[Congressional Record Volume 141, Number 157 (Wednesday, October 11, 1995)]
[Senate]
[Pages S15003-S15005]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                         NURSING HOME STANDARDS

  Mr. PRYOR. Mr. President, I thank the Chair for recognizing me. I 
also thank my friend from North Carolina for making it possible under 
these parliamentary procedures to allow me to speak for a few moments 
about what I consider to be, Mr. President, one of the more critical 
issues that is before the U.S. Senate in the next coming weeks with 
regard to 2 million nursing home patients who live in thousands of 
nursing homes across America.
  I do not know, Mr. President, if people are aware of what is 
happening, what has happened in the Senate Finance Committee and the 
Ways and Means Committee, what will be happening on the Senate and 
House floors with regard to the Federal standards which were 
established in 1987 in a bipartisan effort that protects residents of 
nursing homes from abuse and neglect.
  Mr. President, what is happening to these standards is they are about 
to be abolished. They are about to be annihilated. Mr. President, there 
are about to be no Federal standards--no Federal standards to protect 2 
million elderly and infirm individuals who live in America's nursing 
homes.
  I think that we ought to look, Mr. President, for just a moment at 
these 2 million people who are now residents of America's nursing homes 
to see if these protective standards should actually be eliminated as 
proposed by the Republican majorities in the Senate Finance Committee 
and the Ways and Means Committee.
  Back in 1987, as part of the Omnibus Budget Reconciliation Act, the 
Congress put into place a set of standards known as Nursing Home 
Reform. Senator George Mitchell actually led in that effort, and I am 
pleased to say that I played a very small part in drafting these 
important standards.
  In fact, it was a bipartisan effort. Republicans and Democrats came 
together, because nursing home standards should not be political. Now, 
even though these standards have led to improved care in our Nation's 
nursing homes--we are about to consider a so-called Medicaid reform 
bill, Mr. President, which would totally wipe these standards out.
  Two weeks ago in the Senate Finance Committee meeting I offered an 
amendment to restore these protections during a Finance Committee 
markup and debate on Medicaid and Medicare.
  My amendment was defeated on an 10-10 vote because, according to the 
leadership of the committee, it is ``contrary'' to the philosophy of 
the reforms being proposed, and we don't want to sacrifice flexibility.
  Mr. President, just for a moment, I will draw a picture. I will draw 
a picture, a composite if I might, of the people who are living in the 
nursing homes in America. First, there are 2 million citizens, elderly 
and young and middle aged. People who reside in the nursing homes today 
are of all ages. Most of them are over 60.
  In 25 years, we will no longer have 2 million people in the nursing 
homes, Mr. President, we will have 3.6 million people in nursing homes. 
That is going to come about two decades from now and it will be here 
before we know it.
  We also find in these nursing homes, 80 percent of the residents 
depend on Medicaid to help them pay for their care; 77 percent of this 
nursing home population need help with their daily dressing; 63 percent 
need help with toileting; 91 percent need help with bathing; 66 percent 
have a mental disorder, and one-half of these residents have no living 
relative to serve as their advocate.
  Let me repeat that, Mr. President: One-half of the residents of 
nursing homes, or approximately 1 million of these individuals, have no 
living relative as their advocate to come to their rescue and to take 
their case to the nursing home administrator or to the inspectors who 
inspect the nursing homes. One-half of this nursing home population of 
our country who reach the age of 65 are going to require nursing home 
care.
  That means that one-half of all the people in this Chamber, one-half 
of all the people in the galleries in this great Capitol of ours, when 
they reach the age of 65, half of these folks, including me--I assume 
if I am around here that long--are going to require nursing home care.
  Mr. President, that is basically a composite of who we are looking at 
and who we are trying to protect by restoring the Federal nursing home 
standards.
  I find it very hard to believe that any meaningful reform that we 
might propose would be inconsistent with quality care in nursing homes. 
The very essence of reform is to get rid of what does not work, keep 
what does work and to make the whole program better.
  Mr. President, we are committing an enormous mistake, an enormous 
mistake in even considering the elimination of our quality standards. 
The very reason that we have these standards to begin with, let us go 
back, the very reason the Federal Government stepped in is because the 
States would not. The Federal Government had to protect these people in 
these nursing homes because the State regulations were inadequate.
