[Congressional Record Volume 140, Number 116 (Wednesday, August 17, 1994)]
[Senate]
[Page S]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: August 17, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                          HEALTH SECURITY ACT

  The Senated continued with the consideration of the bill.


                           Amendment No. 2564

   (Purpose: To improve the access of individuals in rural areas to 
                          quality health care)

  Mr. DASCHLE. I have an amendment at the desk. I ask for its immediate 
consideration.
  The PRESIDING OFFICER. The clerk will report the amendment.
  The legislative clerk read as follows:

       The Senator from South Dakota [Mr. Daschle], for himself, 
     Mr. Harkin, Mr. Rockefeller, Mr. Baucus, and Mr. Reid, 
     proposes an amendment numbered 2564.

  Mr. DASCHLE. Mr. President, I ask unanimous consent that reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:
       On page 112, line 6, insert ``including residents of rural 
     areas'' before the period.
       On page 215, line 10, strike ``(c)'' and insert ``(d)''.
       On page 215, between lines 9 and 10, insert the following 
     new subsection:
       (c) Transfer of Duties.--Effective January 1, 1996, the 
     functions, powers, duties, and authority that were carried 
     out in accordance with Federal law by the Office of Rural 
     Health Policy in the Department of Health and Human Services 
     are transferred to the Office of the Assistant Secretary for 
     Rural Health in the Department of Health and Human Services.
       On page 612, line 24, insert before the period the 
     following: ``, at least one of whom resides in a rural 
     area''.
       On page 613, line 9, insert before the period the 
     following: ``, at least one of whom resides in a rural 
     area''.
       On page 647, strike lines 25 and 26, and insert the 
     following:
       ``For purposes of carrying out section 3341, there are 
     authorized to be appropriated $15,000,000 for each of the 
     fiscal years 1997 through 2001.''.
       On page 664, line 10, strike ``or health professional 
     shortage areas'' and insert ``area, health professional 
     shortage area, or other rural underserved area (as designated 
     by the Governor)''.
       On page 651, between lines 9 and 10, add the following new 
     paragraph:
       (3) Subpart f.--For the purpose of providing funds under 
     subpart F, there are authorized to be appropriated 
     $10,000,000 for each of the fiscal years 1996 through 2000.
       On page 652, line 18, strike ``and''.
       On page 652, between lines 18 and 19, insert the following 
     new paragraph:
       ``(7) rural health clinics, except that for-profit rural 
     health clinics shall only be eligible for direct loans and 
     grants under subpart C; and''.
       On page 652, line 19, strike ``(7)'' and insert ``(8)''.
       On page 653, after line 23, add the following new 
     subsection:
       (f) Purposes and Conditions.--Grants shall be made under 
     this part for the purposes and subject to all of the 
     conditions under which eligible entities otherwise receive 
     funding to provide health services to medically underserved 
     populations under the Public Health Service Act. The 
     Secretary shall prescribe comparable purposes and conditions 
     for eligible entities not receiving funding under the Public 
     Health Service Act, including conditions with respect to the 
     availability of services in the area served (as provided for 
     in section 330(e)(3)(A) of such Act), and conformance of fee 
     and payment schedules with prevailing rates (as provided for 
     in section 330(e)(3)(F) of such Act). With respect to 
     federally qualified health centers, such comparable purposes 
     and conditions shall include conditions concerning sliding 
     fee scales under section 1128B(b)(3)(D) of the Social 
     Security Act and waivers of deductibles under section 1833(d) 
     of such Act.
       On page 672, line 1, strike the subsection heading and 
     insert ``Federally qualified health centers and rural health 
     clinics''.
       On page 673, line 3, insert ``and rural health clinics'' 
     after ``Act)''.
       On page 675, between lines 16 and 17, add the following new 
     subpart:

               Subpart F--Rural-Based Managed Care Grants

     SEC. 3467. RURAL-BASED MANAGED CARE GRANTS.

