members of Congress shouting insults or wasting time on political games.

And they get frustrated, and they should be frustrated because we should be focused on how do we make their life better. We have 8 bipartisan bills before us today. These will make their life better. Bills that help Americans get a life-saving organ transplant, increase access to affordable drugs, support mothers and babies through healthy pregnancy. And many of these should be easy bills moving through the—.

Quickly. Quickly. Moving through the committee quickly. Now, I don't know if they're going to be offered, but my ranking member has introduced partisan amendments which are irrelevant to these bills, and that would have the effect to sabotage our bipartisan work. These bills, these amendments, if attached, will keep this legislation from passing the committee and the Senate.

Now, I don't know if my ranking member is actually going to offer them, but they've certainly been filed. And it's frustrating. Uh, in all due respect to my ranking member, it seems more about messaging, and it's grinding the committee to a halt rather than passing simple, common-sense bills that help the American people. Now, the argument will be, well, these help the American people. We're having a markup in July.

That's the appropriate time for these amendments, not for this. And people on both sides say that they want regular order. It is the responsibility of people on both sides to do the activities, the hard activities, sometimes going against their leadership in order to produce regular order. I'm leaving the Senate. I was asked earlier, what will be my legacy?

I want part of my legacy is he tried to preserve the institution. But that is a responsibility of us all. And now returning, I understand why Americans are frustrated with Congress. Remember, our original founders said we shouldn't have parties because they thought it would descend into partisanship. We should not accept this as our new reality.

I will note, as chair, I have provided members of this committee a forum to discuss topics of importance, to move legislation on multiple occasions.

When Democratic priorities are not being elevated to me for consideration through normal mechanisms, this committee held the first-ever member day hearing in the Senate. Now, the ranking member was not there, but colleagues in this room and other senators raved about how much they enjoyed this. Now we're trying to get ideas, act on ideas that came out of that hearing that our colleagues raved about their opportunity to present. And I don't know if they're going to be presented, but what we have filed now are partisan poison pill amendments to consider. We have other bills that Republicans and Democrat members have identified as priorities that I wish to mark up in July, as I said.

But if we can't get through this markup productively, we're not going to be able to have that markup. There is a consequence for not having regular order. I'll remind my colleagues briefly of remarks from the late Senator Mike Enzi's farewell address. And Enzi was loved. I gotta admit, of all of us, if we're all loved like Mike Enzi was loved, we'll have a special place in heaven.

He believed in the 80/20 rule, and it's how he ran the committee. No senator got everything they wanted all the time, but bills got passed and laws were made. I've told Senator Sanders we'll continue to work together on his priorities. We've talked about this extensively. Of course we have disagreements.

We can work through those disagreements.

The public health extenders that are of great importance to him are also of great importance to members of my side and of his side. We just recently increased and extended these programs. They have not lapsed. This committee is not going to finish this year without addressing them. Thank you.

I'm hopeful we can address them next month. That's my plan. But my colleagues on the Democratic side have to make a choice. If they choose to support some of these poison pills amendments no matter what, it will blow up the bills they want. The bipartisan bills that I have been called about— 2 minutes.

Will be denied the opportunity for future markups, future markups to help constituents for whom we know it is important. I suggest we put aside partisanship and do what is best for the American people. To my Republican colleagues, don't take the bait of political poison bill amendments. This just empowers bad behavior. Policy differences are fine, part of the process, but taking hostage is not.

It is up to all of us to allow this committee to function as a normal committee. And we should all deny one member the ability to blow up a bipartisan markup when they don't get what they want. Let's do our jobs as legislators and legislate. And with that, I recognize Senator Sanders. Thank you, Mr. Chairman.

I would say that I agree with one point that you made. The American people certainly are frustrated with Congress. I think we are somewhere ahead of Iran right now in terms of favorability, but not by much. And why is that? The reason for that is that all over this country, people are hurting.

And I don't know about my Republican colleagues, who I think the answer will be the same, but I do talk to a lot of Democratic candidates. Thank you. And they tell me that we're out there on the campaign trail, and they hold town meetings. The issue that comes up probably more often than anything else is the understanding that our healthcare system today is broken, it is dysfunctional, and it is wildly expensive. And the American people are saying, does anybody in Congress know that?

Do they know that I can't afford to send my kid to a doctor. I can't afford prescription drugs for my parents. So today, the so-called— let me say a word about the so-called poison pills that I will be offering to address some, some of the crises that we face. And I want the American people to decide whether or not these They think these are poison pills, outrageously bipartisan efforts trying to sabotage the work of the chairman. For a start, as bad as our overall healthcare system is— and by the way, as everybody on this committee knows, we spend twice as much per capita on healthcare as the people of any other nation, over $15,000, and yet 85 million Americans are uninsured, underinsured, Some 60,000 people a year die because they can't afford to go to a doctor.

Maybe we want to be addressing that issue. Now, as bad as the overall healthcare system is, the primary healthcare system is in even worse shape. In America today, tens of millions of people live in communities where they cannot find a doctor, a dentist, or a psychologist, even when they have decent insurance. Mm-hmm. I know that's true in Vermont.

I suspect that is true in every state in this country. And if we do not get our act together, given the enormous shortage of doctors, dentists, and psychologists we have right now, the situation will only get worse in the future. We are facing a shortage of 400,000 nurses over the next 2 years alone. So, Mr. Chairman, you think this is a poison pill that we talk about the need to make sure that we have nurses and doctors all over this country? Doesn't seem to me to be a poison pill.

It seems to me to be something we should have addressed years ago and we should address now. Over the next 12 years, we face a shortage of 180,000 doctors and 400,000 mental health practitioners, while over— 60 million Americans live in districts where they can't find a dentist. Every major medical organization agrees that our investment in primary healthcare is woefully inadequate. And I suspect that every member of this committee understands that as well. There is a reason why most other major countries spend over twice as much as we do on primary healthcare and end up with far lower capital costs than we do.

They invest in keeping people healthy. [FOREIGN LANGUAGE] keeping them out of emergency rooms, out of the hospital, and that makes sense to me. The backbone of our current primary healthcare system, as weak as it is, is the Federally Qualified Community Health Center program, the FQHC program, an issue that I have worked on for many years. Today, more than 30 million men, women, and children receive high-quality primary healthcare at community health centers in more than 16,000 neighborhoods located in every state in America. Many of these centers also provide dental care, mental health counseling, and low-cost prescription drugs.

Unfortunately, George Washington University projects that community health centers will lose nearly $42 billion in revenue over the next 5 years. So, Mr. Chairman, if you think it's a poison pill— Excuse me. That we begin to address that issue right now. I would respectfully disagree. The National Association of Community Health Centers estimates that health centers will see an increase of 4 million uninsured patients in the coming years.

And that is why, Mr. Chairman, the first amendment I will be proposing would increase community health center funding from $4.6 billion this year to $5.8 billion next year. Given the fact that a majority of senators, senators on this committee have already voted in favor of this funding bill, funding level, I hope it will pass. But that's not the only amendment that I'm going to offer. This amendment would also provide loan forgiveness and scholarships so that we get more doctors and nurses into underserved areas. Mr. David, as the next— Mayor, this amendment would provide $120 million over a 3-year period so that every state in America has a teaching health center in their state.

Teaching health centers, enormously important. Way to make sure that we have doctors and nurses in rural areas. So, Mr. Chairman, I do not agree with you that these are poison pills. I would say that every amendment that I am offering is widely supported by the American people— Democrats, Republicans, and independents. I hope you will support them.

A couple things for clarity. You said that this— you're sabotaging the work of the chairman. Actually, this is the work of our colleagues, bipartisan work of our colleagues. These amendments are not germane, and they were filed Tuesday. Now, there's a process, a process by which there's full consideration of a bill, of an amendment that comes before us, and then we take that processed amendment so that we all understand it.

We all have an ability to understand it. If you drop a non-germane amendment, which, by the way, is not paid for, 2 days beforehand, you're going to have histrionics about how millionaires and billionaires are ripping off the American people. But there is a process here, and the Congress works better as a process. Mr. Chairman, did I get these amendments in on time according to the process? Absolutely.

And are they paid for? Are they paid for, Senator Sanders? They will be paid for. They will be paid for. Let's work on it.

Yeah, let's work on it. In the future, let's work on it. Let's work on it. We actually are going to have a hearing in July in which we can pay for it, and I told you that, and that's when we're going to do this. And that's the way that Congress is supposed to work, and that is fair to the American people, not moonbeams and flatus somehow finding a way to pay for things.

Chairman, the Congress does not work Well, clearly it's not working with that, but it can work, and that's my mission. So let's move on. We'll begin consideration of today's bills. For the awareness of all senators and staff, we intend to vote on amendments as they are raised, but we'll hold the vote on final passage of both bills until the end of session. We'll keep members and staff updated on the timing of the vote for final passage.

As a reminder, when discussing an amendment, identify the amendment you're discussing by name and number. We'll begin with consideration of S.1782, the Charlotte Woodward Organ Transplant Discrimination Prevention Act. I'd like to thank Senator Moody for her leadership. She has taken up the mantle of former Senator, but now Secretary of State Marco Rubio, who championed this legislation in the last two Congresses. I thank Senator Hassan, who has remained a steadfast partner in this bill and has consistently in her time on the committee spoken passionately for those who are disabled.

This legislation is another example of the important work achievable working in a bipartisan manner and a critical step in improving and restoring trust in the U.S. transplant system. We have a manager's amendment to S.1782. I move to adopt it in the nature of a substitute and have it considered original text for the purpose of future amendments. All those in favor, please say aye. Aye.

