[Congressional Record Volume 141, Number 82 (Wednesday, May 17, 1995)]
[Senate]
[Pages S6784-S6792]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




     EXTENDED USE OF MEDICARE SELECTED POLICIES--MOTION TO PROCEED

  Mr. DOLE. In light of the objection, I move to proceed to the 
consideration of H.R. 483.
  The PRESIDING OFFICER. The question is on the motion to proceed.
  Is there debate on the motion?
  Mr. ROCKEFELLER addressed the Chair.
  The PRESIDING OFFICER. The Senator from West Virginia.
  Mr. ROCKEFELLER. Mr. President, this is not one of the most broadly 
understood issues. But it is a very important one, Medicare Select. 
There are, I guess, two issues that concern me. One--and this is less 
important, but nevertheless important to me--is the area of process. I 
had written Senator Dole, the majority leader, a number of months ago 
asking for a hearing on the subject of Medicare Select. I was told in a 
letter back from the majority leader that we would have hearings on 
Medicare, obviously, and that Medicare Select would be a part of those 
hearings. The Finance Committee has not had any hearings on Medicare 
Select and, therefore, that constitutes a problem.
  Second, there is a study on Medicare Select which is going to be 
completed by the end of the summer, and it is not a frivolous study or 
a frivolous problem. It is a serious problem involving seniors and 
Medicare supplementary insurance. Currently, 15 States are 
participating in the 3\1/2\-year experimental Medicare Select Program. 
This bill would expand Medicare Select to all 50 States for 5 years.
  One of the States that has Medicare Select is, in fact, the State of 
Florida. I cosponsored legislation sponsored by Senator Graham that 
would temporarily expand Medicare Select for another year. So this is 
not just a question of those States that have Medicare Select wanting 
to continue to expand it, or to make it permanent, or whatever. We have 
genuine concerns.
  There are other issues involved. One of the conclusions of the 
preliminary evaluation of this study which I have been referring to, 
which will be completed at the end of the summer--and that is why I 
hoped we could wait until that time, this being the first year of a 2-
year session--was that about half of the savings in the form of cheaper 
MediGap premiums for beneficiaries came about as a result of 
discounting payments to hospitals.
  Now, theoretically, if seniors are having their care actually 
managed, the Medicare Program would realize savings from the lower use 
of health care services. [[Page S6785]] 
  If, in fact, the savings are merely the result of hospital 
discounting arrangements, the Medicare Program is not going to benefit 
at all financially. Again, that is not an overwhelming factor, but a 
very important factor in view of the overall Medicare cuts we are 
looking at this year.
  CBO, in fact, scored the expansion of the Medicare Select Program as 
budget neutral, not as saving or costing Medicare, but budget neutral. 
They said it does not cost and it does not save the Medicare Program 
any dollars at all.
  Now, my colleagues and friends on the other side talk about expanding 
choice and restructuring Medicare by getting more seniors into managed 
care in general. Yet Medicare Select, one of the managed care options 
already available under the Medicare Program in at least 15 States, 
does not save the Medicare Program money.
  So far, therefore, claims from the other side on the so-called magic 
of the marketplace does not seem to be doing anything to save costs for 
Medicare. That is the point I am trying to make. Many people believe 
that managed care is not going to save the amount of money that some 
people think it is because the elements of managed care are not enough. 
There is the cost of technology and more people getting older faster--
that number is increasing very fast.
  The Consumers Union testified before the House Commerce Health 
Subcommittee that:

       Lawmakers should not make permanent a managed care form of 
     insurance to plug gaps in Medicare coverage because of very 
     serious questions about the supplemental's plan deceptive 
     pricing practices and its effectiveness at holding down 
     health care costs. We should not make this program permanent 
     and expand it to other States until we know that it is really 
     a good deal for the customers.

  That is all I am saying. I am simply requesting that the study which 
will be ready by the end of the summer, which is already in progress, 
which has already issued a beginning report, be allowed to be 
completed, that we see if, in fact, it is good for consumers, before we 
take any further steps.
  Consumers Union has raised concerns that because of insurance 
underwriting practices, seniors may be locked into Medicare Select 
managed care policies and be unable to purchase another MediGap policy.
  We looked at MediGap 5 years ago, in 1990. We passed legislation on 
MediGap. It was very good legislation and it cut down on abuses and 
consumer confusion. Seniors, for the most part, do have Medicare 
supplemental policies. Sometimes they use it to help pay part of their 
premiums. Sometimes they use it to get more services that Medicare does 
not offer. But it is very, very important.
  HCFA, the Health Care Financing Administration, has voiced a concern 
about a lack of quality assurance requirements for Medicare Select 
managed products.
  Medicare HMO's are required to have an active quality assurance 
committee headed by a physician that gathers and analyzes data and 
works for continuous quality improvement. That is important. There is 
no comparable requirement for Medicare Select managed care products.
  Medicare HMO's are required to provide data on such indicators as 
waiting times for appointments in urgent care, telephone access to HMO, 
both during and after hours. There is no comparable requirement for 
Medicare Select managed care products.
  Understand, I am not condemning Medicare Select. Fifteen States are 
using it. Some of those States want it to be made permanent. Some are 
less happy about it, but this bill is a major expansion. Therefore, it 
is something that we need to look at closely.
  To go from 15 to 50 without the benefit of at least the study 
Congress ordered so that we could make an orderly decision about this, 
just does not seem to me to make sense. It is for that reason that I am 
here talking, hoping that we can do something about it.
  If Medicare Select managed care is to be made permanent as a Medicare 
option, beneficiaries should be guaranteed the same level of assurance 
on issues of quality, issues of access, and, for example, grievance 
rights, as they have already in other Medicare managed care options. 
That seems sensible. Do the 15 have it? Do all of them have it? Do none 
of them have it? We need to know.
  A preliminary analysis of the Medicare Select experiment that was 
completed last year by the Research Triangle Institute concluded that 
from Medicare's perspective, unless Medicare Select reduces use or 
directs use to providers that cost Medicare less money, it offers 
little benefit to Medicare.
  The preliminary case study also indicates:

        Aggressive case management and restriction of networks to 
     the more efficient providers in the communities are rare. 
     Thus, it appears unlikely that Medicare Select will result in 
     claims cost savings for HCFA.