       (a) In General.--The Secretary shall award grants for the 
     development and operation of rural-based managed care 
     networks that integrate the medicare population of the area 
     served.
       (b) Eligible Entities.--To be eligible to receive a grant 
     under subsection (a), an applicant organization shall--
       (1) prepare and submit to the Secretary an application, at 
     such time, in such manner and containing such information as 
     the Secretary may require;
       (2) be based or provide services in rural or rural 
     underserved areas; and
       (3) be currently operating or in the process of 
     establishing a provider network serving the nonmedicare 
     population .
       (c) Use of Funds.--Funds provided under a grant under this 
     section may be used--
       (1) for the development and implementation of rural-based 
     managed care networks;
       (2) for data and information systems, including 
     telecommunications;
       (3) for meeting solvency requirements for a risk-bearing 
     entity under the medicare program under title XVIII of the 
     Social Security Act;
       (4) for the recruitment of health care providers; or
       (5) for enabling services, including transportation and 
     translation.
       (d) Priority.--In awarding grants under subsection (a), the 
     Secretary shall give priority to--
       (1) applicants that will use amounts received under the 
     grant to develop and operate rural-based managed care 
     networks that would serve at least one rural underserved 
     area; and
       (2) applicants that involve local residents and providers 
     in the planning and development of the rural-based managed 
     network.
       (e) Definitions.--As used in this section
       (1) Rural area.--The term ``rural area'' means a rural area 
     as described in section 1886(d)(2)(D) of the Social Security 
     Act.
       (2) Underserved rural area.--The term ``underserved rural 
     area'' means a health professional shortage area under 
     section 332 of the Public Health Service Act (42 U.S.C. 254e) 
     or an area designated as underserved by the Governor of a 
     State taking into account--
       (A) financial and geographic access to health plans by 
     residents of such area; and
       (B) the availability, adequacy, and quality of qualified 
     providers and health care facilities in such area.
       (f) Study.--The Secretary shall study different risk-
     bearing approaches for rural managed care and payment 
     methodologies that differ from or modify the medicare average 
     area per capita cost payment methodology.
       Beginning on page 675, strike line 24 and all that follows 
     through line 4 on page 676, and insert the following: 
     ``priated $314,000,000 for fiscal year 1996, $285,000,000 for 
     fiscal year 1997, $365,000,000 for fiscal year 1998, 
     $382,000,000 for fiscal year 1999, $386,000,000 for fiscal 
     year 2000, $91,500,000 for fiscal year 2001, $53,350,000 for 
     fiscal year 2002, $38,100,000 for fiscal year 2003, and 
     $38,100,000 for fiscal year 2004, of which $2,000,000 shall 
     be made available in each of the fiscal years 1996 through 
     2000 to carry out section 338L of the Public Health Service 
     Act.''.
       On page 676, line 10, strike ``NURSES'' and insert 
     ``ADVANCED PRACTICE NURSES AND PHYSICIAN ASSISTANTS''.
       On page 676, line 20, strike ``nurse anesthetists'' and 
     insert ``nurse anesthetists or physician assistants''.
       On page 676, lines 21 and 22, strike ``nurse anesthetists'' 
     and insert ``nurse anesthetists or physician assistants''.
       On page 677, between lines 13 and 14, add the following new 
     parts:

       PART 4--ANTITRUST SAFE HARBORS FOR RURAL HEALTH PROVIDERS

     SEC. 3491. ANTITRUST SAFE HARBORS FOR RURAL HEALTH PROVIDERS.

       (a) In General.--The Attorney General, in consultation with 
     the Commissioner of the Federal Trade Commission, shall 
     clarify existing and future policy guidelines, with respect 
     to safe harbors, by providing additional illustrative 
     examples with respect to the conduct of activities relating 
     to the provision of health care services in rural areas.
       (b) Dissemination of Information.--The Attorney General, in 
     consultation with the Commissioner of the Federal Trade 
     Commission and the Assistant Secretary for Rural Health, 
     shall develop methods for the dissemination of the guidelines 
     established under subsection (a) to rural health care 
     providers.

                   PART 5--EMERGENCY MEDICAL SYSTEMS

     SEC. 3495. GRANTS TO STATES REGARDING AIRCRAFT FOR 
                   TRANSPORTING RURAL VICTIMS OF MEDICAL 
                   EMERGENCIES.