Opposed, say nay. The ayes have it. The motion is agreed to. Before we offer any amendments, do any members wish to speak on the bill? Chairman Cassidy, if I might.

Senator Moody. Thank you, Chairman Cassidy. I know you have worked really hard to get us where we are today. Senator Hassan, thank you. I know you were calling a lot of folks last night asking them to withhold amendments that might derail this bill.

I even thank Senator Kaine. I know he was considering offering an amendment. I'm hoping that he has understood that this is so important. It's been coming for a long time. We even have your constituent, Charlotte Woodward, in the room with us today, uh, and all of the senators that, um, have co-sponsored this.

I'd also like to thank Representative Kat Kamek over in the House. Uh, she really has rolled up her sleeves and helped us, uh, get this, uh, to where we are today. Um, baby Zion, who I consider my forever constituent, would have had his 5th birthday Monday. Had he received the life-saving heart transplant he so desperately needed after 40 days in the NICU. So many love and miss Zion, who was born with Down syndrome and passed away in October of 2021.

And that story reminds us that barriers to transplant still exist in our healthcare system, and people with intellectual disabilities shouldn't be discriminated against for something as vital as an organ transplant. And today we are happy, uh, to have Charlotte Woodward, with us in the room. This bill is bipartisan. It passed the House unanimously just last year. We, as we vote today, will be thinking of Charlotte and baby Zion and all those who will benefit from this legislation.

And I urge my colleagues to vote in favor of this bill to protect people like them from discrimination moving forward. Thank you again, Chairman. Senator Sanders. This is an important bill, and I hope we can pass it. Senator Hassan.

Thank you. I am also really grateful that we have Charlotte here with us today as we consider this bill. And I'm grateful to Senator Moody for her taking up leadership on this bill as she came to the Senate. No one should be discriminated against because they experience disabilities. And on few— and few issues have stakes as high as whether somebody receives a life-saving transplant or not.

So I urge my colleagues to support the bill. And I would love to see it move forward separately. Thank you. Senator Kaine. I'd like to call up and discuss Kaine Amendment 1 to this bill.

And let me describe it, and then the chairman and I will chat a little bit about it. I'm very glad that Ms. Woodward is here. This is a good bill. I'm co-sponsor of it. I really like it.

The timing of the bill— this is the one bill on the list that deals with the rights of folks with disabilities. And the timing is sort of exquisite, in a way, maybe kind of exquisitely bad because of the announcement by the administration this week that they're forcing the special ed functions of the Department of Ed— Mm-hmm. —To be pushed over to HHS. And so what this amendment would do would be to block shifting the functions of the Office of Special Ed and Rehab Services to other federal agencies. Let me explain why I think this is so important and not a poison pill and something I hope we can work on together.

President Trump was elected president and he promised that he wanted to get rid of the Department of Education. So that's what he said. Mm-hmm. Now, if you want to do it, I would disagree, but he has a majority in both houses. And so the way to do that would be to get Congress to approve getting rid of the Department of Education and change the law.

That's not what the president has done. Instead, he's treated the Department of Education as if it's a going-out-of-business sale as a— of a discount furniture outlet and handed off willy-nilly the responsibilities of that agency. Just to remind folks, student loan portfolio, let's give that to the Small Business Administration. They didn't want it. They weren't staffed up to do it, and they weren't competent to do it.

So now they're trying to hand it over to the Department of Treasury. Career and technical education. Let's give that to the Department of Labor. The Department of Labor melted down because of the scandal-prone nature of the secretary that I sadly voted for, and that agency has hurt itself. But on this one, this was the core, Mr.

Chair, of the DOE that we cared the most about, that we asked Secretary McMahon about when she was here for her confirmation hearing, who's going to have the backs of American kids that have disabilities and special needs? And so given that this is the only bill in this that deals with disabilities, I filed this amendment, and then you and I have chatted about it. And so, um, I would like to call it up or find an acceptable way to deal with this issue so that the committee can try to block these services from being put in the hands of an HHS headed by a Cabinet Secretary that many of us have lost confidence in.

So you're offering— okay. I'm offering it as an amendment, but—. The amendment is unrelated to the underlying bill, which is a bipartisan measure intended to ensure that healthcare providers and the organ transplant centers may not deny or restrict access to organ transplants solely on the basis of an individual's physical or mental disability. The Office of Special Education and Rehab Services, OSERS, in the Kaine Amendment would not be moved to HRSA or OCR, which are the only two agencies at HHS implicated by the underlying bill. This amendment would prevent passage of a thoughtful, balanced, bipartisan bill supported by disability advocates like Charlotte Woodward, sitting in the audience.

For the record, I will share with everyone, I agree that that should not be moved to HHS. Let me just put that on the record. And if an IAA is signed, I think it should be with DOL. Better served to provide rehabilitative services to introduce people with disabilities into the mainstream. Thank you.

But I will say to my colleagues, this is not the time and place to address the issue. But I ask my colleague to withdraw the amendment, and I will publicly commit to working with him for the next markup in July at finding something which is an accommodation for everyone's concern. Mr. Chair, let me say I appreciate that, and I think that's a good faith offer. So here's what I would, would like to do.

I will withdraw the amendment to the Charlotte Woodward bill if I get a commitment that at the July markup I will get a vote either on a bipartisan solution that we reach or on this amendment, which I would— I will introduce as standalone legislation. And I would ask— I hope we can find a bipartisan accord, and I think we can, because I think there's members on both sides of the aisle that don't want this put in HHS's hands. So I think we can find a bipartisan agreement. You are a United States senator and you have the right to offer that, and I'll protect that right, and you have my commitment. Okay, so either we— we'll have a vote either on a bipartisan accord or on this amendment that I will file as separate legislation at the next markup, which will be before the August recess.

Yes. In that case, I withdraw the amendment. Okay. Anyone else?

We now begin with consideration of S.3014, Ensuring Tiny Access to Generics Act. I thank Senators Collins and Baldwin for their work on this legislation to help Americans access lower-cost generic medications. I am committed to making healthcare more affordable, and the high cost of healthcare is multifaceted, which means it takes more than one approach. So I urge my colleagues to support this bill. I'm going to take the chair's prerogative and call up first Sanders number 6 as we begin consideration of S3014.

Mr. Mr. Chairman. See, Sanders number 6 will add portions of Senators Collins and Shaheen's Insulin Act to S3014, legislation to address the abuse of FDA processes, processes that delay the entry of cheaper generic drugs. Before we proceed to debate, there are a few things that should be noted for the record. First, S.3014 is identical to a version of the Ensuring Timely Access to Generics Act that the HELP Committee passed last Congress on a bipartisan basis when Ranking Member Sanders was the chair. This 2023 markup occurred after Senators Shaheen and Collins first introduced the Insulin Act, but at the time, the ranking member did not file an amendment to incorporate the policy or otherwise attach it to this bill.

I will also note that during the time that Senator Sanders served as the chairman, there was no vote scheduled on the Insulin Act. Instead, he publicly disparaged CEOs of insulin manufacturers and pharmacy benefit managers at a hearing, but there was no vote on the Insulin Act. Senator Sanders even titled the hearing "The Need to Make Insulin Affordable for All Americans." Yep. I will think intuitively That if the ranking member believed the Insulin Act was the way to solve the problem, as chair, he would have brought the bill before the committee the last time we considered the Ensuring Timely Access to Generics Act. But that brings us to today.

I'm fully committed to affordable insulin. I am on the record in support of $35 insulin. The rebate pass-through part of Insulin Act was signed into law in January as part of our larger PBM reform efforts. S.3014 is also part of the Insulin Act as introduced this Congress. I commend Senators Collins and Shaheen for tireless work advocating on behalf of patients who need insulin to survive.

Partly because of their efforts, most commercial insurance companies voluntarily cover insulin for only $35 out-of-pocket. TrumpRx and other direct-to-consumer platforms make insulin available for $25 today. The Insulin Act, as introduced, has 25 bipartisan co-sponsors, including 9 from the committee. I venture to say that the math suggests that the amendment will pass. But I'll let senators know that transparently, when Senator Sanders was chair, this was never addressed.

It suggests to me that the amendment today was not sincere nor done properly, particularly since it contains text of matters that have already been signed into law. It has not been scored by the CBO, nor does it have technical assistance from HHS. Thank you. It's easy to speak about how we need to have something for the American people, but to get that something done, there's a process you go through, and that includes getting a score from CBO and getting technical assistance from HHS. I plan to move to table this amendment, but understand that senators may choose to vote differently.

Regardless of the outcome, I'm committed to working with Senators Collins and Shaheen to refine their legislation and thank them for the longtime work in this space. Thank you. But before I make a motion to table, Senator Collins has requested to speak, and I'm sure Senator Sanders and others may as well. Senator Collins. Thank you, Mr. Chairman.

First, let me thank you for including the Ensuring Timely Access to Generics Act on today's markup agenda. This is a bill that I first introduced in 2019 with Senator Shaheen and Senator Baldwin, both of whom have been very committed to it. I just want to explain a little bit about how this bill works. It increases competition from generic drugs through better oversight of the FDA citizen petition process. Brand name manufacturers were behind roughly 86% of all citizen petitions filed between 2016 and 2019.

Overwhelmingly, these petitions did not raise legitimate safety concerns, which is why the FDA rejected more than 9 out of 10 of these petitions. Despite the low success rate, petitions are still able to delay generic drug entry and can unfairly consume FDA resources. Our bill, our bipartisan bill, would strengthen the FDA's ability to reject citizen petitions if it believes that the primary purpose of the petition is to delay approval of the lower-priced generic competitor. Thank you. If enacted, this bipartisan bill would improve competition, save patients money, and also, according to the latest assessment from the CBO, save taxpayers $49 million.

