[Congressional Record Volume 142, Number 50 (Thursday, April 18, 1996)]
[Senate]
[Pages S3578-S3609]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                      HEALTH INSURANCE REFORM ACT

  The Senate continued with the consideration of the bill.
  Mr. HATCH. Mr. President, I understand the pending business is the 
Brown amendment. It is my understanding that he will make his arguments 
and then withdraw the amendment; am I incorrect on that?
  Mr. BROWN. Mr. President, the Senator is correct.
  Mr. HATCH. I am correct.
  Mr. SIMPSON. I yield the floor.
  Mrs. KASSEBAUM addressed the Chair.
  The PRESIDING OFFICER. The Senator from Kansas.
  Mrs. KASSEBAUM. Mr. President, prior to returning to Senator Brown's 
amendment, if I may propose a unanimous consent request on behalf of 
Senator Dole.
  Let me yield and say, evidently, this has not been cleared fully on 
both sides, so we will return to Senator Brown's amendment.
  Mr. KENNEDY addressed the Chair.
  The PRESIDING OFFICER. The Senator from Massachusetts.
  Mr. KENNEDY. Mr. President, we want to try and accommodate the 
greatest number of Members. We have several Senators who are here with 
their amendments ready to address them and ready to act on them. We 
believe that if we are able to do that, we can afford, whoever wants to 
speak, as much time as they want to speak on other kind of matters. But 
we are here to deal with this legislation.
  We have been urging Senators to come over here and offer their 
amendments. They are here now, and we can either do this later--I plan 
to stay here until it is done, but the greater numbers of Members would 
like to have at least some finality to the legislation. I believe we 
can do it. It is 6 o'clock now and we had the chance for general 
discussion during the course of the day. Many of our colleagues have 
come over here to address these issues and to vote on them, and they 
have been waiting as well.
  I hope we will urge our colleagues who are not going to talk on these 
matter--we know they can; people can get up and address any other 
matters--but out of consideration of other Members, please try and see 
if we cannot focus on the matter that is at hand, and that is the 
Kassebaum-Kennedy bill, which is of enormous importance to many 
American families.
  I see other Members here, and I am sure they will do what they have 
to do, but we are trying to conclude this and then to let others speak 
so that at least others will not be here tomorrow. We are going to end 
up being here tomorrow as sure as I am standing here unless we are able 
to make progress. That is fine with me, if that is what it is. But with 
some cooperation of the Members, we have a very good chance of 
finishing this. Otherwise, Members ought to understand we are going to 
be here late tonight voting and end up starting the votes later this 
evening and tomorrow.
  We are just about to ask for the final list so that we can agree with 
that. But in the meantime, we have the Senators who are here who are 
prepared to move ahead. Senator Brown is here, and Senator Jeffords was 
here just a few moments ago to deal with an extremely important measure 
and has been here now for an hour and a half trying to gain the floor.
  Mr. CHAFEE addressed the Chair.
  The PRESIDING OFFICER. The Senator from Rhode Island.


                           Amendment No. 3678

  Mr. CHAFEE. Mr. President, I am going to address the amendment that 
is before us, the Brown amendment,

[[Page S3579]]