       Part E of title XII of the Public Health Service Act (42 
     U.S.C. 300d-51 et seq.) is amended by adding at the end 
     thereof the following new section:

     ``SEC. 1252. GRANTS FOR SYSTEMS TO TRANSPORT RURAL VICTIMS OF 
                   MEDICAL EMERGENCIES.

       ``(a) In General.--The Secretary shall make grants to 
     States to assist such States in the creation or enhancement 
     of air medical transport systems that provide victims of 
     medical emergencies in rural areas with access to treatments 
     for the injuries or other conditions resulting from such 
     emergencies.
       ``(b) Application and Plan.--
       ``(1) Application.--To be eligible to receive a grant under 
     subsection (a), a State shall prepare and submit to the 
     Secretary an application in such form, made in such manner, 
     and containing such agreements, assurances, and information, 
     including a State plan as required in paragraph (2), as the 
     Secretary determines to be necessary to carry out this 
     section.
       ``(2) State plan.--An application submitted under paragraph 
     (1) shall contain a State plan that shall--
       ``(A) describe the intended uses of the grant proceeds and 
     the geographic areas to be served;
       ``(B) demonstrate that the geographic areas to be served, 
     as described under subparagraph (A), are rural in nature;
       ``(C) demonstrate that there is a lack of facilities 
     available and equipped to deliver advanced levels of medical 
     care in the geographic areas to be served;
       ``(D) demonstrate that in utilizing the grant proceeds for 
     the establishment or enhancement of air medical services the 
     State would be making a cost-effective improvement to 
     existing ground-based or air emergency medical service 
     systems;
       ``(E) demonstrate that the State will not utilize the grant 
     proceeds to duplicate the capabilities of existing air 
     medical systems that are effectively meeting the emergency 
     medical needs of the populations they serve;
       ``(F) demonstrate that in utilizing the grant proceeds the 
     State is likely to achieve a reduction in the morbidity and 
     mortality rates of the areas to be served, as determined by 
     the Secretary;
       ``(G) demonstrate that the State, in utilizing the grant 
     proceeds, will--
       ``(i) maintain the expenditures of the State for air and 
     ground medical transport systems at a level equal to not less 
     than the level of such expenditures maintained by the State 
     for the fiscal year preceding the fiscal year for which the 
     grant is received; and
       ``(ii) ensure that recipients of direct financial 
     assistance from the State under such grant will maintain 
     expenditures of such recipients for such systems at a level 
     at least equal to the level of such expenditures maintained 
     by such recipients for the fiscal year preceding the fiscal 
     year for which the financial assistance is received;
       ``(H) demonstrate that persons experienced in the field of 
     air medical service delivery were consulted in the 
     preparation of the State plan; and
       ``(I) contain such other information as the Secretary may 
     determine appropriate.
       ``(c) Considerations in Awarding Grants.--In determining 
     whether to award a grant to a State under this section, the 
     Secretary shall--
       ``(1) consider the rural nature of the areas to be served 
     with the grant proceeds and the services to be provided with 
     such proceeds, as identified in the State plan submitted 
     under subsection (b); and
       ``(2) give preference to States with State plans that 
     demonstrate an effective integration of the proposed air 
     medical transport systems into a comprehensive network or 
     plan for regional or statewide emergency medical service 
     delivery.
       ``(d) State Administration and Use of Grant.--
       ``(1) In general.--The Secretary may not make a grant to a 
     State under subsection (a) unless the State agrees that such 
     grant will be administered by the State agency with principal 
     responsibility for carrying out programs regarding the 
     provision of medical services to victims of medical 
     emergencies or trauma.
       ``(2) Permitted uses.--A State may use amounts received 
     under a grant awarded under this section to award subgrants 
     to public and private entities operating within the State.
       ``(3) Opportunity for public comment.--The Secretary may 
     not make a grant to a State under subsection (a) unless that 
     State agrees that, in developing and carrying out the State 
     plan under subsection (b)(2), the State will provide public 
     notice with respect to the plan (including any revisions 
     thereto) and facilitate comments from interested persons.
       ``(e) Number of Grants.--The Secretary shall award grants 
     under this section to not less than 7 States.
       ``(f) Reports.--
       ``(1) Requirement.--A State that receives a grant under 
     this section shall annually (during each year in which the 
     grant proceeds are used) prepare and submit to the Secretary 
     a report that shall contain--
       ``(A) a description of the manner in which the grant 