I find it extremely interesting that the ranking member has proposed 9 amendments to this Common Sense bill. He has not proposed amendments to any other bill. I think it's pretty easy to figure out what the motivation is here. I am pleased that the ranking member finally supports the insulin bill and has proposed it as an amendment to this bill. I've worked alongside with Senator Shaheen, my co-chair of the Senate Diabetes Caucus, on legislation to lower the cost of insulin since 2019.

And before that, I held a hearing in the Aging Committee on the cost. That's what led us to the Insulin Act, which has many components, including the ensuring timely access to generics. This bill, though, is the one that before us now passed out of the HELP Committee. I would note that when Senator Sanders was chair in 2023, he had absolutely no interest in adding the Ensuring Timely Access to Generics Act to the Insulin Act. Thank you.

Senator Sanders.

Chairman, It is true that when I was chair, we brought the CEOs of the major pharmaceutical companies before us. That's absolutely true. And as you recall, we did that because they are charging the American people by far the highest prices in the world for prescription drugs, in some cases 10 times more. And I and the American people wanted a simple answer. Why do you charge us 10 times more than our Canadian friends or people in Europe.

And out of that hearing, among other things, what we did get is a commitment which has been carried through to lower the outrageous, then outrageous cost of asthma inhalers. Millions and millions of people have asthma. They buy inhalers, cost them hundreds of dollars. The price now is $35. That's what we did in this committee.

And furthermore— in the Inflation Reduction Act. And I worked hard on that as chairman of the Budget Committee at that time. We now pay— seniors now will not pay more than $35 for insulin in Medicare. So I think we did have some significant success. And once again, Mr. Chairman, I think the issues that you consider to be poison pills are amendments that the vast majority of the American people support.

There are amendments without technical assistance and without a CBO score. Mr. Chair. Further discussion on Sanders Amendment 6? Mr.

Chair, just quickly, I also just want to recognize Senator Shaheen. Her name has been mentioned. She's not a member of the committee, but this is a very important priority for hers, and I just wanted to underline that she's worked really hard on this issue. Anyone else? I make a motion to table Amendment 6.

I shall be voting yes to table. Will the clerk call the roll? Mr. Chairman. Senator Sanders. I oppose the motion to table and urge my colleagues to vote no.

I want to make clear to members that this vote is really a vote on my amendment. I urge a no vote on the motion to table. It is on Sanders Amendment 6. It is not on the underlying bill. So, clerk shall call the roll.

Senator Paul. By proxy, yes.

Senator Collins. No.

Senator Murkowski. No. Senator Marshall. Senator Scott. Senator Hawley.

Senator Tuberville.

Senator Banks.

Senator Husted? Yes. Senator Moody? Yes. Senator Armstrong?

By proxy, yes. Well now— Clerk! Senator Sanders? No. Senator Murray?

Uh, no by proxy. Senator Baldwin? Yeah. Senator Murphy? No by proxy.

Senator Kaine? No. Senator Hassan? No. Senator Hickenlooper?

No by proxy. Senator Markey. No, by proxy. Senator Kim. Senator Blunt Rochester.

Senator Ulster Brooks. No, by proxy. Chairman Cassidy. Cassidy. Cassidy is yes.

I have 8 ayes, 15 nos. So we are not tabling. So now we'll vote on adoption of the amendment. I shall be voting no. The clerk shall call the roll.

I'm sorry, which amendment? Sanders 6. This will be the one we just discussed. We shall now vote on passage. We did not table, so we're voting to pass.

Clerk shall call the roll. Senator Paul. No by proxy. Senator Collins. Aye.

Senator Murkowski. Senator Marshall. Senator Scott. Senator Hawley. Senator Tupperville.

Senator Banks. Senator Houston.

Senator Moody. Senator Armstrong. No by proxy. Senator Sanders. Yes.

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

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

Senator Markey. Yes, by proxy. Senator Kim. Aye. Senator Blunt Rochester.

Aye. Senator Ulser-Brooks. Senator Ulser-Brooks. Oh, sorry. Yes, by proxy.

Chairman Cassidy. Cassidy is a no. I have 15 ayes, 8 nays. The amendment passes. I ask unanimous consent to consider Sanders Amendments 1 through 5 and Amendments 7, 8, and 9 on block.

No, no, I object.

Okay. Mr. Chairman, I call up Sanders Amendment 1. Clerk.

Okay, Mr. Chairman, um, let me, let me begin, please. We now be, um, wait, where is my comments in a minute? Oh, I'm sorry, please, Senator Sanders. Uh, Mr.

Chairman, I think that it's no secret to anybody on this committee that we have a crisis in primary healthcare. I don't need to go through a long explanation. Everybody knows That is the case. Everybody here has community health centers in their districts, and I think most of the people on this committee, if not all, are proud of the work that those federally qualified community health centers are doing. I think every member of this committee understands that these community health centers— I know in Vermont, that I expect in every state— are under a lot of pressure now for a lot of reasons.

They need help. And as I mentioned earlier, and I don't think anybody disagrees, if we want to cut healthcare costs, if we want to ease human suffering, we got to make healthcare available to people when they need it. They need access to doctors and access to psychologists, access to low-cost prescription drugs, and that is what community health centers do. So what this bill does are 3 basic things. It increases funding for community health centers from $4.6 billion to $5.8 billion.

Second of all, it does something which again, I think everybody in this committee understands is important, this concept of teaching health centers where medical school residents can now practice in primary healthcare facilities, FQHCs, other type of facilities rather than just at teaching health centers. That will bring more young doctors into rural areas, underserved areas, and into primary healthcare. There are now a number of states— we've expanded funding for this program recently, but there still remain a number of states— Alaska, Kansas, Kentucky, Maine, South Carolina, Indiana, Vermont, New Hampshire, Virginia, Colorado, New Jersey, and Delaware— that do not have one teaching health center. And that is addressed in this bill. And lastly, what this bill does, this amendment does, is at a time when we have a massive shortage of doctors and nurses in this country.

It substantially increases funding for the National Health Service Corps, helps our young doctors and nurses pay off their student debt if they agree to practice in underserved areas. So the problems are real. I think there's nobody in this room who disagrees with it. Let's do it. Thank you, Mr. Chairman.

Mr. Chairman, go ahead. I think— let me comment first, please, Dr. Marshall.

This amendment is unrelated to the underlying bill on generic drugs, and adopting it would prevent this bill from advancing at today's markup. Think about what I said at the outset. If we want Congress to work, we have to work to make it work. And having a bill which creates unrealistic increases in funding for some programs, but for some reason strangely ignores the special diabetes program which is a bipartisan priority of HELP members, and includes the Insulin Act, which we just passed, indicates it is not well thought through. I repeat that.

We are supposed to be deliberative here. We're not supposed to just be doing political punches. Earlier this year, we increased funding with pay-fors for all of the public health extenders in a bipartisan fashion. So to, to, to, to say that we're not doing this is to ignore the work we've already done. There's some $6.6 billion in this new spending which is not offset.

It takes other members' priorities and inserts them into an unrelated bill in bad faith. The ranking member had months to engage with me on these priorities. I approached him first for a list of bills for markup 2 months ago. Instead, we get something on Tuesday without technical assistance, without a score. Thank you.

Which, by the way, hurts the ability of us to pass the underlying legislation, which is bipartisan, bipartisan, Democrat and Republican priorities. We should all be frustrated with this. I'm committed to working towards a positive outcome in the public health extender funding. We can address these issues and we will address them when we have technical assistance, when we just do the blocking and tackling that we have to do. Do.

I urge my colleagues to oppose this poison pill effort. I make a motion to table the amendment.

Mr. Chairman, do we—. We can vote first. Go ahead. Mr. Chairman, I think that many of us on this side of the aisle have supported community health centers and certainly want to continue to support them. But I do think we need to go back and measure twice and cut once here.

We've thrown a lot of money at them. Unfortunately, if you've seen one community health center, you've seen one community health center. There's no— they're not measuring success in any uniform fashion yet. And I beg them to come back to me and say, here's what we're going to measure. We have these 8 chronic diseases that are spending— we're spending 90% of our money treating those diseases.

The community health center is the perfect place to treat those chronic diseases. But they need to find out how to measure it. I feel like sometimes we're just throwing money at it and we're not solving the problem. Certainly want to continue to work with the ranking member on how to best fund these community health centers, how to fund more nurses out there. All those things, a lot of the same goals we share together.

But I'll have to vote no, or I'll vote yes on tabling for today. Thank you, Mr. Chairman. Mr. Chairman, the Sanders Amendment excludes, as you point out, the special diabetes program. Perhaps the ranking member is unimpressed with that program. I can tell you it is absolutely essential to children, teens, and others with type 1 diabetes, and also with Native— for Native Americans and Native Alaskans who have a disproportionately high rate of type 2 diabetes.

Along with Senator Shaheen, I've long been a champion For the Special Diabetes Program, I co-founded the Senate Diabetes Caucus and now serve as co-chair with Senator Shaheen. In February, as chair of the Appropriations Committee, I secured a $200 million reauthorization of the Special Diabetes Program, which expires on December 31st of this year. We increased funding by $40 million— that's the highest funding level in the program's history. It has driven remarkable progress in preventing, treating, and managing diabetes while supporting critical research. It is inexplicable that other programs are being extended, but the ranking member, either deliberately or by mistake— Mistake, Excuse me.

Did not include the special diabetes program. For that reason, I will vote to table this amendment. Mr. Chairman, Senator Sanders. This amendment does not solve every aspect of the healthcare crisis in America.