but I say to the managers of the bill, I join with them in their 
enthusiasm to finish it up. I do not see why we do not seek time 
agreements, in case we get off on another Social Security argument, 
whatever it might be. But that is up to the managers.
  Mr. President, I have a statement that I wish to make that deals with 
the subject Senator Brown has been addressing, and Senator Pryor, 
likewise, and which I joined in the past.
  All I can say, Mr. President, is I just wish we would address this 
matter, both in the committee, and I understand Senator Brown has been 
trying to achieve that, but also on the floor of the Senate. We have 
had one vote. It was a one-vote margin difference. Perhaps people's 
minds have been changed since then. Nonetheless, I support the efforts 
of Senators Brown and Pryor.
  Congress and the administration made a simple--but costly--error in 
drafting the Uruguay Round Agreements Act of 1994. That inadvertent 
error is costing consumers, State governments, and the Federal 
Government millions of dollars, while providing an unintended windfall 
to a handful of drug companies. I don't believe we should let that 
error stand.
  What happened? The facts of the case are straightforward. Back in 
1994, Congress was drafting omnibus trade legislation designed to bring 
the United States into conformity with the important new global trade 
agreement known as the GATT. As part of our commitment to fulfill our 
new GATT obligations, the United States pledged to increase patent 
protection for future patents. In addition, the United States also 
pledged to boot protection for patents already in existence--a key 
point that goes to the heart of the issue before us today.
  Accordingly, the trade bill that Congress wrote, boosted existing 
patent terms by up to 3 years, giving current patentholders a valuable 
extension on their patents. To be fair to generic manufacturers who had 
been preparing to go to market on the old patent expiration date, 
Congress fashioned a compromise: generic companies who had made a 
substantial investment in preparing for market would be allowed to 
proceed as planned, but would have to pay equitable remuneration--that 
is, a royalty--during the extended term. This carefully balanced 
compromise became law as part of the 1994 Uruguay Round Agreements Act.
  However, in drafting this 653-page bill, Congress and the 
administration made a small--but very costly--mistake. A simple 
conforming amendment to an FDA statute was omitted. Yet the impact was 
enormous: the omission singlehandedly prevented the generic drug 
industry from going to market during the extended term. The result is 
that a handful of brand-name drug companies have received a staggering 
$4.3 billion windfall, at the expense of consumers, that Congress, 
United States trade officials, and even the brand-name companies 
themselves, neither intended nor expected.
  The cost to consumers is enormous. The drugs that are covered by the 
windfall are widely prescribed, and are used for everyday ailments that 
affect millions of Americans. Keeping the generic version off the shelf 
for up to 3 years means that Americans--including and especially older 
Americans--are paying far more than was ever intended for their 
medications.
  Not only are consumers paying for this error, but so are State 
governments and the Federal Government--in the form of higher 
reimbursements for prescription drugs for the elderly, veterans, and 
low-income Americans.
  This is not right. We made a mistake. We should fix it. In this case, 
the solution is obvious and easy: simply enact the missing conforming 
amendment. That is exactly what Senator Pryor, Senator Brown, and I--
and many others--have been working to do.
  Let me take a moment to put to rest a few red herrings. Our amendment 
would not affect our GATT commitments or our efforts to promote patent 
protection worldwide. Our amendment would not upset the balance in U.S. 
drug patent laws, nor impede research and development of new drugs. If 
any of these misrepresentations were true, we simply would not be 
sponsoring this amendment. It is that simple.
  It is time to correct this injustice--an injustice to consumers in 
our Nation, an injustice to the Federal and State governemnts that are 
paying extra and needless sums into Medicaid and Medicare and an 
injustice to the generic manfuactures who made the investment in 
reliance on the law as it was supposed to be.
  It is time we fixed this unfairness.
  Mr. BROWN addressed the Chair.
  The PRESIDING OFFICER. The Senator from Colorado.
  Mr. BROWN. Mr. President, it is my intention to try and expedite the 
deliberations here tonight. In that regard, my thought would be to make 
a statement, hopefully, shedding some light on this amendment. I know 
Senator Pryor has worked so hard in this area. He wants to make a 
statement, and then it will be my intention to withdraw the amendment. 
I withdraw it reluctantly, because I think it needs to be considered 
and dealt with as soon as possible. But I am persuaded that we will not 
have some votes that we need to adopt it if we insist on attaching it 
to this measure.
  Having said that, let me simply outline the issue that is before us. 
It is well described in a New York Times editorial of February 28. I 
will quote a portion of that, because I think it is quite succinct and 
to the point:

       Congress finds it hard to remedy the simplest mistakes when 
     powerful corporate interests are at stake. In 1974, when 
     Congress approved a new trade pact with more than 100 other 
     countries, it unintentionally handed pharmaceutical drug 
     companies windfall profits. More than a year later, Congress 
     has yet to correct the error. The trade pact obliged the 
     United States to change its patent laws to conform with those 
     of the rest of the world. They had the effect of extending 
     some American patents for up to 20 months.