     proceeds were utilized;
       ``(B) a description of the effectiveness of the air medical 
     transport programs assisted with grant proceeds; and
       ``(C) such other information as the Secretary may require.
       ``(2) Termination of fundings.--In reviewing reports 
     submitted under paragraph (1), if the Secretary determines 
     that a State is not using amounts provided under a grant 
     awarded under this section in accordance with the State plan 
     submitted by the State under subsection (b), the Secretary 
     may terminate the payment of amounts under such grant to the 
     State until such time as the Secretary determines that the 
     State comes into compliance with such plan.
       ``(g) Definition.--As used in this section, the term `rural 
     areas' means geographic areas that are located outside of 
     standard metropolitan statistical areas, as identified by the 
     Secretary.
       ``(h) Authorization of Appropriations.--There are 
     authorized to be appropriated to make grants under this 
     section, $15,000,000 for fiscal year 1995, and such sums as 
     may be necessary for each for fiscal years 1996 and 1997.''.
       Beginning on page 718, strike line 23 and all that follows 
     through line 5 on page 719, and insert the following new 
     paragraph:
       ``(8) with respect to the National Health Service Corps 
     program referred to in section 3471, $314,000,000 for fiscal 
     year 1996, $285,000,000 for fiscal year 1997, $365,000,000 
     for fiscal year 1998, $382,000,000 for fiscal year 1999, 
     $386,000,000 for fiscal year 2000, $91,500,000 for fiscal 
     year 2001, $53,350,000 for fiscal year 2002, $38,100,000 for 
     fiscal year 2003, and $38,100,000 for fiscal year 2004, of 
     which $2,000,000 shall be made available in each of the 
     fiscal years 1996 through 2000 to carry out section 338L of 
     the Public Health Service Act;''.
       On page 720, line 22, strike ``; and'' and insert a 
     semicolon.
       On page 720, between lines 22 and 23, insert the following 
     new paragraph:
       ``(14) with respect to the development of rural 
     telemedicine under section 3341, $15,000,000 for each of the 
     fiscal years 1997 through 2001; and''.
       On page 720, line 23, strike ``(14)'' and insert ``(15)''.
       On page 725, strike lines 7 through 11, and insert the 
     following:
       ``(6) in subsection (l), by striking paragraph (1) and 
     inserting the following new paragraph:
       `` `(1) In general.--The Secretary shall use amounts made 
     available under section 3471 of the Health Security Act to 
     carry out this section in each of the fiscal years 1996 
     through 2000.' ''.
       On page 777, line 18, strike ``and medical assistance 
     facilities''.
       On page 780, line 3, insert ``In the case of payment under 
     this subsection to medical assistance facilities, the lesser-
     of-cost-or charges provisions under subsection (j) are not 
     applicable.'' after ``services.''.
       Beginning on page 808, strike line 16 and all that follows 
     through page 809, line 4, and insert the following:
       (2) by inserting ``described in paragraph (2) and services 
     furnished by a physician assistant, nurse practitioner, or a 
     clinical nurse specialist described in such paragraph that 
     would by physicians' services if furnished by a physician'' 
     after ``physicians' services'',
       (3) by inserting ``physician assistant, nurse practitioner, 
     or a clinical nurse specialist'' after ``physician'',
       (4) by striking ``10 percent'' and inserting ``the 
     applicable percent'', and
       (5) by adding at the end the following new paragraph:
       ``(2)(A) The applicable percent referred to in paragraph 
     (1) is--
       ``(i) in the case of physicians' services that are primary 
     care services, a percent determined by the Secretary that may 
     not be less than 10 percent and may not exceed 20 percent,
       ``(ii) in the case of services furnished by a physician 
     assistant, nurse practitioner, or a clinical nurse specialist 
     described in such paragraph that would be physicians' 
     services that are primary care services if a physician 
     furnished the services, a percent to be determined by the 
     Secretary that is equal to the percent determined in clause 
     (i) and determined so that the total amount of such payments 
     under this clause and clause (i) is equal to the amount that 
     would have been paid under clause (i) if the applicable 
     percent for such clause was equal to 20 percent, and
       ``(iii) in the case of physicians' services other than 
     primary care services furnished in a health professional 
     shortage area located in a rural area (as defined in section 
     1886(d)(2)(D)), 10 percent.
       On page 873, line 20, insert ``urban and rural'' after 
     ``representative of the''.
       On page 874, line 1, insert ``, at least one of whom 
     resides in a rural area'' before the first period.
       On page 874, line 4, insert ``, at least one of whom 
     resides in a rural area'' before the first period.
       On page 1390, line 22, insert ``and that at least one 
     member of the Commission is a resident of a rural area'' 
     before the period at the end.