  Now, Mr. President, I do not think that these concerns mean that we 
should end the Medicare Select Program. I want to be very certain on 
that. I think that experimentation--State experimentation--is 
tremendously important. I believe in it.
  However, I do think that several serious issues have been raised 
about the Medicare Select Program, and as a result I have grave 
reservations about extending this program to all 50 States--that would 
be 35 more States--in 5 years.
  Instead, to avoid any potential disruption in those States that 
currently are participating in the Medicare Select experiment, we ought 
to extend their programs so that they do not have to stop enrolling new 
people on June 30, 1995.
  Now, that is an important point to make. We have a drop dead date we 
are facing rather quickly. They cannot take new enrollees unless we 
extend the current States that have the programs, which I am very much 
for doing, so that we can learn more from those programs.
  I would sincerely hope that before expanding it beyond those States 
that now have it, we take a much closer look at the Medicare Select 
Program in the committee of jurisdiction, which is the Finance 
Committee.
  Then I go back again to the process question. I asked the majority 
leader by letter if he would hold hearings on this subject. He answered 
me earlier, some months ago, that we would hold general Medicare 
hearings in the Finance Committee, and Medicare Select would be part of 
those hearings.
  They have not been part of those hearings. They have not been even 
mentioned in these hearings. That is important to me because I think 
that process and the knowledge that one gains from that is tremendously 
important.
  I find it somewhat disturbing that my friends on the other side of 
the aisle who want to cut Medicare by $256 billion to balance the 
budget and pay for tax cuts, and who talk on a daily basis about 
restructuring Medicare, will not even take the time to consider a final 
evaluation of the Medicare Select Program. Congress mandated that this 
study be done. This was not somebody's whim. It was a congressionally 
mandated study. The Federal Government has already paid for this study 
to be done. But my colleagues are apparently not willing to wait a 
couple of months to consider the results of that congressionally 
mandated study.
  In some ways it seems to me that we are here more because the Senate 
is looking for something to do. I do not think this is the right way to 
handle the problem of the Medicare Select Program. This came up 
suddenly and here we are with it.
  I want to make it very clear why I have objected to the idea of the 
Senate simply rubberstamping a bill passed by the other body. There is 
absolutely no reason for us to be using up the time of the Senate on 
this at this time. If the majority leader would simply give the 
committee of jurisdiction the chance to review the legislation and the 
study through something as basic as a hearing or a partial hearing or a 
subcommittee hearing, then we could work out a course of action based 
on a responsible process and careful thought about the substance which 
I have raised, which is very much in question. The Senate should, I 
think, not acquiesce to a cavalier way of doing business, and that is 
what concerns me.
  The majority leader wants the Senate to rubberstamp a bill that would 
turn a limited demonstration program, called Medicare Select, into an 
open-ended national program. I am very concerned about an attempt to 
pass legislation affecting the Medicare Program [[Page S6786]] without 
having it carefully considered by anyone in the Senate.
  I ask my colleagues, who are not present on the floor with the 
exception of the distinguished Presiding Officer, how many of them can 
really tell me much about the Medicare Select Program? How many could 
give me one short paragraph on what the Medicare Select Program is? I 
would daresay it is probably six people; probably six people. And here 
we are at a moment when there is not much else to do, awaiting the 
budget resolution, but with some time to kill, and we are about to 
expand into a national program something which is being experimented 
with locally, by the States.
  If anything is clear these days, the Senate should know what it is 
doing when it changes Medicare. We are about to enter into a major 
debate on Medicare as it concerns the budget resolution. So anything 
that has the word Medicare in it, we ought to be precise, 
knowledgeable, and informed rather than having an hour's discussion and 
then a vote of some sort, affecting profoundly what happens in this 
country. Medicare affects 33 million people--36 million to 37 million 
people when you add on end-stage renal disease and the disabled, as 
well as those over 65. It has enormous consequences. It has enormous 
consequences.
  As we learned during the MediGap debates, it is very hard, often, for 
seniors to resist buying policies which are constantly offered to them. 
That was what the MediGap legislation was about. It was to discipline 
this proliferation of policies to ensure folks could not prey on 
seniors who could not necessarily understand all the small print, or 
even read the small print in the policy. So this is about protecting 
seniors; about not misleading seniors; about making sure that seniors 
get the quality assurances that are verbally offered to them by those 
who would sell Medicare Select.
  It just seems to me that if we are about to talk about a $256 billion 
cut in Medicare, we really ought to know what we are talking about when 
we do anything about Medicare, much less add on a new program, whether 
it costs or not.
  Just yesterday Dr. June O'Neal, who is the new head of CBO, the 
Congression Budget Office, and whom I had not seen before, testified 
before the Finance Committee that quality--hear this, ``The quality 
will suffer under the Medicare Program if we enact Medicare cuts of 
$256 billion.''
  She said that seniors will have to pay more to get the same level of 
quality that they are currently receiving under Medicare. And I think 
this is a very serious consequence. In fact, by the year 2002, I think 
they will be paying $900 more per year and I think on an aggregate 
basis they will be paying close to $3,500 more between now and the year 
2002. When you consider the fact that only a very tiny proportion of 
Medicare recipients have incomes of higher than $50,000 a year and that 
the enormous majority of them are way down at $15,000 or $10,000 or 
below, in that area, something like that becomes an enormous 
consideration. An additional $3,500? They already spend over 20 percent 
of their income on health care.
  In fact, we had an interesting minidebate yesterday on whether or not 
the cuts in Medicare will in fact cut Social Security for seniors. Of 
course, if that were to be the case, that would be a kind of third-rail 
item on the American scene because cutting into Social Security is 
something we have all decided not to do. We came up with the judgment, 
not so much during the hearing but after the hearing, that because of 
the increases in premiums, et cetera, in copayments, seniors will have 
to pay for more costs for Medicare, that in effect their COLA increases 
under Social Security in many cases will be wiped out entirely.
  Will seniors see that as a cut in Social Security? I think it is 
quite possible they will. Because it is interesting--I would not have 
guessed this, I say to the Presiding Officer--that Social Security and 
Medicare are looked upon, in many ways, as the same by the people of 
this country and by the seniors of this country. That whereas we said 
before ``Do not cut Social Security,'' people look upon Medicare as the 
same sort of a sacred contract, so to speak, that the American 
Government and the American people have with each other, and not 
another incidental program.
  So I think this is a very serious problem. The Health Care Finance 
Administration, HCFA, has voiced a concern about lack of Medicare 
Select quality assurance requirements. HCFA is not a radical 
organization. It is a big organization, 4,000 people, who in fact are 
very expert. Nobody knows they exist but they do, and they do all kinds 
of complicated work. They are expressing concern about Medicare Select 
quality assurance requirements, that they do not exist in this 
legislation and they do exist for other managed care options. As I 
said, Medicare HMO's are required by law to have active quality 
assurance committees.
  So I think there is lot at question here, and I just hope we could 
work this out. I had suggested a variety of alternatives, options; that 
we could take the States that now have Medicare and extend those for a 
year and a half or 2 years. Some people say if you extend it for a 
year, that does not really give the managed care company that is 
interested in looking at Medicare much incentive to move ahead. It 
sounds like a year-by-year basis. Maybe we could do it for longer than 
that. Maybe we could add on some more States, add on four or five more 
States and allow that to happen.
  But to take the entire country and open it up to Medicare Select when 
a study which has already raised questions is still out there and 
questions have been raised by health care experts in HCFA about 
insurance problems, plus the fact that it is Medicare, which is 
probably the most sensitive subject that could be discussed on the 
floor of this Chamber, we ought to be careful. That is why I am not for 
going ahead at the present time with expanding this the way the 
majority leader seems to want to do.
  I will have more comments. But I do not see anybody at this point who 
wishes to say anything. So I yield the floor and note the absence of a 
quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. ROCKEFELLER. Mr. President, I ask unanimous consent that the 
order for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. ROCKEFELLER. Mr. President, I note the presence of the 
distinguished Senator from Rhode Island on the floor. I know he wants 
to speak. I will not take long. I talked a moment ago about the 
concerns of the consumer groups and the Medicare Select Program. One of 
their concerns is called attained age rating. Just as insurance 
companies charge older people more for insurance in the under 65 
market, MediGap insurers charge older seniors more for their MediGap 
policies as they grow older. In the under 65 market, insurers claim 
that age rating is a sound business practice because older people use 
more health care services and because older people are better off 
financially than those who are 20 years old or younger. This argument 
does not work at all for those who are over 65 years old. In that 
important market, 85-year-olds are generally, as I hope we all know, a 
lot poorer than 65-year-olds.
  Another question that has been raised is the so-called one time open 
enrollment period. When we worked in the Finance Committee--I know the 
Senator from Rhode Island worked very hard on that also--on the MediGap 
legislation in 1990, we required insurers to have a one-time, 6-month 
open enrollment period when seniors first turned 65 so that they would 
have 6 months to simply enroll. During this 6-month period, an insurer 
under the MediGap Program is not allowed to deny insurance to any 
senior based upon their health status. That is an enormous statement in 
the health insurance industry. It is an enormous statement. They are 
not allowed during those first 6 months to make any health status 
judgments and thus say no to people. Consumer groups have raised a 
concern that if seniors sign up with a Medicare Select managed care 
product and decide that they do not like that product, they may be 
unable to buy a MediGap policy later because the open enrollment period 
would have gone by, especially, of course, if their health status is 
poor.
  I want to just add those things.
  I yield the floor.
  [[Page S6787]]
  