I concede that. I concede the community health centers in America are not perfect. But Mr. Chairman, the American people understand that our current healthcare system, where we are today, is broken, is dysfunctional. Let me repeat. According to some very good studies, some 60,000 Americans die every year unnecessarily because they can't afford to go into a doctor's office.

Community health centers are the best tool that we have at this moment. Delighted to work with the Senator from Kansas. Let's improve community health centers. But right now they are in desperate financial shape. They need help.

So again, all this bill does— it doesn't solve every healthcare crisis in America. It addresses the major tool that we have for primary healthcare, that is community health centers. It allows them to serve more people. It helps us get— [FOREIGN LANGUAGE] Doctors and nurses into rural and underserved areas by increasing the National Health Service Corps. And it also allows us to get more doctors and nurses through the Teaching Health Center Program, a very important provision.

Doesn't solve all the problems. It is a major step forward in giving access to millions of Americans who desperately need healthcare. Anyone else who wish to comment on this? I'll just point out that we will consider these same bills in July at our markup when they've been fully vetted, had technical assistance, and scored. This remains a bipartisan priority for us all, but there is a process that you have to go through in order to make Congress work.

You don't just drop them in on Tuesday. We shall now vote to table. The chair shall be voting yes to table. Clerk shall call the roll. I'm sorry?

Yeah, I'll vote yes. Didn't I say yes? Yep. Yep. Yeah.

The chair shall be voting yes. Senator Paul? A yes by proxy. Senator Collins? Yes.

Senator Murkowski? Aye. Senator Marshall? Yes. Senator Scott?

Aye. Senator Hawley? I don't have a proxy on him. He's yes—yes-by-proxy. All right.

Uh, Senator Tuberville? Senator Banks? Yes. Senator Houston? Aye.

Senator Moody? Aye. Senator Armstrong? Aye-by-proxy. Senator Sanders?

Nope. Senator Murray? No proxy. And Baldwin— Senator Murphy? No proxy.

Senator Kaine? No proxy. Senator Hassan? Sen Hickenlooper? Senator Markey?

No proxy. Senator Kim? Senator Blunt Rochester? Yes! Senator Ulster Brooks?

No proxy. Chairman Cassidy? Chairman Cassidy is yes to table.

No in person. Senator Murphy is no in person. We have 12 ayes, 11 nays. The amendment is tabled. Does anyone else have an amendment they would like to call up?

Senator Sanders on number 2.

Mr. Chairman, unlike my first amendment, uh, this amendment simply calls for an increase in funding for community health centers from $4.6 billion to $5.8 billion. I think I previously discussed why community health centers right now are in desperate need of increased funding, and I would hope that members would support I support the amendment.

Does anyone else wish to comment on this?

I will say the same thing I did before. We are considering this in July after the appropriate— after the amendment or this appropriate legislation has been vetted, technical assistance, and scored. Right now there is no pay-for for this. So if we wait for a month, we will actually have a pay-for. And that's the way that Congress is supposed to work, is not scoring cheap political points when we're trying to pass bipartisan legislation, which is bipartisan priority.

Mr. Chairman, Mayor? Sure. Very briefly, you say that you're going to be bringing this, uh, this need up in July. Is that correct? We're having a markup in July, and I presume that you're going to offer this then, and that—.

What I'd like to know is, and maybe we can get rid of all these amendments very quickly. Among other things, will you be supporting in July an increase in funding for community health centers from $4.6 to $5.8 billion? I am so happy to have that conversation, but there are resources, limited resources, and so within those limited resources we have to live. That is an uncomfortable reality of the, of the Congress and of the government. And so when I see what the funding is When Senator Marshall's point is that when we see the money that we've already laid out, how it's being used, and we have some fuller assessment of full need, then I will make my decision.

But I am— my bio is I worked for 25 years or something like that in hospitals for the uninsured and Medicaid. I got street cred when it comes to taking care of poor people without insurance. I will hold up to anybody in the United States of America. So to sit and imply that the only way you're righteous is to vote for something which is not scored, without technical assistance, and not thought through is absurd. Well, I would just say that for a party that gave $1 trillion in tax breaks to the 1%, talk about limited resources sounds a little bit far-fetched.

So we got to do math around here. Okay, I shall move. Does anybody else wish to speak on this? I move to table the amendment. Uh, the— I shall be voting yes.

The clerk should call the roll. Senator Paul.

Yes. Senator Collins. Senator Murkowski. Senator Marshall. Senator Scott.

Senator Hawley. Senator Tuberville. Senator Banks. Senator Houston. Senator Moody.

Senator Armstrong. Aye by proxy. Senator Sanders? No! Senator Murray— nope, but I'll see you soon again when it's Murphy or Kaine know about Proxy Senate Hassan Hickenlooper.

Nope, my proxies: Markie— nobody proxied him; Blunt Rochester— also Brooks— not very promising. Chairman Cassidy. I am an— I am an aye to table. I have 12 ayes, 11 nays.

The motion to table passes. Any other amendments? Yep. Sanders Amendment number 3.

Mr. Chairman, the Health Committee has jurisdiction over the Teaching Health Center program. Last year we worked together to substantially increase funding for this program over a 5-year period, and that is the good news. The bad news is that despite this increased funding, there are 20 states in America that do not have one single teaching health center. 12 Of those states are represented by senators on this committee: Alaska, Kansas, Kentucky, Maine, South Carolina, Indiana, Vermont, New Hampshire, Virginia, Colorado, New Jersey, and Delaware. This amendment would provide $120 million over a 3-year period, $40 million a year, to ensure that every state in America can have a teaching health center.

These centers are extremely important because they allow medical school graduates to complete their residencies in community health centers. If we want more doctors and other medical professionals to practice in rural and underserved areas, this is a very important way to do it. I ask my colleagues to vote for this amendment.

This amendment is unrelated to the underlying bill on generic drugs. Adopting it would prevent the bill from advancing at today's markup. The committee has worked to ensure funding for teaching health centers does not lapse, and it does not lapse this year. Earlier this year, we provided $1 billion to this program over the next 4 years.— in a paid-for bipartisan agreement. The $120 million in this new spending is not offset by the savings of the bill.

The bill has not received technical feedback to ensure it meets its intended goals of creating residency programs in states that do not currently have them. This is not a good faith amendment. I am committed to working towards a positive outcome in public health extender funding as part of our July markup and ensuring that they do not expire at the end of the year. I urge colleagues who care about process in the United States Senate and going back to regular order to oppose this poison pill effort, and I make a motion to table the amendment. I shall be voting to table.

Clerk should call the roll. Senator Paul. He is to table by proxy. Senator Collins? Aye.

Senator Murkowski? Aye. Senator Marshall? Aye. Senator Scott?

Aye. Senator Hawley? Aye. Senator Tupperville? Aye by proxy.

Senator Banks? Aye by proxy. Senator Houston? Aye. Senator Moody?

Aye. Senator Armstrong? Aye by proxy. Senator Sanders? Nope.

Senator Murray? No, but proxy. Senator Baldwin? Aye. Senator Murphy?

Senator Kaine? No, by proxy. Senator Hassan? No. Senator Hickenlooper?

No, by proxy. Senator Markey? No, by proxy. Senator Kim? No.

Senator Blunt-Rochester? No. Senator Ulster-Brooks? Yes. Chairman Cassidy?

Cassidy votes yes to table. I have 12 ayes, 11 nays. The amendment is tabled. Does anyone have another amendment they wish to call up? I do, Mr. Chairman.

Sanders Amendment Number 4. Mr. Chairman, we are facing a shortage of more than 187,000 doctors over the next 12 years, including a shortage of tens of thousands of primary care physicians. The National Health Service Corps provides scholarships and loan repayment to primary care providers who commit to practicing in an underserved area, but the program is woefully underfunded. Today, National Health Service Corps scholarship funds are sufficient to fund just 10%— 10%— of the applications received for new awards. According to the latest available data, 43% of eligible medical providers who applied for this program did not receive funding.

While Congress provided a 13% increase in funding for this program, that increase is nowhere near what is required to fully fund the program. The Association of Clinicians for the Underserved estimates that the National Health Service Corps needs at least $950 million annually to provide scholarships and loan repayment programs to all eligible clinicians. Bottom line is, everybody here knows we have a major crisis in terms of the shortage of doctors. It is getting worse. It is worse in primary care.

It is worse in rural and underserved areas. Let's support this amendment. This amendment is unrelated to the underlying bill on generic drugs. Adopting it prevents this bill, this bipartisan bill, from advancing at today's markup. This committee has worked to ensure that funding for the National Health Service Corps does not lapse, and it will not lapse this year.

Earlier this year, we increased funding for this program in a paid-for bipartisan agreement. The sum $415 million in new spending is not offset by the savings of the bill, nor does the bill have technical assistance to explain how the additional funding would be allocated. This is a political messaging amendment which is not in good faith. I am committed to working towards a positive outcome in the public health extender funding as part of our July markup and making sure they don't expire at the end of the year. Thank you.

I urge colleagues to oppose this poison pill effort. I pose them to stand up for regular order in the Congress, and I make a motion to table the amendment. The clerk shall call the roll. I shall be voting yes to table. Senator Paul.

Senator Paul is yes by proxy. Senator Collins. Aye. Senator Murkowski. Aye.

Senator Marshall. Aye. Senator Scott. Aye. Senator Hawley.

Aye by proxy. Senator Tupperville? Aye, by proxy. Senator Banks? Aye, by proxy.

Senator Husted? Aye. Senator Moody? Aye, by proxy for Armstrong. Okay, so Armstrong proxy.

All right. Senator Sanders? Nope. Senator Murray? No, by proxy.