  Mr. DASCHLE. I have a lengthier statement that I wish to make, but I 
will yield to the Senator from Iowa because I understand his time 
constraints and would yield at this time whatever time he may consume.
  Mr. HARKIN. Mr. President, I first want to compliment my friend and 
my colleague from South Dakota for introducing this amendment. I am 
pleased to be a cosponsor of it.
  I wish to thank again Senator Daschle for all of his hard work not 
only on the whole issue of health care reform in America but for his 
paying especially close attention to the needs in rural America to be 
addressed specifically in any health care reform that we pass.
  Rural America is not like urban America, and too often we lose sight 
of the fact that what may work in New York City or Boston or other 
places like that will not necessarily work in a rural State like South 
Dakota or Iowa or many of our rural States. And so the amendment 
offered by the Senator from South Dakota builds on the provisions in 
the Mitchell bill that will expand coverage for Americans in our rural 
towns and communities.
  Mr. President, perhaps nowhere else is the health care crisis more 
acute than in rural America. Rural Americans are more often poor, more 
often uninsured, and more often without access to health care.
  Now, the Mitchell bill provides funding to build up the health care 
infrastructure in rural areas. It provides grant money and loans to 
help local communities develop health care networks and plans. There 
are many provisions in the underlying Mitchell bill and in the Daschle 
amendment that speak to the different needs in rural America. There are 
many provisions in the Daschle amendment that strengthen those 
underlying provisions.
  I wish to focus my remarks particularly on one of those provisions 
included in the Daschle amendment, and that is that part which provides 
funding for a grant program that will expand access to health services 
in rural areas through the use of telemedicine.
  Over a year ago, I introduced similar legislation and have worked 
with Senator Conrad from North Dakota to develop what is now in the 
underlying Mitchell proposal. The amendment now under consideration 
will ensure that this grant program is funded.
  The grant program in the Mitchell bill would encourage the 
development of telemedicine networks which can play a critical role in 
ensuring that people in rural areas have access to high quality health 
care. Telemedicine puts technology to work to improve the delivery of 
health care. It uses technology to link patients and their doctors in 
rural or remote hospitals with highly trained medical specialists in 
state-of-the-art medical technology located hundreds or even thousands 
of miles away. These linkages will allow more patients to receive care 
in their community and will ease the burden on specialists in 
underserved areas. By increasing the education and training 
opportunities for providers in these areas, these links will also help 
underserved communities recruit and retain physicians.
  Telemedicine will help ensure that people who live in small towns and 
rural communities have the same access to quality health care as people 
living in Beverly Hills or in Palm Beach. As I said, Mr. President, by 
having these telemedicine networks, it will certainly help provide for 
the training, the education, and I think, the recruitment and retaining 
of physicians and other health specialists in rural areas.
  Too often, doctors who might otherwise want to serve in a rural area 
feel they do not have access to the latest technology and the latest 
diagnostic services. They are sort of out there on a limb in many cases 
when people need emergency medical care and they may not have that kind 
of ready access to the special care that they would otherwise be able 
to get in an urban area.
  Well, telemedicine can provide to that primary care physician or a 
physician's assistant or a nurse practitioner, a nurse midwife, other 
health care professionals can provide for them that kind of backup they 
need.
  Rural hospitals and other facilities can benefit from the cost 
savings and the access to specialists that telemedicine provides.
  For example, a family doctor in Muscatine, IA, could immediately 
consult with a specialist at the University of Iowa for an instant 
diagnosis in a life or death situation. A specialist at Mercy Hospital 
in Des Moines could provide emergency advice and even help oversee a 
difficult surgery taking place in a small hospital in Centerville, IA, 
and a radiologist at Methodist Hospital in Des Moines could help 
examine x rays just taken in the small town of Jefferson, IA.
  My home State of Iowa, Mr. President, has developed a world-class 
fiber-optic system that holds great potential in the area of 
telemedicine. These fiber-optic cables greatly enhance the potential of 
telemedicine because they carry not only more information than 
traditional copper wires but they also provide more clarity--clearer 
pictures, higher resolution--than copper wires.
  The Iowa Legislature just this year, Mr. President, voted to extend 
our fiber-optic system to all of the hospitals in Iowa. That should be 
done I think by next year sometime. With that kind of system, here is 
what telemedicine will provide, for example.
  Let us say that there was a car accident in a remote, rural area of 
Iowa. They had access to a small clinic or a small rural hospital but 
with no special care there. X rays could be taken, and those x rays 
could be sent over fiber-optics to be read immediately by a 
radiologist, say, in Des Moines or Omaha, maybe even at the Mayo Clinic 
in Rochester for northern Iowans and a decision could be made whether 
or not that person needed to be moved to a more intensive care unit or 
whether that person could remain in the smaller rural hospital, thus 
saving great amounts of money.
  There are all kinds of possibilities for rural doctors to use 
telemedicine to ensure that they get the latest information and the 
latest diagnostic techniques to a rural clinic in a small town.
  Telemedicine will allow patients to stay close to home for support. 
For most people, one of the most traumatic times is when they are sick 
or injured, and we should be helping them stay with their family and 
friends.
  I am not saying there will be times when people will not have to go 
far away from home for treatment, nor am I saying that telemedicine 
will replace local doctors or the need for specialists. But whenever 
possible telemedicine will facilitate local care and provide needed 
relief for overworked small town doctors, nurses, and other health care 
providers.
  I have looked over very carefully Senator Mitchell's bill because on 
the Labor and Health Committee I was very much involved with other 
Senators in putting in very strong provisions for rural health care, 
and those provisions basically have been adopted in the Mitchell bill--
not all of them, most of them. Those positions are strengthened now by 
the Daschle amendment.