  Mr. President, I know that we in Congress are very hard at work 
examining every program to find ways in which to increase flexibility 
to the States. I am for flexibility. I am a former Governor. I believe 
in flexibility. I believe we ought to eliminate what we call big 
government at every opportunity we can, that we need to return more 
power to the States, local decisionmakers, and I think my record 
indicates that I have supported that with my vote.
  Mr. President, I want to say, though, I have a very difficult time 
believing that when people in America think of big government, they are 
thinking of the laws that provide for the most basic and minimum 
standard of care for the most frail and the most vulnerable among us.
  I want to pose a question that I will be posing when we actually get 
to the debate on reconciliation, and I am going to ask this question to 
my good friends and colleagues on the other side of the aisle.
  Now that we have finally, since 1987, finally come to the place in 
this country where we have just the bare minimum of standards to 
protect these 2 million individual residents of nursing homes, I would 
like to ask my colleagues, and I will pose this question at 

[[Page S 15004]]
the appropriate times: Which rights that belong to these individuals 
now would you like to eliminate? What about the right to choose your 
own doctor? I wonder if our Republican friends are going to want to 
eliminate that right, which is today a right given by the full force 
and effect of the statutes of the United States of America?
  I am going to ask my colleagues on the other side of the aisle would 
they like to eliminate the right not to be tied to a bed or a chair, or 
restrained? Are they willing to eliminate that right? I am going to ask 
that question to my colleagues on the other side of the aisle, just as 
I asked that question to my colleagues in the Senate Finance Committee 
on the other side of the aisle 2 weeks ago. I did not get a response to 
that question.
  I am going to ask a third question, Mr. President, when we get to 
reconciliation and we start debating these statutes and these standards 
they are attempting to repeal now. What about the right of privacy, to 
have private medical records protected? Do our colleagues on the other 
side of the aisle want to eliminate that right? I am going to ask that 
question. What about the right of privacy in communications and the 
right to open your own mail and to read your own mail without someone 
reading it before you get it? What about that right, that is today 
guaranteed under the 1987 regulations that we enacted, I must say, 
through a bipartisan effort? These are some of the rights, some of the 
most basic rights that our friends on the other side of the aisle are 
attempting to annihilate.
  There is a great deal of irony here, Mr. President, and that irony is 
that no one outside of the Congress has come to us and said we want you 
to repeal the nursing home reform law. At first, when I heard our 
colleagues, the Republicans, were going to repeal these Federal 
guidelines, these Federal standards that we worked so hard to achieve 
through a bipartisan effort with President Bush helping us to put these 
standards into effect, I said: OK, here comes the nursing home lobby, 
the nursing home administrators, the nursing home owners. They have 
come to Washington and they have gone over here and they have gotten 
them to try to repeal and annihilate these particular regulations.
  Mr. President, the odd thing is, I talked yesterday to one of the 
largest chain operators in America of nursing homes. He said,

       We think the standards are good. We think the standards are 
     working. We think the standards help us treat our residents 
     better and we do not want to see those standards taken away. 
     In fact, we think they are more efficient.

  But, just last Saturday, in the New York Times, the executive vice 
president of the American Health Care Association, Mr. Paul Willging, 
said, ``We never took a position that the 1987 law should be 
repealed.'' The New York Times reporter was unable to find anyone at 
this nursing home owners convention representing the industry who would 
say they wanted the law repealed.
  I would like to point out that not only were these standards enacted 
with broad bipartisan consensus, there is also scientific evidence that 
they are working. They are improving nursing home care. They are making 
life better for those among us who live in nursing homes.
  For example, we have here what is not a very pretty chart, I might 
say. I hope I will have some others in the next week or so. In the area 
of physical restraints, since this particular law has been passed, 
since we finally have minimum standards for nursing homes, we have 
decreased the need for physical restraints from 38 percent of the 
nursing home population down, now, to 20 percent. That is an amazing 
statistic for us to look at, and to show and demonstrate beyond doubt 
that this particular set of goals is working.
  We also see another startling fact. Since we enacted these nursing 
home standards, we see now that when a nursing home patient becomes a 
hospital patient, he or she only has to spend, today, 5.3 days in that 
hospital as compared to 7.2 days before. The reason is because you have 
fewer bedsores, you have nursing home patients who are healthier, who 
are stronger, and whose quality of life has been better.