Senator Baldwin? Yeah. Senator Murphy? Senator Kaine? No, by proxy.

Senator Hassan? No. Senator Hickenlooper? No by proxy. Senator Markey.

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

Senator Ulster Brooks. No. Chairman Cassidy. Aye. Aye.

Aye to table. 12 Ayes, 11 nays. The motion is— the amendment is tabled. Does anyone have another amendment? Yes, Mr. Chairman.

I call up Sanders number 5. Mr. Chairman, it is no secret to anybody on this committee that we face a massive shortage of nearly 400,000 nurses over the next 2 years. Last year, over 90,000 applications for nursing schools were rejected, not because these applicants were unqualified, but because there is a shortage of nurse faculty in America and insufficient capacity. Just tell you one story. During COVID in the largest hospital in Vermont, The hospital spent $25 million on traveling nurses because we did not have enough local nurses.

And I think the story is true in every state in this country. We need to get young people into nursing school. We need nurse educators to do that. Problem right now is nurse educators receive substantially lower salaries than they would— they have graduate degrees— than they do as supervisors in hospitals. So we need more nurse educators so that we can have more nurses graduating nursing school so we can address the nursing crisis.

This is an important amendment. I hope that members will support it. Does anybody wish to have comments? Senator Murkowski. Thank you, Mr. Chairman.

And what Senator Sanders has said in terms of the need is absolutely True, it's undisputed. I think we recognize we have a nursing shortage in this country and the nurse faculty is important. This is something that Senator Durbin and I have been working on for a period of time. In fact, this amendment is our bill. But it comes as a surprise certainly to this senator that it would be included and incorporated as part of this markup.

We've been working with you and your teams to try to get this to the place so that we can get it through this committee. It's my understanding that we are looking to this July markup to do just that. And so I would hope that—. Mm-hmm. —The progress that we're able to make between now and then will be represented, that Senator Sanders would be cooperative in working with us to get this to a place where Again, we can put into law a measure, a bipartisan measure that's going to address the shortage, but to include it at this point in time on this measure, I think, risks that progress that we have made.

So you haven't moved to table, Mr. Chairman, but if you do so, I would be supporting that tabling motion at this time. Anyone else wish to speak? Okay, I will say the amendment is not germane to the bill at hand related to generic drugs. Faculty recruitment, as a guy that used to be on faculty for med school, is a complex challenge that schools have to navigate in a sustainable way to ensure the long-term health of their institution. And we have been discussing the nuances of this policy through good faith bipartisan negotiation to evaluate the idea on its merits and get questions answered.

But when the sponsor of the legislation doesn't know it was coming up today and acknowledges that this ongoing negotiation is ongoing, and Senator Sanders has chosen to take that legislation, to amend it, and bring again another senator's legislation, I only have the ability to assess it on our incomplete information as of right now. Thank you. I am committed to addressing workforce programs, particularly nursing workforce programs, as part of our work, as a part of our markup in July. There is a regular order process that we go to and that anyone on either side of the dais that cares about returning to regular order should be committed to. So I thank Senator Collins and Murkowski for— they've both shown leadership in this space.

Senator Durbin, who's not on the committee, But we still have more work to do. I urge colleagues to oppose this poison pill effort. I make a motion to table the amendment. I shall be voting to table. The clerk shall call the roll.

Senator Paul. He is to table by— yes, to table by proxy. Senator Collins. Aye. Senator Murkowski.

Senator Marshall. Senator Scott. Aye by proxy. Senator Hawley. Aye by proxy.

Senator Tuberville? I buy— Proxy! Senator Banks? By proxy! Houston?

Moody? Armstrong? Aye by proxy. Sanders? Nope.

Murray overproxy. Baldwin? Murphy? Kane now by proxy. Hassan Hickenlooper no but proxies there marking nobody's proxied.

Senator Kim? No. Senator Blunt Rochester? No by proxy. Senator Ulster Brooks?

No. Chairman Cassidy? Aye to table. Senator Kaine, would you like to be noted present? I'm not completely present yet.

Okay. We have 12 ayes, 11 nays. They call that presentism. Okay. Does anyone have another amendment they wish to call up?

I do, Mr. Chairman. Senator Sanders. Um, everybody here knows that we— Amendment Sanders, Amendment Number 7. Uh, everybody knows that we pay by far the highest prices in the world for prescription drugs. One of the reasons, one of the reasons is that TV, uh, is that drug companies spend billions of dollars on TV commercials pushing their outrageously expensive drugs.

Turns out that— and I don't know that everybody here knows this— that with the exception of New Zealand, the United States is the only country in the world where it is legal, where it is legal for pharmaceutical companies to advertise their drugs on television. Every other country thinks it's a good idea for doctors to make that decision, not ads on television. In my view, it is time for us to end that international embarrassment, and that is what this amendment would do. And by the way, this is not just my view. I think members of the committee will recall that HHS Secretary Kennedy has said that he believes that we should ban pharmaceutical ads on television.

The AMA endorsed the ban on prescription drugs more than a decade ago. Uh, and, uh, I think this is a an intelligent way to go forward, to give doctors control over their patients' needs, and end the absurdity of us being one of two nations in the world to allow this travesty. I would urge a yes vote. I shall have comments, but does anyone else have a comment? I will note that the Supreme Court has ruled that drug companies have a First Amendment constitutional right to advertise.

We may not like it, but if you consider supporting the Constitution an important issue, which I certainly do, This is manifestly going to be losing court. I absolutely agree more transparency is needed as to how drug manufacturers market products to consumers, but this is a bad faith effort to do so. Tying a prohibition on advertising to drug approval politicizes FDA's role in reviewing new products. Other senators have policies to address this issue in more thoughtful ways rather than a de facto ban raising constitutional concerns. I urge colleagues to oppose this poison pill effort.

I make a motion to table the amendment. I shall be voting aye to table.

The clerk shall call the roll. Senator Paul. Aye by proxy. Senator Collins. Aye.

Senator Murkowski. Aye. Senator Marshall. Aye. Senator Scott.

Aye by proxy. Senator Hawley. Not voting. Senator Tupperville. Aye-by-proxy.

Senator Banks? I—by proxy! Senate Houston: Ahh... Senator Moody; Armstrong? Aye-by-proxy.

Senator Sanders? Nope. Murray? Nope-by-proxy. Baldwin?

Yeah. Murphy? Yes. Kaine? Senator Hassan.

No. Senator Hickenlooper. No, by proxy. Senator Markey. No, by proxy.

Senator Kim. No. Senator Blunt-Rochester. No. Senator Ulster Brooks.

Yes. Chairman Cassidy. Aye to table. I have 11 ayes, 11 nays. The motion fails.

We shall now vote on adopting the amendment. I shall be voting no. Clerk shall call roll.

Senator Paul? No, by proxy. Senator Collins? Sen— Murkowski? Senator Marshall?

Senator Scott? No, by proxy. Senator Hawley? Not voting. Senator Tupperville?

No, by proxy. Senator Banks? No, by proxy.

Senator Houston? Yeah! Senator Moody?

Senator Armstrong? No, by proxy. Senator Sanders? Yes. Senator Murray?

Yes, by proxy. Senator Baldwin? Aye. Senator Murphy? Aye.

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

Aye, by proxy. Senator Markey? Aye, by proxy. Senator Kim? Aye.

Senator Blunt-Rochester? Senator Ulster Brooks. Chairman Cassidy. I am. I vote against the amendment.

I'm a no. Senator Scott, would you like to be recognized as president? No, no. About to say, leave the room, man. I have 11 ayes, 11 nays.

The vote is tied. The amendment fails. Does anyone else have another amendment to pull up? Yeah, as a matter of fact, I do.

Well, you know, I always enjoy this discussion about process, doing it by the book. Meanwhile, what the American people understand, we've been doing process and doing it by the book, the healthcare system is collapsing. People are dying because they can't afford the healthcare they desperately need, despite the fact we're spending twice as much per capita on healthcare as the people of other nations. So maybe we just stand up, do the right thing, have the guts to take on the big money interests, who make large campaign contributions. Now, everybody knows that we pay by far, and even close, the highest prices in the world for prescription drugs.

Even President Trump understands that. And as a result of that reality, insanely, insanely—. Senator Santillo, what amendment are you bringing up? Number 8. Okay, thank you.

And as a result of the high cost of prescription drugs, I mean, this is really insane. 1 Out of 4 Americans goes to the pharmacist, can't afford the medicine their doctors prescribe. So what happens when you don't get the medicine your doctor prescribes? You get sicker. And maybe you end up in the emergency room.

Maybe you end up in the hospital. And the healthcare system spends a fortune, which could have been saved if you had the bloody money to get the prescription drug in the first place. True. Now, President Trump, to his credit, actually talks about this issue. How much he actually does is another story.

But during his State of the Union address, President Trump asked us to codify a most favored nation drug policy to ensure that the American people pay no more for prescription drugs than people in other countries. Senator, I've been working on for a number of years. Not a radical idea. Guys, maybe we should not be paying 10 times more than Europeans, Canadians, Japanese people, et cetera, et cetera. All it says is, let us in this country not pay more than people in other countries.

Trump believes that's to be the correct approach. I believe that's to be the correct approach. That is what this amendment does. If this amendment is signed into law, The price of Skyrizi, a drug used to treat Crohn's disease, would be reduced from $153,000 a year to just $21,000. And the price of the cancer drug Kipchuda would drop from $210,000 a year to just, just $88,000 a year.

All right? People in countries all over the world, for a variety of reasons, paying a lot less than we do. Let's make sure we don't continue that. Thank you. I would ask for a yes vote for this common-sense amendment.