  Senator Mitchell's bill will expand access to care for rural 
Americans, access to the Federal Employees Health Benefits plan, or 
another purchasing cooperative will help keep the cost of coverage down 
for rural residents. Many people in the rural areas are either self-
employed or work in small businesses, and currently pay much more than 
big businesses for the same benefits. And they face much higher 
administrative costs.
  The insurance reform provisions in the Mitchell bill are critical for 
rural residents, particularly for our farmers. Farming is now the most 
dangerous occupation in America with annual death rates at 52 per 
100,000 workers, almost five times the national average. Under the 
Mitchell bill, farmers will have access to a community rated plan. This 
means that farmers in a given area will be charged the same premium for 
health insurance regardless of their occupational risk. In addition, 
health plans will not be able to deny coverage because of preexisting 
conditions.
  Under the current system, the self-employed can only deduct 25 
percent of the cost of health insurance while, of course, corporations 
can deduct the full cost of coverage. The Mitchell bill would raise the 
deduction for the self-employed to 50 percent. I support this increase. 
Senator Wofford, who I see is on the floor, and I intend to offer an 
amendment that will raise this to 100 percent.
  I again want to compliment the Senator from Pennsylvania for his 
leadership. He understands that our farmers and our self-employed ought 
to have the same kind of tax deduction as a large business would have 
in providing for their own health insurance. I congratulate Senator 
Wofford for taking a leadership position in this area.
  Allowing the self-employed to deduct the full 100 percent of the 
costs of the premium is critical in rural areas where the only health 
plan available is often a more expensive fee-for-service plan. It is 
time that we put the self-employed and corporations on equal footing. 
Again, that is not addressed in this amendment but will be addressed in 
the amendment to be offered by Senator Wofford.
  To address the critical need for health care providers in rural areas 
the Mitchell bill focuses on training more primary care doctors, and 
also provides incentives for health providers to locate in rural areas.
  The Mitchell bill would increase funding for the National Health 
Service Corps which places about 55 percent of their providers in rural 
areas. The amendment offered by Senator Daschle would expand support 
for this program. Forty National Health Service Corps members are 
currently providing care in 20 sites in Iowa. And yet there is still a 
shortage of providers in many of our Iowa communities. We have 18 
counties in Iowa that do not have a doctor that will deliver babies, 
and an additional 14 counties have only one doctor who will deliver 
babies. Right now with the National Health Service Corps we have 47 
bases in Iowa right now. These are communities who are eligible, and 
who have applied, and are on the waiting list to get a National Health 
Service Corps provider.
  The need to expand funding for the National Health Service Corps is 
very clear. Last year there were 4,000 applications, and yet we were 
able to fund only 406 of those applications. The funding provided by 
the Daschle amendment will allow us to return the National Health 
Service Corps to its strength prior to 1980 when the program was 
gutted.
  Again, I point out that there are provisions in the so-called Dole 
bill that would provide authorization for expanded funding for National 
Health Service Corps.
  Mr. President, with the budget caps and the ceilings that we have on 