  Also, let us look at another small chart here: The decrease in 
problematic care. There is a dramatic decrease in indicators or poor 
quality care--use of physical restraints, use of urinary catheters. It 
demonstrates without question we are seeing a very rapid decline in the 
need for these particular restraints to ever be used in nursing homes 
again.
  Last Saturday, a Republican spokesman for the House Commerce 
Committee was quoted in the Washington Post as saying that the proposal 
to strip away the safety standards in nursing homes is ``the ending of 
a 8-year experiment.'' This individual went on to say, and here again I 
am quoting, that the standards are ``confining, expensive, and 
counterproductive.'' Last Friday, at a hearing on the Medicaid Program 
in the Senate caucus room, we were presented with the results of a 
scientific study by the independent, well-respected Research Triangle 
Institute. Rather than being confining, expensive, and 
counterproductive, as the Commerce staff member had claimed, this very, 
very distinguished study showed that the standards are in fact 
liberating, that they are cost effective, and result in improved 
outcomes. I say liberating because the standards have decreased the 
unnecessary use of physical and chemical restraints in nursing homes.
  According to the Research Triangle Institute, since the nursing home 
reform standards were implemented in 1990, the use of restraints has 
dropped by 50 percent. So it does not sound to me like these standards 
have been confining for nursing home patients.
  Mr. President, I would like to address an issue in the Medicaid 
debate which is of great concern to me--the issue of whether or not we 
should repeal the law which protects residents of nursing homes from 
abuse and neglect.
  Back in 1987, as part of the Omnibus Budget Reconciliation Act, the 
Congress put into place a set of standards known as nursing home 
reform. Senator Mitchell led that effort, and I am pleased to say I 
helped draft these important standards. Now, even though the standards 
have led to improved care in our Nation's nursing homes, we are about 
to consider a so-called Medicaid reform bill which would wipe them out. 
I offered an amendment to restore these protections during the Finance 
Committee debate on Medicaid and Medicare. My amendment was defeated on 
a tie vote because, according to the leadership of the committee, it 
is--quote--``contrary''--to the philosophy of the reforms being 
proposed.
  Well, I find it hard to believe that any meaningful reform we would 
propose would be inconsistent with quality care in nursing homes. The 
purpose of reform is to get rid of what does not work, keep what does 
work, and make the whole program better. I think we are making a big 
mistake in even considering eliminating our quality standards. I, for 
one, hope we do not enact this dangerous change. We should not turn our 
backs on our frail elderly nursing home patients.
  Mr. President, I know that we in the Congress are hard at work 
examining every program to find ways in which to increase flexibility 
for the States. There is a general mood in the Nation that we want to 
do away with Big Government and return more power to State and local 
decision makers. However, Mr. President, I have a hard time believing 
that when people in America think of Big Government, that they are 
thinking of the laws which provide a minimum standard of care for the 
most frail and vulnerable among us.
  Mr. President, it is well known that as a former Governor, I am a 
strong supporter of States' rights. I have devoted much of my career to 
doing away with Big Government in the negative sense. I support ending 
Federal mandates which make unreasonable demands on our citizens. 
However, I do not feel that the nursing home reform law makes 
unreasonable demands. It is simply not unreasonable to ask nursing 
homes not to tie up residents, or administer mind-altering drugs to 
them, simply to quiet them down for the convenience of staff. It is not 
unreasonable to ask nursing homes to allow residents and their families 
to participate in decisions about their care. Mr. President, it is 
above all not unreasonable to ask nursing homes to ensure 

[[Page S 15005]]
that care is provided to these vulnerable residents by an adequate 
staff that is well trained.
  When we talk about ending Federal mandates, it is often because an 
industry or some other interest group has asked for the repeal of a 
particular law or regulation. The irony of this instance, Mr. 
President, is that no one outside of the Congress has asked that we 
repeal the nursing home reform law. Not only was this law accompanied 
by unprecedented consensus when it was first enacted, it still enjoys 
the support of the industry being regulated. Mr. President, if anyone 
were clamoring to repeal this law, we would expect it to be the nursing 
home industry. But just last Saturday, in the New York Times, the 
executive vice president of the American Health Care Association, Mr. 