I will have comments. Does anyone else have a comment? Senator Collins. Thank you, Mr. Chairman. I want to make an important distinction here.

I voted for Senator Sanders' amendment to add most favored nation instructions to the reconciliation bill. No. But that is not what this is. Those instructions on the floor were very general. This amendment is very specific and raises important questions that demonstrate why it needs much more thought.

For example, I know that the royalty mechanism in the amendment uses foreign reference pricing to set the price for drugs here, but does not correct for the dangers of discriminatory metrics known as QALYs, or Quality Adjusted Life Years. The problem with QALYs is that they discount the value of life because a patient is older or ill or has a disability. I cannot support that, and I am surprised that the senator from Vermont thinks— Senator Sanders. That that is appropriate. The Affordable Care Act rightfully prohibited the use of QALYs in the Medicare program.

That certainly should be done here too. This is just a perfect example of why something this complicated should go through the committee process. This is an extremely flawed approach. Thank you. I will be voting to table the amendment.

Mr. Chairman. Senator Sanders. The senator from Maine knows this is not the end of the process. And if she has or anybody else has objections, wants to improve the bill, which is often the case, not an unusual circumstance, that can be done. But the American people, frankly, are sick and tired hearing year after year all of the reasons why we can't take on The pharmaceutical industry—.

The senator's already spoken. Thank you.

Just a note. This is a complicated bill, by the way, different from President Trump's bill that has no technical assistance. I mean, we just can't be incontinent saying we got to do something, boom. You got to think about it. In medicine, we have a saying, don't just do something, think.

If there's something that is required to be done on drug costs, we should actually think about it, not go afoul of, uh, what Senator Collins just pointed out. I am so committed to working with— and I have a track record of working on a bipartisan basis and with the White House to lower the cost of prescription drugs. This is not the correct path. Again, doesn't have technical assistance. We don't know if it works.

The amendment represents a significant expansion of federal authority over domestic supply chains, undermining existing market-based reforms designed to reduce costs and increase competition. I urge colleagues to oppose this poison pill effort. Let's be serious about lowering costs. Let's just don't be demonstrative. I will move to table the amendment.

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

Aye. Senator Murkowski? Senator Marshall? Senator Scott? Senator Hawley?

Yes, by proxy. I'm sorry, not voting, not voting. All right. Senator Tuberville? Yes, by proxy.

Senator Banks? Yes, by proxy. Senator Husted? Yeah. Senator Moody?

Senator Armstrong? Aye. Senator Sanders? No— nope! Senator Murray?

No proxy. Senator Baldwin? Sen Murphy? Okay.

Senator Hassan?

Senate Hickenlooper? Nope, but proxy. Senator Markey? No proxy. So Kim?

Blunt Rochester? Yes. 1, 2, 3, 4, 5, 6, 7, 8. Senator Allser-Brooks? No.

Yeah, Allser-Brooks. Senator— yes. Okay, I have 11. Senator— Chairman Cassidy? No, I'm—.

Oh, no, sorry, okay. Cassidy is a yes to table. I have 11 ayes, 11 nays. The motion to table fails. We shall now move to vote on adopting the amendment.

The chair shall be voting no. No! Senator Paul? No—by proxy. Senator Collins?

No! Senator Murkowski? Yes! Senator Marshall? Yes!

Senator Scott? Senor Hawley?! Not voting... Senator Tupperville? No—by proxy.

Senator Banks? No—by proxy. Senator Houston? Yeah. Senator Moody?

Nah. Senator Armstrong? No! Senator Sanders? Yes!

Senator Murray? Just b-proxyed. Senator Baldwin? Yes. Senator Murphy?

Yes. Senator Kaine? Aye. Senator Hassan? Aye.

Senator Hickenlooper? Aye by proxy. Senator Markey? Aye by proxy. Senator Kim?

Aye. Senator Blunt-Rochester? Aye. Senator Ulster Brooks? Chairman Cassidy?

No on adoption of the amendment. I have 11 ayes, 11 nays. The vote is tied; the motion fails. Does anyone else have an amendment they would like to draw up? I do, Mr. Chairman, and you'll be happy to note, I'm sure, that this is the last amendment.

Unless you would like me— no, maybe we could do some more. Roger, what do you think? All right, Sanders Amendment Number 9. Mr. Chairman, President Trump's so-called big, beautiful bill, in my view, the worst piece of legislation in modern history, made the largest cut to education in our nation's history in order to pay for the largest tax breaks for billionaires in American history. If Congress allows these changes to take effect, 7 million Americans will be thrown off of their low-cost student loan repayment plan known as the SAVE plan and into a much more expensive plan.

This means the average college graduate will be forced to pay 4 $4,000 more each year on their student loan payment. $4,000 A year. That's an astronomical amount of money. It has been estimated that if these cuts go into effect, 1 out of every 4 student loan borrowers will be in default by the end of this summer. This is a crisis situation.

Further, in just 2 weeks, working-class students will be priced out of graduate training in programs like nursing, medicine, dentistry, and social work because of new restrictive, arbitrary loan limits. At a time when we have a shortage of nurses, doctors, and dentists in this country, 21% of nursing students, more than half of medical students, and three-quarters of dental students will be priced out of a degree. We cannot and must not allow that to happen. This amendment will repeal these harmful cuts to federal student loans and fully restore access to financial aid. I urge my colleagues to vote yes on this amendment.

I shall have comments, but does anyone else? The amendment is unrelated to the bill being considered. It puts back into place Biden's student loan schemes, which cost taxpayers $284 billion and allow students to once more incur excessive amounts of debt. In the Working Families Tax Cuts Act, Congress placed common sense limits on federal student loans for post-baccalaureate degrees to help drive down the cost of college and added accountability metrics to prevent steering of students into low-value, high-tuition programs. By the way, college tuition has increased much faster than any other household expense in the last 40 years.

Something was wrong. What was wrong? In 2023, the National Bureau of Economic Research found that uncapped federal borrowing for graduate programs did not— Uh-huh. Improve access or degree attainment. Colleges merely raise tuition, capturing more student loans, trapping kids into debt.

Thanks to loan limits Senate Republicans enacted, college costs are now going down. UC Irvine recently announced they'll be cutting tuition for their MBA program by 38% in the upcoming fall semester. Other colleges are starting to ask—. To offer steep discounts. This amendment would allow students to once more load up with excessive amounts of student loan debt.

I ask colleagues to oppose the poison pill effort, and I make a motion to table the amendment. I shall be voting to table. The clerk shall call the roll. Senator Paul. He is yes to table by proxy.

Senator Collins. Senator Murkowski. Aye. Senator Marshall. Senator Scott.

Senator Hawley. Aye by proxy. Senator Tupperville? Aye, by proxy. Senator Banks?

Aye. Senator Husted? Aye. Senator Moody? Aye.

Senator Armstrong? No. Senator Sanders? Nope. Senator Murray?

No, by proxy. Senator Baldwin? No. Senator Murphy? Yes.

Senator McCain? Yeah. Senator Hassan? Yes. Senator Hickenlooper?

No, by proxy. Senator Markey? No, by proxy. Senator Kim. No by proxy.

Senator Blunt-Rochester. Senator Ulster Brooks. Chairman Cassidy. Cassidy is yes to table. I have 12 ayes, 11 nays.

The motion passes. The amendment is tabled. I think the— I think that is the last of the amendments. I'm looking around. Okay.

We shall now go to the consideration of S.3799, the Healthy Start Reauthorization Act. I thank Senators Marshall, Gillibrand, and Baldwin for work in this legislation to reauthorize the Healthy Start program, improving maternal and infant health outcomes before, during, and after pregnancy. This bipartisan legislation, an example of the important work we can achieve when we work across the aisle, I encourage my colleagues to support it. Before we offer any amendments, do any members wish to speak on the bill? [FOREIGN LANGUAGE] You okay?

Do any amendments— do any members wish to offer amendments? Mr. Chairman. Senator Marshall.

I call up Marshall number 1 on Senate 3799.

Marshall 1. Yeah, Mr. Chairman, I want to emphasize what a great success story this Healthy Start program is that targets communities with high infant mortality rates. It improves health outcomes before, during, and after pregnancy. This amendment aligns the funding amount with what was appropriated in the fiscal year '26 appropriations bills. It also shifts the start date to next year since the program has been funded for this year already.

Thank you. Senator, by the way, this is why it's nice to have an OB-GYN on the committee. Thank you, Dr. Marshall. Anyone else? We shall now vote on the amendment.

The chair shall be voting yes. The clerk shall call the roll. Senator Paul. I'm sorry? Click the record button.

Oh, can we do a voice vote? All in favor say aye. Aye. All opposed say nay. The ayes have it.

The amendment is adopted. Thank you.

Okay. Next is S.4109, Stem Cell Therapeutic and Research Reauthorization Act. I'm thankful for the work of Senators Reid, Scott, Lankford, and Smith on this legislation to extend the C.W. Bill Young Cell Transplantation Program and improve access to stem cell therapy and bone marrow transplantation. This legislation facilitates further research and life-saving advancement in the field While technology and innovation continue to improve, I urge colleagues to support this bill.

We have a manager's amendment to S.4109. 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 those in favor, please say aye. Aye. Opposed, say nay.

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

Senator Scott. Let me just thank you, Mr. Chairman, for your leadership on this really important legislation and the colleagues on this committee, as well as Senator Reid. I think this is incredibly important. Frankly, you think about the impact that bone marrow and cord blood transplants are having around the country is positive and powerful. We're looking at the 150,000th transplant, which means that more patients have more time with their families than ever before because of the legislation, the work that we are doing on this committee around the Congress, but it's under your leadership.