right now, that authorization is worthless. It is meaningless. It 
sounds nice. But it does not do anything. So the Dole bill really does 
not address the need to fund the National Health Service Corps. The 
Daschle amendment does. It provides a stream of funding for the 
National Health Service Corps.
  So some get up and say perhaps this is the same as in the Dole bill. 
It is quite a bit different, Mr. President. This provides the funding. 
The Dole bill only provides the promise.
  In order to recruit doctors and nurses to rural areas, the Mitchell 
bill also provides tax credits for primary care providers serving in 
underserved areas.
  I am also pleased that the amendment offered by Senator Daschle would 
expand support for rural health clinics. Rural health clinics are 
located in health professional shortage areas, and are often the only 
source of care in a community.
  I have visited a number of these in Iowa, including the Redfield 
Clinic in Redfield, IA. Most of the patients in this clinic are seen by 
Ed Friedman, a physician's assistant, who also sees patients in five 
area nursing homes. Physicians visit the clinic once a week, and are 
always available by phone.
  Over one-half of the patients seen in this clinic are Medicaid or 
Medicare patients. Of course, with telemedicine, Ed Friedman, a 
physician's assistant, will have ready access at all times to 
specialists in Iowa, and perhaps even in other States to back him up.
  This rural health clinic in Redfield is an essential element of the 
health care system in rural Iowa. I am pleased that the amendment 
offered by Senator Daschle will provide assistance for clinics such as 
this one.
  Mr. President, I am pleased to support the amendment offered by 
Senator Daschle.
  I urge its adoption by my colleagues.
  Again, I will close my remarks by complimenting the Senator from 
South Dakota by focusing our attention on rural health care.
  I believe the bill that we reported out of the labor and health 
committee addressed these issues. Now for whatever reason they were not 
as tightly formed in the Mitchell bill. But this amendment addresses 
that, brings them up to speed, and brings these back up to the level we 
had in the labor and health bill, but for the provision of the 100 
percent deductibility, and for which, as I said earlier, an amendment 
will be offered to correct that by Senator Wofford from Pennsylvania.
  Mr. President, as we continue the debate on the health care reform 
bill, and we continue all the talking about this amendment, and that 
amendment about employer mandates and other things that we are going to 
be talking about, let us not lose sight of the fact that people who 
live in rural America, as I said, are more often poor and more often 
underserved than anywhere else in this country.
  If any group of Americans need health care reform, it is the people 
who live in our small towns in rural America. They are not getting 
access because they do not have the providers. They do not have the 
providers because the system is skewed against providers being able to 
serve in underserved areas.
  The Mitchell bill addresses all of that. It does it in a very 
forthright manner. The Daschle amendment enhances that and strengthens 
that, especially, as I point out one more time, in funding for the 
National Health Service Corps. That is most critical to make sure that 
our people in rural areas have the kind of access and quality of care 
that they not only need, but they deserve.
  Mr. President, I thank the Senator from South Dakota for yielding 
this time.
  I yield the floor.

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