  Mr. CHAFEE addressed the Chair.
  The PRESIDING OFFICER. The Senator from Rhode Island.


                         Privilege of the Floor

  Mr. CHAFEE. Mr. President, I know the distinguished Senator from 
North Carolina is waiting to give a brief statement, and then I would 
like to speak. Let me discuss it with the Senator from Oregon.
  But meanwhile, I ask unanimous consent that privileges of the floor 
be granted to a member of my staff, Douglas Guerdat during today.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. CHAFEE. Thank you.
  Mr. HELMS addressed the Chair.
  The PRESIDING OFFICER. The Senator from North Carolina.
  Mr. HELMS. I thank the Chair.
  (The remarks of Mr. Helms pertaining to the submission of S. Con. 
Res. 14 are located in today's Record under Submission of Concurrent 
and Senate Resolutions.)
  Mr. PACKWOOD addressed the Chair.
  The PRESIDING OFFICER. The Senator from Oregon.
  Mr. PACKWOOD. Mr. President, let me make a few comments on the so-
called Medicare Select policies and explain first what they are.
  Medicare does not cover all medical expenses. So a popular policy 
that is sold in this country is called MediGap. You can buy it. It is 
voluntary. You do not have to buy it. You can buy it. It basically 
fills in the holes that Medicare does not cover. There are different 
kinds of MediGap policies. You can get some that are more expansive and 
with more coverage than others and they cost a bit more. But I 
emphasize they are voluntary.
  Medicare Select is a particular form of MediGap policy. It is one of 
the most popular policies that are around. It is about 40 percent less 
expensive than other policies. It exists now in 15 States. You have to 
have Federal permission to sell it. The authority to issue these 
policies expires on June 30 of this year.
  The House has passed a bill--let me check my figures--I think 408 to 
14, to extend Medicare Select to the rest of the Nation. This is hardly 
a partisan issue with that kind of a vote. And if we, frankly, get a 
vote on it in the Senate, it is going to pass probably 80-20 or 90-10, 
unless I am mistaken. So do not let anybody be of the impression this a 
Republican-Democrat issue. This has overwhelming support.
  The National Association of Insurance Commissioners is one group that 
supports it, and they monitor complaints about insurance policies 
throughout the Nation. There are about 500,000 people enrolled in just 
these 15 States in Medicare Select, and of those 500,000 policies, in 
1994, all of the insurance commissioners in those 15 States had 9 
complaints--9--in comparison with 967 complaints against other types of 
MediGap policies, nonselect MediGap policies.
  We passed this in the Senate 5 years ago. We were awaiting a report. 
The report was due in January. It is not going to be out until next 
January now. It is late. It is not going to come.
  And again, Medicare Select has overwhelming support. I am going to 
read just a list of the groups that support expanding this to the 50 
States: The American Group Practice Association, the American Hospital 
Association, the American Managed Care and Review Association, the 
Association of Public Pension and Welfare Plans, Blue Cross and Blue 
Shield Association, California Association of Hospitals and Health 
Systems, the Federation of American Health Systems, the Group Health 
Association of America, the Health Insurance Association of America, 
the Medical Group Management Association, the National Association of 
Insurance Commissioners, the National Conference of State Legislatures, 
and the National Governors' Association.
  Now, Mr. President, you are not going to get a much better group than 
that in terms of breadth and philosophical support. Our problem is that 
this apparently is going to face an objection to coming up and 
apparently a filibuster. I have no question but what the filibuster is 
going to be broken and going to be broken overwhelmingly. We will get 
the 60 votes. But one of the problems the leader faces, of course, is 
that once we are on to a bill and once cloture has been invoked, you 
cannot go to anything else. You can pull it down. And he would like to 
get onto the budget bill.
  I say again, this is the middle of May. The authority for these 
programs runs out next month. This Congress goes on recess in about 10 
days. And so unless we act now, these people who like these policies, 
to which there is almost no complaint, will be faced with rising 
premiums because they cannot be sold to anyone else.
  So I hope that the leader will be successful in bringing this bill 
up, that we would have a short debate. I will be happy to agree to a 
time limit on amendments or a time limit on the bill and get to final 
passage. I will emphasize again it passed 408 to 14 in the House of 
Representatives.
  I thank the Chair.
  Mr. CHAFEE addressed the Chair.
  The PRESIDING OFFICER (Mr. Gregg). The Senator from Rhode Island.
  Mr. CHAFEE. Mr. President, I see the distinguished Senator from West 
Virginia in the Chamber. I would be glad to pose him some questions if 
he is available to respond.
  As the chairman of our committee just pointed out, we are talking 
about Medicare Select. But what is Medicare Select, anyway?
  Medicare Select is the name of a type of MediGap policy. It is 
something that seniors can buy to cover their Medicare deductibles and 
copayments.
  Medicare Select is a type of MediGap policy that permits managed 
care; that is, a managed care MediGap policy. That is what it is.
  What was the problem in getting this plan started and why the 
restrictions? Why could not the insurance companies offer Medicare 
Select if they wanted to? Because when MediGap legislation was 
originally passed in the House of Representatives, there were some 
objections to Medicare Select. A Representative from California did not 
believe in managed care. Consequently seniors were not able to have 
these plans.
  Well, finally, after patiently working at this several years ago in 
late evening sessions, we arranged that there would be 15 States that 
could try this and see how it worked out. And so 15 States have done 
it, and as the chairman of our committee pointed out, it has worked 
very well. The trouble is that the option of these 15 States to offer 
this policy ends June 30; which is what--a month and a half from now.
  As the chairman pointed out, there is now a danger that we cannot 
extend Medicare Select because of having to deal with the budget, and 
so forth, and then all these people who have these MediGap policies--
and, indeed, it is a MediGap policy--will not be able to buy it or 
renew it.
  Indeed, there is question about enrollments right now: Should a 
senior enroll in a MediGap policy that has this managed care plan or 
should I not? What happens if the plan is going to disappear?
  Our point is not only should we extend Medicare Select but should we 
also make it permanent.
  But what about the rest of the States? Why should not seniors in 
other States have this option? In my State, for example, why should not 
my citizens have the option of buying a MediGap policy that is $25 to 
$27 less per month, depending on the situation, than they are paying 
for other MediGap policies?
  Mr. ROCKEFELLER. Will the Senator yield?
  Mr. CHAFEE. Let me just finish. The Senator is objecting to that. 
What I find puzzling is the Senator, a distinguished member of the 
Finance Committee, has twice voted in the Senate Finance Committee and 
twice on the floor to pass a permanent 50-State extension of 
legislation that is before us. What has changed?
  Mr. ROCKEFELLER. What has changed, I say to the distinguished Senator 
from Rhode Island, is that I had correspondence with the majority 
leader of the Senate, a letter that I ask unanimous consent to have 
printed in the Record, and also the majority leader's response to this 
Senator.
  There being no objection, the letters were ordered to be printed in 
the Record, as follows:

                                   [[Page S6788]] U.S. Senate,

                                   Washington, DC. March 21, 1995.
     Hon. Robert Dole,
     U.S. Senate,
     Washington, DC.
       Dear Senator Dole: As ranking member of the Finance 
     Subcommittee on Medicare, Long-Term Care, and Health 
     Insurance that you chair, I would like to propose a hearing 
     on the Medicare SELECT program for oversight and an education 
     on its results so far.
       As you know, Congress approved a 3-year, 15-state Medicare 
     SELECT demonstration project as part of the Omnibus 
     Reconciliation Act of 1990. Medicare SELECT offers seniors 
     less expensive Medigap premiums in exchange for receiving 
     their health care services from a selected network of health 
     care providers. Under current law, Medicare SELECT's 
     authorization--which was extended temporarily last October--
     is due to expire on June 30, 1995, unless Congress takes 
     further action.
       Personally, I would support extending this program for 
     another six months to maintain program continuity, with a 
     strong interest in avoiding the program's disruption while 
     allowing Finance Committee members an opportunity to fully 
     examine the knowledge available so far on the SELECT 
     demonstration. A temporary extension would give the 
     Subcommittee an opportunity to have a full hearing on the 
     Medicare SELECT program that would include results of a 
     formal evaluation of the demonstration project.
       It is my understanding that preliminary results of an 
     evaluation study that is being performed by Research Triangle 
     Institute will be ready by the end of the summer. Information 
     that will be available includes data gathered from insurer 
     and beneficiary surveys, as well as claims analyses that will 
     examine the impact of SELECT enrollment on the use and costs 
     of Medicare services. Therefore, I believe it would not be 
     appropriate or prudent to extend this program on a permanent 
     basis to all 50 states until Finance Committee members have 
     the most up-to-date information on which to base future 
     legislative action.
       Thank you in advance for your attention to this matter, and 
     I hope to work with you on this issue. Mary Ella Payne is the 
     contact on my staff.
           Sincerely,
     John D. Rockefeller IV.
                                                                    ____

                                                      U.S. Senate,


                                Office of the Majority Leader,

                                    Washington, DC. April 3, 1995.
     Hon. John D. Rockefeller IV,
     U.S. Senate,
      Washington, DC.
       Dear Jay: Thank you for your letter regarding the Medicare 
     Select Program. I agree with you that this issue deserves 
     careful consideration, particularly if Congress intends to 
     extend the program permanently.
       I know that the Chairman plans to hold extensive hearings 
     at the full committee level on the Medicare program--it's 
     costs, it's benefits, and what changes need to be made to 
     improve it. I have been assured by the Chairman that through 
     this process we will take a close look at Medicare Select, as 
     we will all parts of the Medicare program.
       The Committee will obviously have its work cut out for it 
     this year. I look forward to working with you as we debate 
     some very important and complex issues.
           Sincerely,
                                                         Bob Dole.