  Mr. President, those are the opening lines of the editorial.
  The simple fact is this. We had people research drugs and put the 
investment into it and receive the full length of their exclusivity 
that this Congress has supported and put into statute. The GATT 
agreement gave a serendipitous extension to that. In other words, under 
the GATT agreement and the conforming changes of law that this Congress 
adopted, people who had invested in and relied on our laws got a longer 
period of patent protection than they have ever planned for. But the 
GATT agreement also had a provision, an exception for that extended 
protection when someone had made a substantial investment in reliance 
on our laws in providing competitive products.
  In other words, what we propose in this amendment is nothing more 
than absolutely the process that was contemplated and planned for under 
GATT. And, I might mention, Mr. President, many countries have done 
exactly the same thing. As a matter of fact, this country has done a 
similar kind of thing with other products.
  What this amendment simply suggests is that where we have given 
someone an unexpected, unplanned extension in their patent protection, 
that we make an exception for that extension where someone else has 
made a substantial investment in producing and providing a competitive 
product--in this case, a generic drug.
  If we do not adopt this, we will have said to people who produce 
products in reliance to our laws, ``After you have made the investment, 
after you have put the money into it, after you have made under the 
terms of what will be the statute a substantial investment on reliance 
of our laws, we are going to pull the rug out from under you and change 
the rules retroactively.''
  Mr. President, that is not right. That is not honest. That is not 
fair. That is not a good way to do business. We have talked about the 
horrible damage--and it is enormous damage--done to consumers by this 
unjustified quirk of the ratification document.
  But I want to focus the Members' attention on what is unfair to 
business. I believe it is unfair to business to say, ``Look, here are 
the laws. Here is how long you have for patent protection. And by the 
way, we're going to change the law retroactively, and even though you 
made substantial investment in producing a competing product, we're not 
going to let you compete.'' Now, that is what has happened.
  If we do not pass this bill as it is in committee or the amendment as 
we offer it on the floor, what you are going to do is not only impact 
consumers to the tune of billions of dollars, but you are going to say 
to businesses that have relied on the law, that it is tough luck, you 
should not have believed us. You should not have relied on what we did.

[[Page S3580]]

  Why is it important to pass it on this bill or pass it quickly? I 
think that is a fair question. I must tell the Members, I am 
disappointed I have not been able to persuade all the other people who 
support the concept that it is important to pass it on this measure.
  It is important because the impact of this, if it goes uncorrected, 
could be over $2 billion, according to the Washington Post. It is 
important because this costs consumers up to $5 million a day while we 
delay. Mr. President, let me repeat that because I am not sure people 
have focused on the impact of delay. It costs up to $5 million a day to 
consumers in this country if we do not act. Some estimates indicated it 
may have cost consumers already $700 million.
  Mr. President, this is not anything other than fairness. This is not 
anything other than saying the patent protection that was planned in 
the law ought to be delivered as it was planned in the law.
  Mr. President, I will not prolong the argument. I know the 
distinguished Senator from Arkansas has worked on this and has some 
remarks, but I ask unanimous consent to have printed in the Record the 
editorial from the Washington Post, a letter from The Seniors 
Coalition, a letter from the National Committee to Preserve Social 
Security and Medicare, a letter from the National Women's Health 
Network, a letter from the Citizen Action, a letter from the Gray 
Panthers, a letter from the Generic Drug Equity Coalition, a letter 
from the Consumer Federation of America, and a letter from the Citizen 
Advocacy Center, all pertaining to this subject and advocating the 
position of this amendment. I ask unanimous consent that all of these 
letters be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                [From the Washington Post, Dec. 4, 1995]

                          The Zantac Windfall

       All for lack of a technical conforming clause in a trade 
     bill, full patent protection for a drug called Zantac will 
     run 19 months beyond its original expiration date. Zantac, 
     used to treat ulcers, is the world's most widely prescribed 
     drug, and its sales in this country run to more than $2 
     billion a year. The patent extension postpones the date at 
     which generic products can begin to compete with it and pull 
     the price down. That provides a great windfall to Zantac's 
     maker, Glaxo Wellcome Inc.
       It's a case study in legislation and high-powered lobbying. 
     When Congress enacted the big Uruguay Round trade bill a year 
     ago, it changes the terms of American patents to a new 
     worldwide standard. The effect was to lengthen existing 
     patents, usually by a year or two. But Congress had heard 
     from companies that were counting on the expiration of 
     competitors' patents. It responded by writing into the trade 
     bill a transitional provision. Any company that had already 
     invested in facilities to manufacture a knock-off, it said, 
     could pay a royalty to the patent-holder and go into 
     production on the patent's original expiration date.
       But Congress neglected to add a clause amending a crucial 
     paragraph in the drug laws. The result is that the 
     transitional clause now applies to every industry but drugs. 
     That set off a huge lobbying and public relations war with 
     the generic manufacturers enlisting the support of consumers' 
     organizations and Glaxo Wellcome invoking the sacred 
     inviolability of an American patent.
       Mickey Kantor, the president's trade representative, who 
     managed the trade bill for the administration, says that the 
     omission was an error, pure and simple. But it has created a 
     rich benefit for one company in particular. A small band of 
     senators led by David Pryor (D-Ark.) has been trying to right 
     this by enacting the missing clause, but so far it hasn't got 
     far. Glaxo Wellcome and the other defenders of drug patents 
     are winning. Other drugs are also involved, incidentally, 
     although Zantac is by far the most important in financial 
     terms.
       Drug prices are a particularly sensitive area of health 
     economics because Medicare does not, in most cases, cover 
     drugs. The money spent on Zantac is only a small fraction of 
     the $80 billion a year that Americans spend on all 
     prescription drugs. Especially for the elderly, the cost of 
     drugs can be a terrifying burden. That makes it doubly 
     difficult to understand why the Senate refuses to do anything 
     about a windfall that, as far as the administration is 
     concerned, is based on nothing more than an error of 
     omission.
                                                                    ____



