[Congressional Record Volume 141, Number 166 (Wednesday, October 25, 1995)]
[Senate]
[Pages S15612-S15613]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                     CHANGES IN MEDICARE PROVISIONS

  Mr. GRASSLEY. Mr. President, I want to touch on portions of this 
reconciliation bill that deal very effectively with the changes in 
Medicare provisions that are very good nationally and provisions that 
are very good for rural America.
  The bill will put the financial situation of the Medicare Program, 
particularly the part A hospital trust fund, but also part B for 
physician services, on a sounder, more sustainable footing. This will 
ensure that current and future Medicare beneficiaries in Iowa and 

[[Page S15613]]

elsewhere can continue to depend on the program.
  In addition to putting the program in good shape financially so that 
it lasts into the future, for the baby boomers particularly, we also 
create a new reformed Medicare alongside this traditional Medicare 
Program that we have known for the last 30 years.
  The Medicare reforms in the Senate bill will increase substantially 
the per capita payments that Medicare programs make to low-
reimbursement States like my State of Iowa, and other rural States of 
our Nation.
  This is a very important component of this Medicare reform. If we are 
able to retain this reform by getting it through the Senate, by getting 
it through conference with the House, it would be a great benefit to 
rural communities of my State and of the United States--all of them. 
The critically important issue is whether Medicare's per capita payment 
will be reformed. I have to emphasize that. Reform of Medicare's per 
capita payment is the essential element of bringing fairness and 
soundness to the system. The payment Medicare makes to health plans for 
those who enroll is the core element in the new reform program.
  Currently, those per capita payments vary greatly from one part of 
the country to another. The per capita payments in the highest 
reimbursement areas are as much as 300 percent greater than the per 
capita payments in the low-reimbursement areas.
  I would now refer my colleagues to this map. Many of the counties on 
this map are in darker colors. All of those with darker colors are way 
below the national average in per capita reimbursement for Medicare.
  The red areas make up only 10 percent of the counties. Dade County, 
FL, counties in California, counties in the metropolitan area of the 
East, and metropolitan counties of the South, particularly Texas and 
Louisiana. Those counties in red are the highest per capita 
reimbursement counties in the United States. The variation from the 
dark, low-reimbursement counties to the high-reimbursement counties, 
can be as much as 300 percent from the county with the highest per 
capita payment to the county with the lowest.
  Now, remember that this map shows per capita reimbursement. So the 
rating of our counties from low-reimbursement to high-reimbursement 
does not depend in any way upon the numbers of Medicare beneficiaries 
in the area. There are differences in input prices around the country, 
of course. But those differences cannot account for the very 
substantial reimbursement differences between the low-cost areas, the 
dark areas, versus the red areas, the very high-cost reimbursement 
areas.
  The differences then reflect the fact that providers in those high-
cost counties, high-reimbursement counties, are getting more money for 
each beneficiary that passes through the system. The more you go 
through the system, the more services allowed, the more times you see 
the doctor, the more times you go to the hospital, the more payment you 
get.
  There is no rational justification for such gross payment disparities 
from one region to another under the present Medicare system. This bill 
reforms that. Furthermore, I might say, the citizens in the low-
reimbursement areas pay the same payroll taxes and the same Medicare 
premiums and the same deductibles as their cocitizens in the higher 
reimbursement areas. This is a problem that we should fix and fix soon. 
We have gone a long way toward fixing it in this bill. And if we can 
retain that through the House-Senate conference, we will have very good 
provisions for most of the United States because most of the United 
States is rural.
  On the traditional Medicare side, the bill does call for a spending 
slowdown, but it contains several provisions which I helped get in this 
bill which will help sustain health care services in rural America. We 
reinstituted the Medicare-dependent hospital program, which will 
provide additional reimbursement for Iowa's 30 small rural counties 
that are very dependent on Medicare programs and in a lot of other 
States as well.
  We establish a critical access hospital program which will help the 
very smallest hospitals in rural America, including Iowa, redefine 
their mission, receive better reimbursement and thereby continue to 
provide services in their communities.
  We increase next the bonus payment for physicians who work in 
communities where there is a physician shortage. We do that from a 10 
percent to a 20 percent bonus.
  Next, we included for the third time in legislation sent from the 
Senate to the House my legislation which would reimburse physicians' 
assistants and nurse practitioners at 85 percent of the physician's 
rate when they provide the same services. I hope and believe that the 
bonus payment and the physician's assistance, nurse practitioner 
legislation will increase the availability of primary health care 
services in rural America, including my State of Iowa.
  Finally, we authorize a program of telemedicine grants which could be 
very helpful in Iowa with our developing telemedicine services. And, of 
course, Medicare beneficiaries may continue to participate in the 
traditional Medicare Program and continue to choose their own doctors 
if that is what they want to do. They are going to have a choice for 
the first time, a choice of keeping exactly what the Government has 
offered for 30 years or a choice of choosing an HMO, a medical savings 
account, or their traditional association or union plan that they had 
where they last worked when they retired.
  So, Mr. President, if we can hold the line in discussions with the 
House on these provisions, this Medicare reform could be good for the 
United States but also very good for our low-reimbursement rural 
counties.
  Mr. President, how much time do I have left of the 10 minutes that I 
allotted myself?
  The PRESIDING OFFICER. One minute fifteen seconds.
  Mr. GRASSLEY. Mr. President, I want to respond to a point made by the 
distinguished Senator from New York earlier, Senator Moynihan, when he 
said you cannot balance the budget by cutting taxes. I do not respond 
just to what Senator Moynihan said; I respond to this point because it 
is made continually by people on the other side of the aisle.
  First of all, it certainly is ironic to be getting lectures from the 
other side about how to balance the budget. The only alternative on 
their side was voted down yesterday 96 to 0. That was the President's 
budget. And it would never balance. A chimpanzee with a typewriter will 
bang out by accident the entire Encyclopedia Britannica before the 
President's budget would be balanced.
  The question is whether or not Republicans then can walk and chew gum 
at the same time. And, of course, we can. We can balance the budget and 
then cut taxes at the same time. We must do this. We can do this with 
minimal risk because we use very conservative and very credible CBO 
estimates, unlike the President who has been afflicted, like some of 
his predecessors, with the narcotic of optimism.
  I yield the floor.
  Ms. MIKULSKI addressed the Chair.
  The PRESIDING OFFICER. The Senator from Maryland.
  Ms. MIKULSKI. Mr. President, I yield myself 3 minutes.

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