  Mr. ROCKEFELLER. I wrote the majority leader on March 21, and I said 
this problem is going to be coming up. We know there is a deadline. I 
am fully aware of that. He wrote back on April 3, and he told me, ``I 
agree with you that this issue deserves careful consideration, 
particularly if Congress intends to extend the program permanently. I 
know that the chairman,'' that being Senator Packwood, ``plans to hold 
extensive hearings at the full committee level on the Medicare 
Program.'' And, ``We will take a close look at Medicare Select, as we 
will all parts of the Medicare Program.''
  What I would say to my friend from Rhode Island is that we have not 
done that. In the meantime, Congress mandated a study to be done, and 
the study is in the process of being done. The study has also already 
raised several questions. Other groups raised other questions about 
quality, about being able to buy other medigap policies. So there are a 
number of questions that needed to be answered. I wished to do all of 
this somewhat earlier, and I was given the promise that we would do 
this somewhat earlier. It is just that the promise was not fulfilled.
  I should say also that a number of questions have been raised which 
have somewhat changed the atmosphere in the last several months. Before 
the Senator came to the floor, I talked about questions which had been 
raised by a number of groups--pricing games, medigap availability, 
illusory costs, and things of that sort. The Senator from West Virginia 
wants to be sure.
  Mr. CHAFEE. Well, the Senator from West Virginia may wish to be 
assured, but I do not know how far we have to go. The National 
Association of Insurance Commissioners supports the extension of this 
program. We just had the list of those who were supporting Medicare 
Select read by the chairman of our committee. You can go on and on and 
find reasons not to do something.
  But we are really in a very, very difficult situation here. This 
program expires in 30 days from now or 45 days from now. It seems to me 
we ought to get on and extend it, and not only extend it but let the 
other States in on it.
  Some mention was made about the Consumers Union's concerns about 
Medicare Select. But the fact of the matter is the Consumers Union's 
problems that were raised apply to all medigap policies, not focused in 
on Medicare Select.
  Mr. ROCKEFELLER. Will the Senator yield?
  Mr. CHAFEE. Yes.
  Mr. ROCKEFELLER. Mr. President, obviously, we need to work this out. 
The time problem is not, in fact, a constraint on those States which 
currently have Medicare Select because I already said I would be 
perfectly happy to go ahead and extend them.
  The question is: How can we, looking at some of these complaints 
about not being able to change MediGap policies, discrimination of 
various sorts, how can we arrive at some kind of compromise which gives 
consumer protection for these Medicare beneficiaries that would choose 
Medicare Select? How can we give them some kind of consumer protection 
over and above what is contemplated in the law that the Senator from 
Rhode Island wants to get passed right away?
  Would the Senator be willing to discuss those matters, if not 
publicly, privately?
  Mr. CHAFEE. Mr. President, the Senator says we have to wrestle with 
these problems. Who says there is a problem?
  Let me just touch on one matter that the Senator raised, and that is 
the so-called attained-age rating, with a suggestion that Medicare 
Select, this type of managed care policy, MediGap policy, has this 
attained-age rating.
  Well, the fact is that the attained-age rating is permitted under 
current MediGap law. It is not restricted. The attained age is not 
something peculiar to Medicare Select. That is permitted under the 
current MediGap law.
  And so while it is true that most medigap policies and most Medicare 
Select policies do not use the attained-age method, I do not see why 
you focus in and say that is something peculiar to MediGap or Medicare 
Select, because it is not.
  Mr. ROCKEFELLER. The Senator from West Virginia did not say it was 
peculiar, but I said it was a problem as far as the Medicare extension 
is concerned. Whether it applies to more medigap policies is not, at 
the moment, of concern to me. I want to make sure that, in Medicare 
Select, we can.
  HCFA has concerns about quality and concerns about access. They are 
not a frivolous organization.
  I just think we have a chance to try to find an accommodation, 
hopefully in a quorum call, in which we could address some of the 
consumer concerns and perhaps also accommodate the Senator from Rhode 
Island, the majority leader, and the Senator from Oregon in the 
process, since I am, obviously, very well aware of where the votes are 
in the situation. I just want to do the best I can to build in consumer 
protection for a program which is young, which is actually only in 14 
States, and is not at all in all 50 States.
  Mr. CHAFEE. Mr. President, I do not concede that there are all these 
problems or that there are these problems. It seems to me what the 
Senator from West Virginia is doing is applying a higher standard to 
the Medicare Select, these managed care MediGap policies, than he is to 
the regular MediGap policies. I do not think that is fair. I do not 
think it is fair to say, ``No, in Medicare Select, you cannot have 
attained age,'' whereas it is permitted in the other MediGap policies.
  The suggestion here is that we ought to have hearings on this. Well, 
I cannot speak for what the majority leader said, but all I do know is 
that the Senate has passed a permanent extension of this proposal twice 
in the past 4 years. It was included in every major health reform 
proposal last year, including Senator Mitchell's, Senator 
[[Page S6789]] Dole's and Senator Packwood's bill, and in the 
mainstream coalition bill. All of them had Medicare Select in them. So 
it is not that we are coming up against some unknown item here that we 
better be terribly cautious of. As I say, it has been out in these 
States. In 15 States, it is authorized. I cannot challenge the 
Senator's information when he says it is actually in practice, I 
believe he said, in 14 States.
  All I know is that I think it is a good option that is less expensive 
and that we ought to give all the citizens a chance at it. And the 
citizens from my State would like a chance at this. If they do not want 
to use it, that is their business. But if they have a right to choose a 
MediGap policy that is less expensive than the current ones, I think 
they ought to have it and not be prevented from doing so because this 
Congress refuses to extend Medicare Select to all the States.
  Again, no one is more thoughtful and compassionate in this Senate 
than the Senator from West Virginia, so I am not sure why he takes this 
particular position. Because, as we mentioned before, this passed in 
the House 408 to 14. You could hardly get a motherhood resolution 
passed by that amount.
  Mr. ROCKEFELLER. If the Senator will yield, I think one could 
practically rewrite the Constitution in the House of Representatives by 
that vote in the current climate.
  If the Senator would further yield, he talked about standards being 
higher for Medicare Select than for other medigap things. I think high 
standards are important and I know the Senator from Rhode Island does, 
too. I want to see the Senator from Rhode Island and his State be able 
to have this program if that is what the State and the Senator wants.
  I think the time crisis that the Senator refers to can be handled in 
60 seconds. That can be changed in 60 seconds.
  My point is that for 2 months I have suggested extending the program 
to the 14 States with the program already in effect. What I am really 
suggesting now is that we first look at the evaluation of the program 
before we open the door to all the other States. What I am really 
suggesting is that, if we could perhaps suggest the absence of a 
quorum, we could work something out on this.
  Mr. CHAFEE. Mr. President, our staff asked the Health Care Financing 
Administration [HCFA] for suggested changes. Any problems? What do you 
think we ought to do? They did not have any. They had no suggestions 
for us.
  Maybe the Senator from West Virginia can find, what we cannot find, 
any documented quality problem with this program. Now, some beneficiary 
somewhere may object, I am sure they have, just like they have objected 
to a host of other medigap policies.
  But, as I say, this has received a favorable report by the Consumers 
Union and by Consumers Report magazine and by the State insurance 
commissioners.
  So, I do not have anything particular to offer. I would be glad to 
talk with the Senator from West Virginia. Whatever ideas we have, we 
would have to transmit them. Obviously, I would have to speak to the 
chairman of the Finance Committee, whom I do not see on the floor here.
  Mr. ROCKEFELLER addressed the Chair.
  The PRESIDING OFFICER. The Senator from West Virginia.
  Mr. ROCKEFELLER. The Senator from Rhode Island made mention of no 
particular problems being raised by HCFA. I think that raises, 
therefore, this very important point. Because, in fact, Donna Shalala 
has written to the Honorable Bill Archer, chairman of the Committee on 
Ways and Means, on March 7 of this year.
  And one paragraph says:

       The case study portion of the Medicare Select evaluation 
     has already raised a number of questions about the Medicare 
     Select demonstration.

  That is from HCFA.

       As managed care options under Medicare are expanded, we 
     want to ensure that our beneficiaries are guaranteed choice 
     and appropriate consumer protections.

  That is precisely what the Senator from West Virginia was asking for.
  Donna Shalala goes on:

       In addition, many of the select plans consist solely of 
     discounting arrangements to hospitals.

  The Senator from West Virginia mentioned that at the beginning.
  Donna Shalala goes on:

       We would be concerned if the discounting arrangements under 
     Medicare Select were to be expanded to Medicare supplementary 
     insurance part B services. Discounting arrangements, 
     particularly for part B services, may spur providers to 
     compensate for lost revenues through increased service 
     volume. Consequently, we are concerned that such an expansion 
     would lead to increased utilization of part B services rather 
     than contribute to the efficiency of the part B program 
     through managed care.

  Then she says:

       We would, therefore, oppose such a change.