        The Seniors Coalition, Protecting the Future You Have 
                                                       Earned,

                                   Washington, DC, April 17, 1996.
     Hon. Hank Brown,
     U.S. Senate,
     Washington, DC.
       Dear Senator Brown: The Seniors Coalition urges you to 
     support legislation offered by Senator Brown in the Judiciary 
     Committee to correct an egregious mistake made in the 
     implementation of the GATT treaty. This mistake has cost the 
     consumers, and primarily the elderly, of this nation millions 
     of dollars. This loophole has allowed a few drug companies to 
     take advantage of a situation that was unintended and to line 
     their pockets with unearned money from American citizens.
       I ask you to read the article ``What you don't know about 
     brand name drugs is costing you millions'' (pp. 4-5) in our 
     latest edition of The Senior Class which outlines the problem 
     and then to vote to support the correction. Your support for 
     this effort is critical to the financial well being of 
     thousands of senior citizens.
       I submitted testimony to the Senate Judiciary Committee on 
     this issue when the committee held hearings on this issue in 
     February. At that time I called for the Congress to correct 
     the mistake and reject the efforts of brand name companies to 
     thwart the correction. The so-called ``compromise'' that has 
     been drafted by Glaxo and may be offered by a member of the 
     Judiciary Committee is nothing more than a thinly veiled 
     effort to codify the mistake that was made. A careful reading 
     of the language will find that it does even more damage to 
     the ability of consumers, especially seniors, to find safe 
     and affordable pharmaceutical products in the marketplace.
       Again, please support Senator Brown and his effort to 
     correct this mistake. Now is the time for the Congress to do 
     something for the American public.
           Sincerely,
                                                   Thair Phillips,
     CEO.
                                                                    ____

         National Committee to Preserve Social Security and 
           Medicare,
                                   Washington, DC, March 27, 1996.
     Honorable Hank Brown,
     Senate Judiciary Committee, U.S. Senate, Hart Senate Office 
         Building, Washington, DC.
       Dear Senator Brown: We understand the Senate Judiciary 
     Committee plans to mark-up legislation addressing and General 
     Agreement of Tariff and Trade (GATT) patent pharmaceutical 
     issue tomorrow. We urge you to support legislation (S. 1277) 
     sponsored by Senators Chafee, Pryor, and Brown to correct an 
     oversight in the GATT implementing legislation that will save 
     consumers and taxpayers billions of dollars in prescription 
     drug costs. We urge you to oppose any alternative measures 
     that would maintain this costly and unintended loophole under 
     GATT.
       As you know, because of an oversight in patent changes 
     approved under the GATT treaty implementing legislation, the 
     availability of lower-priced generic versions of more than 25 
     widely-prescribed drugs must be delayed for up to an 
     additional three years. As a result, seniors and other 
     consumers will wait longer for access to less-costly generic 
     drugs.
       Every day Congress delays in correcting this oversight 
     costs consumers $5 million dollars in additional prescription 
     drug costs. In fact, the delay has already cost consumers an 
     additional $500 million dollars. The biggest losers among 
     U.S. consumers are senior citizens, as older Americans 
     consume about one-third of the prescription drugs sold in the 
     United States. On fixed incomes and with no pharmaceutical 
     coverage under Medicare, three out of four seniors cite 
     prescription drugs as their largest out-of-pocket expense.
       On behalf of our millions of members and supporters, the 
     National Committee to Preserve Social Security and Medicare 
     urges you to support and report out of Committee the Chafee/
     Pryor/Brown generic drug legislation.
           Sincerely,
                                                Martha A. McSteen,
     President.
                                                                    ____