I wanted to say thank you very much for the way that you've led in a bipartisan fashion, keeping healthcare as a primary issue, not Republicans, not Democrats, not red, not blue, not rich, not poor, but frankly serving the people of this country and providing greater access to life-saving opportunities and life-extending opportunities. This will help folks with lymphoma, other blood cancers, and specifically sickle cell anemia as well. Thank you. And Senator, and Senator Scott, I want to acknowledge your leadership on the issue and your sensitivity to the issue that makes everyone else even more sensitive. So thank you very much.

Thank you, sir. Anyone else? We'll now begin with consideration of moving on to the S.2339, the Early Act Reauthorization of 2025. I thank Senators Klobuchar and Crapo for their work on this legislation. This bill helps ensure young women have access to information about breast cancer risk factors and early detection..

I urge all colleagues to support the bill. We have a manager's amendment to S. 2339. 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 in favor, please say aye. Aye.

Opposed, say nay. The ayes have it. The motion is agreed to. Do any members wish to speak on the bill?

Okay, let's move on to S4472, Accelerating Access to Critical Therapies for ALS. Second? We must, I thank Senators Murkowski and Coons for their work on this legislation, which supports the development of cures for rare neurodegenerative diseases. This bill continues programs supporting access to investigational therapies for ALS and rare neurodegenerative diseases. I urge all colleagues to support.

We have a manager's amendment to S4472. 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. Motion is agreed to. Do any members wish to speak on the bill? Mr. Chairman. Senator Murkowski.

Mr. Chairman, thank you for working with us to get this to this place. As you have noted, this is significant in terms of research into the therapies for ALS. In 2021, we passed the Accelerating Access to Critical Therapies for ALS Act. This provides a pathway for people who are not ineligible for clinical trials to receive investigational treatments, and it provides funding to NIH and FDA to accelerate the research and data sharing to speed to speed therapy development. But basically what we're talking about here is a process that allows individuals the right to try.

As we know, an ALS diagnosis is effectively terminal. I mean, there is, there is just a tragic course. And so any opportunity, any ray of hope that can be found out there is what those who are are living with ALS are hoping for. So the bill that we have is a reauthorization of this program. You noted the work that Senator Coons and I have been doing on this reauthorization, but I tell you, we have been working with some extraordinary advocates over the years, people like Dan Tate, Brian Wallach, Sandra Abrevia, Jenny Dwyer, advocates who have also just recently passed away like like Eric Dane.

Many of us have personal connections in this space, and in that vein, Mr. Chairman, I would like to introduce into the record a statement from Senator Coons highlighting the success of the program, acknowledging the work of so many of the advocates and those who have helped us get to this point. Without objection. This is a program that works and needs to keep working as we move towards possible treatments and hopefully hopefully one day a cure. So we've made a few improvements here, but we really want to get this passed and signed into law. And I thank you and all those on the committee for the support.

Anyone else? We'll now move on to S.1954, the Biosimilar Red Tape Elimination Act. I thank the sponsors, Senators Lee and Lujan, as well as Senators Paul and Hassan for their work on this legislation. Legislation to improve access to affordable biosimilar medications. We first began considering this in 2024.

I highlighted this bill at a hearing in April. I'm glad to see the progress. Enabling biosimilars to be interchanged with brand-name products is common sense that both the Biden and Trump administrations took steps to advance. Under this bill, FDA will continue to ensure that there are no clinically meaningful differences between biosimilars and brand-name products so that patients protected. I've received 2 letters of support that I ask unanimous consent to enter into the record.

That is granted. We have a manager's amendment to S. 1954. I move to adopt the manager's amendment in the nature of a substitute and have it considered original text for the purpose of future amendments. All in favor, please say aye. Aye.

Opposed, say nay. The ayes have it. The motion's agreed to. Do any members wish to speak on the bill?

Seeing none, we shall move on to the Medication Affordability and Patient Integrity Act, which is S. 2658. I thank Senators Haston and Senator Hawley for their work on this legislation. Patents are critical to innovation and driving investments in new therapies for patients, but they are and should be time-limited, and abuses can unfairly extend brand monopolies and keep drug prices higher than they should be. This legislation aims to make sure that drug manufacturers give both FDA and the Patent Office the same information. That said, there are provisions in this bill dealing with patent litigation that fall in Judiciary Committee's jurisdiction.

We did not make changes to those parts of the bill. I defer to the Judiciary Committee on patent changes that fall within their jurisdiction and expertise. Second.

I will vote yes on this bill with the expectation that we will need to work with the Judiciary Committee to move this bill forward. We have a manager's amendment to 2658. 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. The motion's agreed to. Before offering amendments, do any members wish to speak on the bill? Mr.

Chair. Senator Hassan. Well, first of all, I want to thank the chair and ranking member for supporting this bill that Senator Hawley and I have, which will help lower drug costs for patients. For too long, Big Pharma has abused the patent process and blocked generic competition from entering the market, which has meant higher prices at the pharmacy counter for families. One of the ways in which Big Pharma boxes out generic medication— is by filing endless patents to block any competition, including by filing brand-new patents for original features of their drug that they disclosed to the FDA years beforehand but withheld from the Patent Office.

Prescription drug costs are pushing families, and seniors in particular, to the brink, and it is time to end this Big Pharma loophole, which is exactly what my bipartisan bill with Senator Hawley will accomplish. I too acknowledge that we need to continue to work with Senator Cornyn and the Judiciary Committee moving forward, but this would be a very good start. I appreciate the chair and ranking member's support. Mr. Chairman. Senator Hawley.

Mr. Chairman, I just, I just want to add my voice in support of this legislation, and I want to thank Senator Hassan for her leadership on this. Prescription drugs are just too expensive. I mean, that's the bottom line. They are way too expensive for every family and every individual in this country, and one of the reasons they're are too expensive is that the big pharma companies game the system.

They tell the FDA one thing, and then they tell the Patent Office something else, and they keep that disparity to themselves until it comes time for a piece of another competition, a competitor, somebody who wants to get into the market to try to enter, and then lo and behold, big pharma discovers, "Oh, oh, actually, actually, we've got some more information. We have that patent. Actually, no, you can't file that. Actually, no, we can't allow a generic to get into the market." And what's the net effect? Effect of that, that there's less competition.

Prices remain high. It's a blatant attempt to game the system. Our patent system is a great system. They're gaming it. And because they're gaming it, they're keeping prices high for Americans all across this country.

This is a simple bill that would put a stop to that chicanery. We should have done it a long time ago. I look forward to doing it today. Thank you, Mr. Chairman. Anyone else?

Do any members wish to offer an amendment? Mr. Chairman, I call Amendment Number 1. Sorry, Senator Banks. Thank you, Mr. Chairman. I appreciate the intent of the legislation by the bill's authors.

What I, what I don't favor, though, is doing anything that would help the Chinese Communist Party cheat and steal our IP. And that's what my amendment would would go at lengths to stop. My amendment would ensure that the same protections for trade secrets at the FDA would also apply at the Patent and Trademark Office. We know Chinese biotech companies have been sifting through US patent applications for a long time, looking to steal intellectual property so they can copy our drugs. Now they are using AI to analyze our patent applications on a massive scale to develop their own drugs.

I understand the bill's sponsor's intent to eliminate patent thickets, but we need to make sure that the bill doesn't inadvertently expose U.S. drug companies' trade secrets and intellectual property to competitors. My amendment would first maintain all confidentiality and trade secret laws that already apply to the FDA. Then it would also create procedures for the Patent and Trademark Office to notify patent applicants before their information is publicly disclosed. And then third, it would allow patent applicants 30 days to object to disclosures and redact trade secrets or confidential information. I urge my colleagues to support my amendment to preserve the intent of the bill and avoid giving China our biotech industry's most precious trade secrets.

I yield back.

I appreciate, Senator Banks, your concern about the Chinese Communist Party. It is a concern I share, but the Patent Office already has procedures for the handling of trade secret propriety and other proprietary and other protected materials. Even so, as part of our bipartisan agreement, the underlying bill expands upon existing trade secret protections and directs the Patent Office to update its regulations to ensure that sensitive information is protected when appropriate. Instead of simply protecting trade secrets though, this amendment from Senator Banks would go much further and undermine the core obligation of the Patent Office to publish basic information about each patent that it issues. So I urge my colleagues to oppose this amendment.

Mr. Chairman. Senator Hawley. I just want to add one thing to that. Senator Hassan is exactly correct. This bill actually expands the protection for trade secrets at the Patent Office.

And I just want to note that that's what the pharma companies asked for last time we introduced this bill. Last time we introduced this bill, they were opposed to it. Of course, they're always opposed to it, but they said, well, We'd think differently about it if you'd just put some more protections around the Patent Office disclosures. So that's what we did. And now they came back and said, actually, we don't like those.

We want something else. And next year it'll be something else, and then it'll be something else. So long as they keep reaping billions of dollars in profits and nobody can afford their prescription drugs, we got to put an end to this. I urge a no vote. Thank you, Mr. Chairman.

Anyone else? I thank Senator Banker. I thank Senator Banks for offering this amendment. It is essential we safeguard confidential and proprietary information from unnecessary disclosures while ensuring that bad actors don't misuse these protections for their own advantage. I support this amendment.

If not adopted, I will support the final passage of the bill. The clerk shall call the roll. Senator Paul. He is not voting. Senator Collins.

Yes. Senator Murkowski. She is—.

Not voting. Senator Marshall? He's yes-by-proxy. Senator Scott—. He is yes-by-proxy.

Senator Hawley, Senator Tupperville— Yes, by proxy. Senator Banks— Aye! Senator Houston— Aye! Senator Moody— Aye! Senator Armstrong— Aye!