  There is honest and open debate on this matter. I am still willing to 
talk with the Senator from Rhode Island. I think we can work something 
out. Again, I, unfortunately, can count the votes, but the Senator 
would like to have some consumer protection in this, and I think the 
Secretary of HHS would, too. I think, frankly, George Mitchell, in his 
bill, had open enrollment and major insurance reforms, and the Senator 
from Rhode Island knows that well.
  The Mitchell bill, in fact, did not propose to make Medicare Select 
permanent in the absence of coordinated open enrollment.
  So I think there is room to work something out here, Mr. President, 
because I think everybody is talking with good will on both sides on 
this matter.
  Mr. CHAFEE addressed the Chair.
  The PRESIDING OFFICER. The Senator from Rhode Island.
  Mr. CHAFEE. Mr. President, the problem here is--I know the Senator is 
concerned about this--but the points he raises affect not Medicare 
Select but affect the whole MediGap range. In other words, when he says 
he is interested in open enrollment, there is no open enrollment now in 
the MediGap policies. He is saying he wants it for Medicare Select. But 
that means you want it presumably for all of MediGap.
  Now, that is a very big separate issue that can come up any time. You 
do not have to tag it on to a Medicare Select policy which, as I say, 
is just one of a whole series of medigap policies.
  If the Senator wants to do that, that is changing the rules for the 
whole series of policies that are issued under medigap.
  Mr. ROCKEFELLER. Will the Senator yield?
  Mr. CHAFEE. I will make one other point, if I might, and that is, as 
you recall, when I said my staff spoke to the Health Care Financing 
Administration, what I said was they asked for suggested changes and 
none came back. In the letter the Senator quoted from Secretary 
Shalala, he mentioned somewhere in there concerns about expansion into 
the part B plan. We do not do that. There is no expansion into that in 
this Medicare Select.
  So I will be glad to talk with the Senator. If he would like, we can 
suggest the absence of a quorum and have a little chat here.
  Mr. ROCKEFELLER. The Senator from West Virginia would like to do 
that, but if I might add one more thing, that is, the Senator is right 
about part B, and the Senator from West Virginia just got carried away 
and read too much of a paragraph, which was a mistake on the part of 
the Senator from West Virginia.
  Donna Shalala, on the other hand, is referring to the Medicare Select 
evaluation. She is referring to the Medicare Select evaluation in this 
letter which she wrote back on March 7, which should have been 
available to all of us.
  Bruce Vladeck, in his testimony on February 15 in front of the House 
Committee on Energy and Commerce, raised a major concern with the 
adequacy of beneficiary protections under Medicare Select.
  If that is not HCFA speaking, I do not know what is. Bruce Vladeck 
said:

       There is no requirement for States to review the actual 
     operations of the Select plans once they are approved to 
     assure that quality and access standards are being met.

  He does not like that. He is worried about that, and he says:

       We feel strongly that beneficiaries should not have to 
     worry about the quality and access provisions on their 
     Medicare choices. We look forward to working with the 
     subcommittee * * *

  And then Bruce Vladeck, the head of HCFA, said:


[[Page S6790]]

       Our second concern is whether Medicare Select will make any 
     contribution to increasing the efficiency of the Medicare 
     program.

  I think that goes off into another area. It is the consumer 
protection area, I say to my friend from Rhode Island, which concerns 
me the most.
  I might suggest the absence of a quorum in order for some 
conversation to go on.
  I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. KENNEDY. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. KENNEDY. Mr. President, the Medicare Select is a demonstration 
program. Evaluation will not be completed until December 1995. While 
the demonstration program technically expires on June 30, the 
regulations governing the program clearly state that insurers must 
continue their coverage of current enrollees, even if no extension is 
approved.
  There is no overwhelming urgency to pass this legislation. I do favor 
a temporary extension, and I am prepared to support such an extension 
today. But I have a number of concerns about permanent extension of the 
Medicare Select Program.
  First, extension of Medicare Select should be considered in the 
context of a whole range of managed care options we might wish to make 
available to Medicare beneficiaries. There is a great deal of interest 
on both sides of the aisle in expanding choice. The administration is 
working on development of a PPO option. Before we make the Medicare 
Select Program permanent, we should understand its impact and balance 
it against other options.
  Second, Medicare Select raises significant concerns about beneficiary 
protections. HHS has stated concerns about quality oversight. Most 
important, Medicare Select requires enrollees to receive their care 
from a limited set of providers. This may be perfectly acceptable to 
younger, healthier, enrollees. As beneficiaries age and become sicker, 
however, they may find themselves dissatisfied with providers in the 
select network. They can find themselves permanently locked out of 
regular MediGap coverage, with no ability to buy a policy to protect 
themselves from the costs that Medicare does not cover.
  This seems to me to be an excessive denial of choice that we should 
not enshrine in permanent legislation without more consideration.
  These concerns have been raised by Consumers Union and other consumer 
advocates. Consumers Union, Families USA, and the National Council of 
Senior Citizens all are on record as opposing this legislation. These 
concerns are serious and they deserve to be addressed.
  We must always be especially concerned about the frailest and the 
most vulnerable elderly. We want to provide options that improve the 
choices available, not limit them. We want to provide benefits and 
services that seniors need, not deprive them of necessary care. We 
should move with great care in considering a measure that might have 
that affect.
  It is not my intention to terminate the Medicare Select demonstration 
or put it out of business. I would be willing to support the short-term 
extension of the program or a permanent program if these concerns are 
considered and addressed.
  It is ironic that this particular Medicare issue should surface just 
a day before we are to consider a budget resolution which would strike 
a mighty blow at the integrity of the Medicare Program as a whole and 
at the retirement security of senior citizens it was designed to 
secure.
  This budget plan proposes to break America's compact with the 
elderly, and all to pay for an undeserved and unneeded tax cut for the 
wealthiest Americans.
  The cuts in Medicare are unprecedented: $256 billion over the next 7 
years. By the time the plan is fully phased in, the average senior is 
likely to pay $900 more a year in Medicare premium and out-of-pocket 
costs.
  An elderly couple would have to pay $1,800 and, over the life of the 
budget, would face $6,400 in additional costs. Part B premiums, which 
are deducted right out of the Social Security check, will rise to 
almost $100 a month at a cost of an additional $1,700 over the life of 
the budget plan.
  The typical senior needing home health services will have to pay an 
additional $1,200 per year. Someone sick enough to use the full home 
care benefit will have to pay $3,200. The fundamental unfairness of 
this proposal leaps out from a few simple facts.
  Because of gaps in Medicare, senior citizens already pay too much for 
the health care they need. The average senior pays an astounding one-
fifth of their total pretax income to purchase health care, more than 
they paid before Medicare was even enacted. Lower income older seniors 
pay even more.
  Medicare does not cover prescription drugs. Its coverage of home 
health care and nursing home care is limited. Unlike virtually all 
private insurance policies, it does not have a cap on out-of-pocket 
costs. It does not cover eye care or foot care or dental care.
  Yet this budget plan heaps additional medical costs on every senior 
citizen, while the Republican tax bill that has already passed the 
House, gives a tax cut of $20,000 to people making more than $350,000 a 
year.
  I ask any of our colleagues to travel to any senior citizens' home in 
their State and have a visit with retirees. Ask the retirees by a show 
of hands how many pay $50 a month or more for prescription drugs. 
Anywhere from 25 percent to 50 percent of the hands will go up in the 
air. Ask them how many pay $25 a month or more for prescription drugs, 
and the spontaneous groan in the audience will be enormous. It is an 
expression that they are astounded that we do not understand that they 
are paying at least $25 a month or more and now 80 percent to 90 
percent of the hands go into the air.
  What has been the cost of the prescription drugs over recent years? 
They have been rising at more than double, sometimes even triple, the 
Consumer Price Index.
  Look also at the profits of the major pharmaceutical companies. It is 
an interesting fact that they are some of the most profitable companies 
in America, while at the same time the cost of prescription drugs, 
which are absolutely essential in order to relieve suffering or to even 
live life in many instances, is going right up through the roof.
  Now, that is a real issue for the seniors. That is an issue that we 
ought to be debating out here this afternoon. That is an issue of prime 
concern to every senior citizen.
  I daresay, if any Member of the Senate went to a group of senior 
citizens and asked them this afternoon, ``What do they want the U.S. 
Senate to be focusing on? The issue of prescription drugs or Medicare 
Select?'' Ninety-nine percent would say, ``Look after the problems that 
we are facing with prescription drugs.'' ``Look after the problems we 
are facing in terms of dental care and eye care.'' Look around the room 
and count the number of senior citizens who are wearing glasses. Look 
around the room at the numbers who need help and assistance with dental 
care. Look around the room at the number of seniors who need the care 
of a podiatrist.
  Our seniors think the U.S. Senate ought to be focusing on Medicare 
here this afternoon. But we should not focus solely on Medicare Select, 
until we have a full and complete evaluation of that program, which has 
the potential of some very important adverse effects, as well as some 
potentially beneficial effects.
  We ought to insist that we have all of the facts before we move 
forward on a program that will unquestionably mean enormous profits to 
some companies and industries. It will perhaps give at least the 
appearance of security to some of our senior citizens for a period of 
time, but that security will be illusory unless it is carefully crafted 
and there are built-in kinds of protections which are not evidenced in 
the proposal that we are reviewing or considering this afternoon.
  It is interesting, Mr. President, to compare the generous benefits 
that the authors of the Senate resolution enjoy under our Federal 
Employees Health Benefit Program plan available to every Member of 
Congress to the less adequate benefits provided for Medicare.
  We are going to find out that while the measure we will be debating 
here in [[Page S6791]] the U.S. Senate cuts back on protections for our 
senior citizens, we sure are not cutting back on the protections for 
any of the Members in the U.S. Senate. That is an interesting irony.
  We heard so much in the early part of the year about how we will make 
sure that every law that we pass in the Congress is going to be 
applicable to the Members of Congress. Remember those speeches? We 
heard them from morning until eveningtime here in the Senate.
 And it is right that we do that. But how interesting that we do not 
say we are going to provide for the American people all the benefits 
that we have here in the U.S. Senate.