                              National Women's Health Network,

                                   Washington, DC, March 21, 1996.
       Dear Judiciary Committee Member: In this time of federal, 
     state and local budget-cutting, threats to Medicare and 
     Medicaid, and continually rising medical costs, health care 
     savings are more important than ever to the American public. 
     Given the seriousness of skyrocketing health care costs, it 
     is unconscionable that Congress has so far failed to address 
     an error that needlessly increases the cost of health care 
     for millions of Americans, and unnecessarily boosts costs to 
     the federal government, as well.
       More than a year ago, Congress discovered that the 
     legislation implementing the GATT Treaty contained an 
     unintended loophole for some pharmaceutical drug companies. 
     An error of omission granted the manufacturers of brand-name 
     drugs treatment unique in all of American industry.
       By failing to include generic drugs in its rules concerning 
     transition to new patent terms under the GATT Treaty, 
     Congress has done a disservice to women's health, 
     specifically, and to consumers and taxpayers, generally. 
     While the mistake was unintentional, the consequences are 
     grave. Each day that passes without Congressional action to 
     correct this error costs millions of dollars; the total cost 
     is expected to exceed $2 billion.
       The beneficiaries of the current situation are the handful 
     of giant pharmaceutical corporations that will enjoy windfall 
     profits for three additional years. Their glee at this 
     unanticipated windfall is evidenced by the fierceness with 
     which the lobbyists for these companies are fighting to 
     preserve their protected status.
       The exemption of drug companies from the GATT transition 
     rules was a mistake. It

[[Page S3581]]

     would be intolerable to compound this mistake by failing to 
     correct it. Please support the solution proposed by Senators 
     Brown, Chafee and Pryor.
           Sincerely,
                                                  Cynthia Pearson,
     Program Director.
                                                                    ____



                                               Citizen Action,

                                   Washington, DC, March 26, 1996.
       Dear Judiciary Committee Member: On behalf of Citizen 
     Action and our three million members, I would like to ask 
     your support for a proposal which will shortly be offered by 
     Senators Brown, Chafee and Pryor. This proposal would undo a 
     legislative error which, if not corrected, will cost U.S. 
     consumers hundreds of millions of dollars in unnecessary 
     prescription drug costs.
       When Congress passed new patent terms under the GATT 
     Treaty, it failed to include prescription drugs under its 
     transition rules. GATT extends patent terms of U.S. products 
     from 17 to 20 years. Because many manufacturers had already 
     invested millions of dollars in competing products in 
     expectation of the 17-year limit, Congress adopted transition 
     rules to allow those companies to introduce generic 
     alternatives on the date that the 17-year patent would have 
     expired.
       The omission of prescription drugs in the transition rule 
     means that makers of lower-cost generic drugs will be unable 
     to bring their products to market until the full 20-year term 
     of patent protection has expired. This loophole will allow a 
     few large pharmaceutical companies to reap more than $2 
     billion in windfall profits. Because lower-cost generics will 
     be kept off the market, consumers will be forced to pay 
     higher prices for more than a dozen drugs, including big-
     sellers Zantac and Capoten.
       Without a correction, taxpayer-funded federal and state 
     health programs, as well as individual purchasers of 
     prescription drugs, will be forced to pay higher than 
     necessary costs. The Department of Veterans Affairs estimates 
     that it alone will spend $211 million in additional costs 
     over the next three years.
       The Judiciary Committee has an opportunity to correct a 
     provision that will have grave consequences for consumers. 
     Again, Citizen Action urges that you act now to remove this 
     unique loophole which rewards certain large pharmaceutical 
     companies at the expense of taxpayers and consumers.
           Sincerely,
                                                  Cathy L. Hurwit,
     Legislative Director.
                                                                    ____