Senator Sanders— Nope. Senator Murray— No vote. No proxy? Senator Baldwin? Yeah!

Murphy— Sorry, Kane— Senate Hassan— Hickenlooper— Markie— no by proxy— Sen Kim— Blunt Rochester— Alstebrooks— Chairman Cassidy have 8 ayes; 12 nays. Oh, Collins is a "no." Okay. So I have 8 ayes, 13 nays. The amendment is not adopted. Are there any other amendments?

Mr. Chairman. Senator Hustead. I would like to call up Hustead Amendment Number 1 to S.2658. This is an issue that was brought to my attention by constituents in Ohio. Ohio has some of the best children's hospitals and academic research institutions in the world in the bio, gene, and cell therapies.

And the concern that was expressed to me that this amendment would fix is the bill lets patent infringers escape liability just because a company's FDA and PTO filings don't perfectly match. Excuse me. But those agencies do different jobs. They review different information, so of course those differences are normal. A mismatch isn't proof of wrongdoing.

It's merely just how the process works. Houston Amendment 1 makes one fix. The inconsistency has to have an actual material effect before it can avoid a patent. This will help achieve the bill's goal of driving down costs rather than driving them up, and I urge a yes vote. Does anyone wish to speak on this amendment?

Senator Hassan. Thank you, Mr. Chair. Yet again, this is another example of Big Pharma picking away at a bill no matter how hard we try to end a deceptive practice that they've been engaged in, in years. This amendment would make it possible for Big Pharma to endlessly block generic medications from reaching patients.

The effect of the Houston Amendment would be to effectively remove the defense for generic companies that is provided in the bill, allowing Big Pharma to continue playing unfair patent games in order to block low-cost medications from the market. I think all of us have hospitals and scientists in our states who want to make sure that they are being accurate with their submissions to the FDA and the Patent Office. But it is critical that we pass the underlying bill without this amendment in order to help lower drug prices for patients, because of course, if patients can't afford the things our brilliant scientists are developing, it makes the work—. Does anyone else wish to—. —Difficult.

I'm sorry. Yeah, and I urge my colleagues to vote against this. Mr. Chairman, if I could just briefly—. I want to apologize to Senator Hassan for— No, that's fine. We're good.

Senator Hawley. Just to piggyback on that, I just want to be clear because sometimes it's opaque when we're dealing with an area of law that's as complicated as this one, but this is the enforcement mechanism of this bill. The way that this bill works is if a generic company enters the market and they see that the pharma company has withheld information, then if Pharma Suzuma says, no, no, no, you can't offer your generic, they have a defense in court. If this amendment were to pass, it would gut that defense. There wouldn't be any way to enforce the bill.

It would become just a resolution. And this is what we're trying to do, is get more competition. I'm a free market guy. I love competition. We need more of it in the pharma space.

We need to get these prescription drug prices down. I appreciate John's concern, Senator Hustead's concern, and happy to think about ways that we can work with you going forward. But I just want to point point out that if we were to adopt this, the entire enforcement mechanism of this bill would just fall away. So I urge a no vote. Thank you, Mr. Chairman.

Does anyone else wish to speak? I thank Senator Husted for offering this amendment. It's important we balance transparency and disclosure to prevent gamesmanship while ensuring the confidentiality of important information remains protected. This makes changes to policy in the bill that are within the Judiciary Committee's jurisdiction. I commit to working with Senators Husted and Judiciary Committee to address these concerns.

But I will support this amendment. If not adopted, I will still support final passage of the bill. The clerk should call the roll. Senator Paul. Senator Paul is not voting.

Senator Collins. No. Senator Murkowski. Not voting. Senator Marshall.

He is yes by proxy. Senator Scott. Yes by proxy. Senator Hawley. Senator Tupperville.

Yes by proxy. Senator Banks. Yes, but— oops! Aye. Okay.

Senator Heastad? Aye. Senator Moody? Aye. Senator Armstrong?

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

Senator Baldwin? Yes. Senator Murphy? No. Senator Kaine?

Senator Hassan? No. Senator Hickenlooper? Senator Markey? No, by proxy.

Senator Kim? Senator Blunt-Rochester? Senator Alcerbrooks. Senator Chairman Cassidy. Senator Cassidy is an aye on the amendment.

I have 8 ayes, 13 nays. What's that again? 8 Ayes, 13 nays. So the amendment fails. Does anyone else have an amendment?

Mr. Chairman. Mr. Husted. Dr. Husted. Senator Husted. That's a promotion there from a health care point of view.

So thank you, Mr. Chairman. I ask I'd like to call up Hustad Amendment No. 2 To S. 2658. So as we proceed with this, knowing that it has strong tools of enforcement in this bill, nothing in the current bill prohibits entities tied to a foreign adversary from using the defense to undermine American innovators. The Hustad Amendment No.

2 Makes sure that no person with ties to an adversary of the United United States can utilize this defense against them to infringement. Without this limitation, the bill opens up a door to subsidize China and other hostile foreign nations on the backs of the American innovator. I'm very concerned about this, using this legislation by our foreign adversaries as a tool against our innovators and the new therapies in biogene and cell therapy that can come from the research going on here in America. America, Thank you. And I urge a yes vote.

Mr. Chair, anyone else wish to speak? Senator Hassan. I want to thank Senator Husted for this amendment. I appreciate the intention of it.

We are still examining whether there are any unintended consequences to this bill and how it would actually operate. But I would look— I do not oppose the amendment. I would look forward to continuing to work with you to make sure that we get this right. I think Senator Hawley is in the same place. Okay.

Mr. Chairman. Senator Sanders. Just like many other products, most of the generic drugs that Americans buy are produced overseas. Big Pharma would like us to think that this amendment is about Chinese companies stealing intellectual property. Is it better for American patients if a Swiss drug company sues a Chinese generics manufacturer to keep cheaper generic drugs off the shelves The answer is no.

My colleagues want to have a conversation about revitalizing American manufacturing. Let's do it. But that's not what this amendment is about. This is about big drug companies protecting their profit margins at the expense of American patients. I urge a no vote.

I'd just like to note the amendment deals with foreign adversaries, not the Swiss. Say that one more time. We deal with foreign adversaries, not the Swiss. As was suggested. This is about China.

Senator Sanders has said he's a no, but would people be open to a voice vote? Sure. Yeah. All in favor say aye. Aye.

All opposed say nay. No. The ayes appear to have it. The ayes have it. We shall proceed.

This concludes consideration of 2658. We'll now vote on final passage of today's bills. I will note that we will not vote on final passage of S.3014 today. I'm committed to working with Senator Sanders on refining the—. Collins.

Senator Collins. Senator Collins, not Sanders, on refining the Insulin Act moving forward.

We'll now move to final passage of S.1782 as amended. I move to favorably report 1782. Are people open to a voice vote? We can't do voice. What's that?

Can we on final— can't on final passage. I can't on final passage. Yeah. The clerk, can we do it? Parliamentarian.

Can we do it on block? You can do it on block. Are people open to doing final passage on block by voice vote? We can't do a voice vote. No.

Oh, by one vote, by one vote. Yes. By roll call vote. So, so we'll do en bloc of. We'll do en bloc of S1782 as amended.

S30, I'm sorry, S3799 as amended. S4109 as amended. S2339 as amended. S4472 as amended. S1954 as amended.

S2658 as amended. And that's it. The clerk should call the roll. I shall be voting aye. Senator Paul.

Is it okay on the— we have to maybe don't do the last bill because I think there were a few people against it. Oh, wait, wait. So let's exclude— I'm excluding on the recommendation of my staff S.2658, as there might be some people voting against that. Okay. So we'll be doing en bloc for everything but that.

Okay. I shall be voting aye. The clerk should call the roll. Senator Paul. He is not voting.

I'm sorry. What's not voting? Senator Collins. Aye. Senator Murkowski.

Aye by proxy. Senator Marshall. Aye by proxy. Senator Scott. Aye by proxy.

Senator Hawley.

Senator Tuberville. Aye by proxy. Senator Banks. Senator Husted. Senator Moody.

Senator Armstrong. Senator Sanders. Aye. Senator Murray. Aye by proxy.

Senator Baldwin. Aye by proxy. Senator Murphy. Senator Kaine. Senator Hassan.

Senator Hickenlooper. Senator Markey.

Senator Kim. Senator Blunt-Rochester. Senator Ulster Brooks. Chairman Cassidy. Aye.

I have 22 ayes, 0 nays. The bill passes as amended. We shall now— the bill's passed. We shall now move to final passage of S.2658 as amended. I move to favorably report S.2658 as amended.

The clerk shall call the roll. I shall be voting aye. I shall be voting aye. Senator Paul? He is not voting.

Senator Collins? Aye! Senator Murkowski? Aye by proxy. Senator Marshall?

No by proxy. Senator Scott? No by proxy. Senator Hawley? Senator Tupperville?

No by proxy. Oh, I'm sorry— yeah. No by proxy? Tupperville's no by proxy. Okay.

Senator Banks? Senator Houston? No. Senator Moody? Aye.

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

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

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

Aye. Senator Markey? Aye, by proxy. Senator Kim?

Senator Blunt-Rochester. Senator Ulzer-Brooks. Chairman Cassidy. Aye. I have 16 ayes, 6 nays.

The ayes have it. The bill passes.

It will be favorably reported. I now move to authorize staff to make any required technical and conforming changes when preparing S.1782, S.3799, S.4099, S. 2319, S. 4472, S. 1954, and S. 2658. All those in favor say aye. Aye. All opposed say nay.

The ayes have it. The motion is agreed to.

Got it? The committee stands adjourned.