  If we wanted to, we could give to the American people the kind of 
health benefits that we have, by extending the Federal Employees Health 
Benefit Program. Many of us have supported this in the past; many of us 
fought last year to try to make this available. FEHBP affects 10 
million Americans. We have 40 million Americans who do not have health 
care coverage, and 16 million of those who are children. We could do 
very well if we just provided the extension of the Federal Employees 
Health Benefit Program to all Americans. But, again, we are not 
debating that issue here. We are not involved in that debate here on 
the floor of the U.S. Senate.
  We are talking about the Medicare Select issue, a very narrow, very 
defined issue. We will be debating, tomorrow, and perhaps the day after 
tomorrow, and for a series of tomorrows, the proposed cuts that are 
coming in Medicare, in the budget proposal, that will not be utilized 
for health care reform as we tried to do last year. We tried to provide 
some prescription drug benefit. We tried to provide some home care. We 
tried to provide some community-based care. We tried to provide some 
additional protections for our elderly.
  But no, this year we are going to go ahead and cut the Medicare 
Program to set aside a little kitty of $170 billion that can be used 
someday in the future for tax cuts for the rich. Take benefits away 
from the seniors in the Medicare Program, raise their copayments, raise 
their premiums, raise their deductibles, raise all of their costs so 
that we can put over here a little saving account that can be drawn 
down to allow tax cuts for the wealthiest individuals.
  That is what we will be debating. And it is also amazing to me that 
we will have a time constraint on this issue that is going to affect 
the quality of life for our senior citizens in such a dramatic way. We 
do not have that time restraint this afternoon, when we are debating 
Medicare Select, but we will have it when that budget bill is called 
up.
  It is important that we put some of these measures into proportion. 
This issue, Medicare Select, is being pressed this afternoon. We are on 
the eve of what will be a very important debate, not only here on the 
floor of the U.S. Senate but across this countryside; whether or not we 
want to say to our senior citizens we are going to cut your benefits so 
we can use those savings, those cuts, those resources that we have 
captured from you to give a tax cut to the wealthiest individuals.
  Maybe that is what the election was about last November. It certainly 
was not about that in my State of Massachusetts. People will say, out 
here on the Senate floor: They voted for change. Is this the kind of 
change that the people voted for, Mr. President, $256 billion in 
Medicare cuts so we can provide $170 billion for tax reductions for the 
wealthiest individuals? Is that what the election was about last fall?
  I do not believe so. And I think that is why all of us are seeing, in 
our own States, that those who are paying increasing attention to what 
we are debating and what we are acting on, are going to be so concerned 
by this particular budget proposal.
  Sure we have to get some savings in Medicare. Sure we have to have 
some reductions in expenditures. But what we did last year, when we 
proposed comprehensive health care reform, was to try to bring about 
the kinds of changes that over the long term are going to provide 
important quality health protections for our senior citizens, and 
second, to get a handle on health care costs. We need to get a handle 
not only on Medicare and Medicaid costs but also on the total health 
care system, since Medicare costs are only 15 percent of total national 
health expenditures. The notion that we can deal with escalating health 
care costs by cutting Medicare alone, shows a fundamental lack of 
understanding of the basic elements of the health care debate.
  Medicare provides no coverage at all for outpatient prescription 
drugs, but they are fully covered under the most popular plan in the 
Federal Employees Health Benefit Program. The combined deductible for 
doctor and hospital services under the average Blue Cross and Blue 
Shield plan is $350; for Medicare the combined deductible is $816. Blue 
Cross and Blue Shield covers unlimited hospital days with no 
copayments; under Medicare, seniors face $179 per day copayments after 
60 days; $358 after 90 days. After 150 days Medicare pays nothing at 
all.
  Compare the differences between what our seniors are facing and what 
the Members of the U.S. Senate are facing. Medicare covers a few 
preventive services but does not cover screenings for heart disease, 
for prostate cancer, for other cancer tests--all FEHBP benefits. Dental 
services are covered for Members of Congress. We have them for Members 
of Congress--not for the Medicare recipients. Members of Congress are 
protected against skyrocketing out-of-pocket costs by a cap on their 
total liability. There is no cap on how much a senior citizen has to 
pay for Medicare copayments on deductibles.
  Members of Congress earn $133,600 a year. The average senior's income 
is $17,750. For the limited Medicare benefits seniors receive they pay 
$46.10 a month, but for their comprehensive insurance coverage Members 
of Congress will pay a grand total of $44.05 a month. Seniors actually 
pay $2 more out of incomes about an eighth as large.
  Is that something for our seniors to hear about as we are going to be 
considering a program that is going to cut their programs even more--
and yet not affecting the Members of Congress at all? We have had this 
debate, some of us, for a number of years. Let us just give to the 
American people what we give to the Members of Congress. But we are not 
doing that, not with Medicare. We are being told to go ahead and 
provide additional burdens on the senior citizens that are not being 
asked of the Members of Congress.
  No wonder people wonder what this is about. Is this the change that 
we voted for? I would love to ask a group of citizens in any State, is 
this the change you voted for last November? For further cuts on the 
Medicare benefits, increasing copayments, increasing deductibles to the 
tune of $256 billion, taking $170 billion of it and reserving it over 
here for tax cuts? Is that what the American people wanted as the 
change? Or did they believe in what we have as Members of the U.S. 
Senate, and what more than 9 million other Americans have, the Federal 
employees? Surely they were thinking when they voted, ``OK, if it is 
good enough for the Members of Congress it ought to be good enough for 
all Americans, young and old alike?''
  This debate is going to be important in these next several days. I 
hope and urge our seniors to watch this debate and listen carefully. 
Listen carefully to those who are making recommendations to cut 
Medicare. Listen to their responses to the challenges about equity to 