                                       Gray Panthers Project Fund,


                                      Age and Youth in Action,

                                Washington, DC, February 29, 1996.
     Hon. Hank Brown,
     U.S. Senate, Senate Hart Office Building, Washington, DC.
       Dear Senator Brown: Attached please find copies of 
     Tuesday's ABC World News Tonight news story focusing on the 
     negative impact that the GATT loophole will have on American 
     consumers like Eleanor Black and her mother Sally. In 
     addition, attached are copies of the testimony submitted to 
     the Judiciary Committee from Ms. Black and myself, as well as 
     Wednesday's New York Times editorial on the issue.
       With the Senate Judiciary Committee hearings on GATT now 
     behind us, Senators Chafee, Brown, and Pryor have vowed to 
     introduce legislation within the next few weeks that will 
     correct this loophole and bring relief to millions of 
     consumers like the Blacks who rely on the savings that 
     generic pharmaceuticals offer.
       In December, an effort to bring the Chafee-Brown-Pryor 
     amendment to the Senate floor was narrowly defeated by one 
     vote. When the Chafee-Brown-Pryor amendment is introduced in 
     the near future, I urge you and your colleagues to do the 
     right thing and correct this Congressional oversight and save 
     American taxpayers from a costly mistake.
       Please support the Chafee-Brown-Pryor amendment and close 
     the GATT loophole.
           Sincerely,
                                                 Dixie D. Horning,
     Executive Director.
                                                                    ____



                                Generic Drug Equity Coalition,

                                   Washington, DC, March 29, 1996.
     To: Members, United States Senate
     FR: Generic Drug Equity Coalition
     RE: No More Delays, Pass Chafee/Pryor/Brown

       When the Senate adjourns today for the Spring recess, 
     consumers and taxpayers will have paid $580 million more for 
     prescription drugs than they should have because of a mistake 
     Congress and the administration made in December 1994, $580 
     million. Everyday that passes costs consumers and taxpayers 
     $5 million more.
       By the time you return in two weeks, the cost to consumers 
     and taxpayers will have reached $650 million.
       Yet, despite written commitments to markup a bill to close 
     the GATT loophole in the Senate Judiciary Committee in March, 
     nothing has happened.
       A few companies continue to reap unintended windfall 
     profits at the expense of American consumers, taxpayers and 
     generic drug manufacturers.
       While you are away observing the Easter and Passover 
     Holidays be sure to think about Americans like 69-year old 
     Eleanor Black and her 89-year old mother Sally who spend $339 
     a month, one quarter of their monthly income, for Zantac 
     because of the GATT loophole.
       The Generic Drug Equity Coalition urges you to support the 
     Chafee/Pryor/Brown proposal and close the GATT loophole.
       The Judiciary Committee leadership has missed its own, 
     self-imposed deadline. It is time for a vote on the Senate 
     floor.
                                                                    ____



                               Consumer Federation of America,

                                   Washington, DC, March 27, 1996.
       Dear Senate Judiciary Committee Member: The Senate 
     Judiciary Committee plans this week to examine the loophole 
     in the General Agreement on Tariffs and Trade (GATT) which 
     exempts the pharmaceutical industry from patent transition 
     terms. We urge you at this time to support the efforts of 
     Senators Brown, Chafee, and Pryor to redress this unintended 
     and potentially costly, effect of the GATT Treaty.
       As you know, an error of omission in the legislative 
     language implementing the GATT Treaty has exempted the 
     pharmaceutical industry from the patent transition terms. As 
     a result, the pharmaceutical drug industry--alone among all 
     industries--enjoys a 20-year patent term, and generic 
     manufacturers are unable to market long-planned products.
       The unintended effects of the patent extension include 
     diminished market competition, an undeserved windfall to pre-
     GATT patent holders, and further inflated costs to millions 
     of Americans. The Congressional Budget Office (CBO) has 
     estimated that this simple mistake will cost consumers and 
     taxpayers as much as $2 billion as drug companies reap 
     windfall profits in the absence of competition. This windfall 
     was not intended by Congress, nor envisioned in the GATT 
     treaty itself.
       Senators, Brown, Chafee, and Pryor have proposed closing 
     the loophole, thereby protecting consumers' health and 
     taxpayers' wallets. This solution would not convey special 
     status on the generic drug industry; instead, this amendment 
     provides for equal treatment, and would compel brand-name 
     drug manufacturers to live under the same rules as every 
     other American industry.
       In the interest of consumers, taxpayers and fairness, we 
     urge you to support the efforts Senators, Brown, Chafee, and 
     Pryor have made to redress this costly error.
           Sincerely,