Paul Willging, said--and I quote--``We never took a position that the 
1987 law should be repealed.'' The New York Times reporter was unable 
to find anyone representing the industry who would say they wanted the 
law repealed.
  Mr. President, I would like to point out that not only were these 
standards enacted with broad bipartisan consensus, there is scientific 
evidence that they are working. These standards are improving care. 
They are making life better for those among us who live in nursing 
homes.
  Last Saturday, a Republican spokesman for the House Commerce 
Committee was quoted in the Washington Post as saying that the proposal 
to strip away the safety standards is ``ending an 8-year experiment.'' 
He went on to say--and here again I am quoting--that the standards are 
``confining, expensive, and counterproductive.''
  Mr. President, the data we have so far lays waste to those unfounded 
assertions. Last Friday, at a hearing on the Medicaid Program, we were 
presented with the results of a scientific study by the independent, 
well-respected Research Triangle Institute. Rather than being 
confining, expensive, and counterproductive, as the Commerce Committee 
staffer claimed, this research indicates that the standards are 
liberating, cost-effective, and result in improved outcomes.
  I say liberating because the standards have decreased the unnecessary 
use of physical and chemical restraints in nursing homes. According to 
the Research Triangle Institute, since the nursing home reform 
standards were implemented in 1990, the use of restraints has dropped 
by 50 percent. And the Republicans claim that the standards are 
confining? It does not sound to me like they have been confining for 
nursing home patients.
  And lest you think that unrestrained patients are more difficult to 
care for, let me get to the second point--the standards are cost-
effective. This study indicated that less staff time is needed to care 
for patients who are unrestrained. In addition, because patients are 
receiving better care and staying relatively healthier, they are being 
hospitalized less often. According to RTI, nursing home patients are 
suffering from fewer injuries and conditions caused by poor care--this 
translates to a 25-percent decrease in hospital days--resulting in a $2 
billion per year savings in Medicare and Medicaid combined. So how can 
it be said that these standards are expensive?
  The RTI study also points to improved patient outcomes--and I know of 
no better measure of nursing home productivity. There has been a 50-
percent reduction in dehydration, a 4-percent reduction in the number 
of patients developing nutrition problems, and we see 30,000 fewer 
patients suffering from bedsores. We are also seeing significant 
declines in the use of indwelling urinary catheters, a reduction in the 
use of physical restraints, and far fewer patients who are not involved 
in activities. This contributes greatly to quality of life. The RTI 
data also show that since nursing home reform was implemented, patients 
are suffering less decline in functional and cognitive status. So I ask 
my colleagues on the other side of the aisle, how can it be said that 
these standards are counterproductive?
  Mr. President, I pointed out earlier that the nursing home industry 
has not asked for a repeal of these standards. The industry is 
concerned, however, about the depth of the cuts being considered with 
respect to the Medicaid Program. Although nursing homes support the 
quality standards, they are understandably concerned about their 
ability to maintain these standards in the face of deep cuts in 
funding. This is a serious issue which we must address, Mr. President. 
But when we address these concerns about funding, we should start with 
the assumption that standards must be maintained. We should start with 
the assumption that we will not repeal a law which no one has asked us 
to repeal. Instead, what I fear my colleagues on the other side of the 
aisle would rather do is throw standards out the window, cut the 
funding indiscriminately, and then hope for the best. Mr. President, I 
am not willing to take such a chance with our frail elderly. I hope my 
colleagues in the Senate will join their voices with mine in this call 
to protect our vulnerable nursing home residents.
  Mr. President, I would like to close by saying, during this debate on 
reconciliation, in which there will be very little time, we are going 
to look at this particular issue and a lot of other issues that relate 
to it. We are going to look at the need to continue, for example, the 
reimbursement, the rebate for the States that have Medicaid 
prescription drug programs. This is something the drug industry is 
fighting, but it is something we have to maintain so the States can get 
the best possible price for the drugs that they provide for poorest of 
the poor population.
  There are going to be many other areas that we are going to look at. 
But we thought today would be a good day to start the debate on 
reconciliation, because we know the time will be short once that debate 
is actually, technically and literally begun.
  Mr. President, I again thank my good friend from North Carolina who 
has been most cooperative.
  I yield the floor.

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