our seniors.
  This President has indicated he will listen. He will listen to 
proposals to cut Medicare if they are about total health care reform. 
This means that we are going to do something for our seniors that is 
going to enhance the quality of health care in such areas as 
prevention, home care, and community-based systems. It means making a 
difference by reducing deductibles or making payments for 
pharmaceuticals so seniors will not be distressed every time they take 
much-needed prescription drugs; so they do not need to decide whether 
they can afford to go down and get that prescription for $50, $75, $100 
per month, when they do not have enough food on their table or heat in 
their home? We will have the chance to debate that. We welcome the 
opportunity to do so.
  The authors of the budget resolution do not seem to understand how 
limited the incomes of senior citizens are. Because of their budget, 
millions of senior citizens will be forced to go without 
[[Page S6792]] the health care they need. Millions more will have to 
choose between food on the table, adequate heat in the winter, paying 
the rent, or medical care. This budget resolution is cruel. It is 
unjust. Senior citizens have earned their Medicare payments. They have 
paid for them, and they deserve them.
  Medicare cuts in this resolution harm more than senior citizens. 
These proposals will strike a body blow to the quality of American 
medicine by damaging hospitals and other health care institutions that 
depend upon Medicare. These institutions provide essential care for 
Americans of all ages, not just senior citizens. And progress in 
medical research and training of health professionals depends upon 
their financial stability. The academic health centers, the public 
hospitals, and the rural hospitals will bear especially heavy burdens. 
As representatives of the academic health centers that are the 
guarantors of excellence in health care in America said of this budget, 
``Every American's quality of life will suffer as a result,'' because 
there will be less funding to support the best health professional 
education and training to the young people of this country, and there 
will be a diminution in support for the research that is associated 
with the great medical centers in this country.
  In addition, massive Medicare cuts will inevitably impose a hidden 
tax on workers and businesses, who will face increased costs and higher 
insurance premiums as physicians and hospitals shift even more costs to 
the nonelderly. According to the recent statistics, Medicare now pays 
only 68 percent of what the private sector pays for comparable 
physician services; for hospital care, the figure is 69 percent. The 
proposed Republican cuts will widen this already ominous gap.
  The impact of these cuts on local communities will be astounding. In 
my State of Massachusetts we have 123 hospitals. Historically, one of 
the best and most efficient hospitals has in Barnstable County, not far 
from my home on Cape Cod. But it has had increasing difficulty serving 
its patients in recent years. What changed? The doctors have not 
changed. The nurses have not changed. The ability to get the good kind 
of equipment has not changed. The training that they went through has 
not changed. What has changed? The percentage of Medicare beneficiaries 
being attended to in that hospital changed.
  In my State of Massachusetts, any hospital that gets close to 55 and 
67 percent Medicare is headed for bankruptcy because of the 
reimbursement rates. What are we doing? Do you know what happens? 
Hospitals must cut back on the nurses; they cut back on their outreach 
programs in the community to work with children; they cut back on their 
training programs; they cut back, as much as they regret it, on the 
quality of care people get--not just for the elderly people, but for 
all the people being served.
  What happens locally? Communities raise local taxes to try to assist 
hospitals, or they appeal to the State house and try to get additional 
resources. They try to get the revenues from someplace. Either 
localities accept a decline in health care quality or they have to 
raise additional resources locally or at the State level. Maybe some 
other States are experiencing generous surpluses, but you are not going 
to find many that are in our region of the country.
  Financial cutbacks that have occurred in the past have made it 
difficult for hospitals to provide the excellent services they are used 
to providing, and the kinds of cutbacks being discussed by the 
Republicans now will only exacerbate this problem.
  The right way to slow Medicare cost growth is in the context of a 
broad health reform program that will slow health inflation and in the 
economy as a whole. That is the way to bring Federal health care costs 
under control without cutting benefits or shifting costs to the working 
families.
  In the context of a broad reform, the special needs of the academic 
health centers, the rural hospitals, and inner-city hospitals can also 
be addressed. Unilateral Medicare cuts alone, by contrast, could 
destroy the availability and the quality of care for the young and old 
alike.
  The President said that he is willing to work for a bipartisan reform 
of the health care system, but our friends on the other side have said 
no. The only bipartisan shift they seem to be interested in is the kind 
that says, ``Join us in slashing Medicare.'' That is not the kind of 
bipartisanship the American people want.
  The authors of the budget resolution claim to protect Social Security 
while making draconian cuts in Medicare. But the distinction is a false 
one because Medicare is part of Social Security. Like Social Security, 
it is a compact between the Government and the people that says, ``Pay 
into the trust fund during your working years and we will guarantee 
decent health care in your old age.'' This Republican budget breaks 
that compact.
  As the ceremonies on V-E Day this past week remind us, today's senior 
citizens have stood by America in war and in peace, and America must 
stand by them now. The senior citizens have worked hard. They brought 
us out of the Depression. They fought in the Second World War. Their 
sons fought in the Korean war, and the Vietnam War. They have 
sacrificed greatly to advance the interests of their children. They 
played by the rules.
  If this country is the great country that all of us believe that it 
is, it is really a tribute to the senior citizens. They have 
contributed to Medicare. They have earned their Medicare benefits. And 
they deserve to have them.
  This Republican budget proposes to take those benefits away, and it 
should be rejected.
  Mr. President, I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The bill clerk proceeded to call the roll.
  Mr. SPECTER. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.

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