                                                   Mern Horan,

                                       Legislative Representative,
     Consumer Federation of America.
                                                                    ____



                                      Citizen Advocacy Center,

                                     Elmhurst, IL, March 25, 1996.
       Dear Judiciary Committee Member: An oversight in the 
     legislation implementing the GATT Treaty has granted the 
     pharmaceutical industry a privileged status at the expense of 
     consumers and taxpayers. More than a year after the 
     implementing legislation was adopted, Congress has yet to 
     correct this windfall benefit. Now, Senators Brown, Chafee, 
     and Pryor have developed a solution that is fair and 
     reasonable and deserving of your support.
       GATT is premised on opening world markets to competition. 
     Under our implementing legislation, however, manufacturers of 
     generic drugs, alone among all industries in the United 
     States, are prohibited from bringing products to market until 
     the full twenty-year patent term has expired for brand-name 
     drugs. This anticompetitive windfall is estimated to be worth 
     two billion dollars in profits. Health care consumers are 
     thus forced to pay higher costs, as will taxpayers, who fund 
     drug purchases through a number of government programs. The 
     City of Elmhurst has a high percentage of Senior Citizens, a 
     group that is disproportionately harmed by high health care 
     costs, and the adverse effects of the as yet uncorrected 
     legislation.
       Congress did not intend to bestow this windfall on drug 
     companies when it adopted the transitional rules for GATT. We 
     urge you, in the interest of consumers, seniors, and 
     taxpayers, to correct this oversight and to not be lulled 
     into inaction by the multi-million dollar lobbying blitz of 
     the companies enjoying this windfall daily.
       Senators Brown, Chafee and Pryor have proposed a simple 
     solution that would protect the balance of interest between 
     generic and brand-name manufacturers envisioned in the Hatch-
     Waxman Act of 1984. It's time to support their proposal.
           Very truly yours,

                                                Theresa Amato,

                                               Executive Director,
                                          Citizen Advocacy Center.

  Mr. PRYOR addressed the Chair.
  The PRESIDING OFFICER. The Senator from Arkansas.
  Mr. PRYOR. Mr. President, my apologies to the Senator from Colorado. 
Has the Senator from Colorado finished his statement?
  Mr. BROWN. Yes.
  Mr. PRYOR. Mr. President, I will take but a few moments of the 
Senate's time this evening. We need to move on. The distinguished 
managers have requested that we move to final resolution of this very 
important measure. But I would like to take, Mr. President, in opening, 
a few moments to discuss our particular concerns over this uncorrected 
error in our laws which has led to unnecessarily high drug prices.
  I would like to quote from my good colleague who is departing the 
Senate and is a great friend, Senator Paul Simon of Illinois. Senator 
Simon recently spoke on the issue of correcting

[[Page S3582]]

this problem in the GATT treaty. I quote from Senator Simon when he 
said, ``This is a classic example of special interests versus the 
public interest.''
  Mr. President, that is what this debate, I am afraid, has boiled down 
to. I know my friend from Colorado, Senator Brown, in his eloquent 
statement has placed into the Record a recent editorial of December 4, 
1995 from the Washington Post. I will read a paragraph from that 
editorial:

       All for lack of a technical conforming clause in a trade 
     bill, full patent protection for a drug called Zantac will 
     run 19 months beyond its original expiration date. Zantac, 
     used to treat ulcers, is the world's most widely prescribed 
     drug, and its sales in this country run to more than $2 
     billion a year.

  I continue quoting from the Washington Post editorial:

       The patent extension postpones the date at which generic 
     products can begin to compete with it and pull the price 
     down. That provides a great windfall to Zantac's maker, Glaxo 
     Wellcome, Inc.

  That is the beginning paragraph, Mr. President, of the Washington 
Post editorial. To conclude from that editorial, let me read:

       That makes it doubly difficult to understand why the Senate 
     refuses to do anything about a windfall that, as far as the 
     administration is concerned, is based on nothing more than an 
     error of omission.

  Well, once again, this issue is with us. We failed by one vote back 
on December 7 to rectify this mistake. Since that time, a few companies 
like Glaxo Wellcome have earned more than $600 million in extra 
revenues because of a congressional error. It also means that the 
Veterans Administration, the Medicaid programs, the consumers of 
America, and especially the elderly of America are having to pay double 
for Zantac than what they would be paying had we allowed a generic to 
come into the marketplace and compete.
  This is not fair, Mr. President. We know that this is not fair. The 
Judiciary Committee this morning had scheduled a markup, one which has 
already been delayed from last month. They continue to promise that 
they are going to mark up S. 1277, the measure offered by Senator Brown 
and Senator Chafee and myself to correct this mistake in the GATT 
treaty.
  But, once again, this morning an unnamed Senator objected to the 
Senate Judiciary Committee marking up this measure, and, once again, it 
means more and more windfall profits for undeserving companies at the 
expense of consumers. These delays are completely unacceptable and 
unwarranted. The American public simply cannot abide further delays on 
behalf of special interests.
  What is at stake? Back on November 27, 1995, an editorial in the Des 
Moines Register stated that:

       A month's supply of Zantac ordinarily sells for around 
     $115; the generic price--meaning the same drug without the 
     Zantac label--would be around $35, the generic makers 
     contend.

  Mr. President, I ask unanimous consent that a copy of that Des Moines 
Register editorial be printed in the Record.
  There being no objection, the editorial was ordered to be printed in 
the Record, as follows:

             [From the Des Moines Register, Nov. 27, 1995]

                           A Costly Oversight


        fine print in gatt law could cost zantac users millions

       The nation's prescription drug makers are at war again, 
     with a $1 billion-plus purse going to the winner. If the 
     brand-name drug manufacturers win, the losers will include 
     the millions of Americans who suffer from ulcers or 
     heartburn, and take the drug Zantac regularly to combat the 
     problem. It's going to cost each of them about $1,600.
       Zantac is made by GlaxoWellcome, the biggest in the 
     business.
       Here's what started the current war:
       When a new prescription drug hits the market, generic drug 
     manufacturers await the patent expiration so they can enter 
     the market with the same drug. They offer it for sale without 
     the brand name, usually at a fraction of the brand-name 
     price.
       The new international GATT treaty signed by the United 
     States and 122 other countries sets the life of a patent at 
     20 years from the date of application. Former U.S. law 
     provided patent protection for pharmaceuticals for 17 years 
     from the date of approval. Because the difference could have 
     a significant impact on the number of years a firm could 
     market its patented drug without competition. Congress made 
     special provisions for drugs under patent at the time GATT 
     was approved last summer.
       But when the legal beagles got done reading all the fine 
     print, it turned out that Zantac was granted a 19-month 
     extension of its patent life--and it is such a hugely popular 
     drug that that translates into a multimillion-dollar 
     windfall.
       Generic drug makers call the windfall a congressional 
     oversight, and estimate the difference is worth $2.2 billion 
     to Glaxo, because the generics can't enter the market for 19 
     more months. Glaxo counters that Congress made no mistake, 
     that the extension was part of the compromise with generics. 
     It won't wash. Nothing in the GATT treaty was intended to 
     further enrich the happy handful of brand-name drug makers 
     who hold lucrative patents--or to personalize the users of 
     the drugs.
       A month's supply of Zantac ordinarily sells for around 
     $115; the generic price--meaning the same drug without the 
     Zantac label--would be around $35, the generic makers 
     contend. Unless Congress changes the wording of the law 
     regarding transition to GATT provisions, Zantac users will 
     pay the difference for 19 months longer.
       Some generic drug manufacturers had already spent a bundle 
     preparing to enter the market before the GATT treaty took 
     effect. They lose. So do taxpayers, who pay for Medicaid 
     prescriptions. The Generic Drug Equity Coalition estimates 
     that the higher costs of Zantac and some other drugs affected 
     by the mistake (such as Capoten, for high blood pressure) 
     will cost Iowa Medicaid $3.5 million. Further, say the 
     generic drug makers, it will tack another $1.2 million onto 
     the cost of health-insurance premiums for Iowa state 
     employees.
       Glaxo's political action committee has doubled its 
     contributions to Congress in recent months. Glaxo wants the 
     mistake to stay in the law. Generic drug manufacturers want 
     it out.
       So should ulcer sufferers. So should taxpayers. So should 
     Congress.

  Mr. PRYOR. Mr. President, finally, let me say we all know what this 
issue is about. We have debated this issue to some extent on the floor 
of the Senate and to a great extent in the Judiciary Committee. We 
heard our U.S. Trade Representative, Ambassador Kantor conclusively 
explain the situation, and I quote:

       The provision was written neutrally because it was intended 
     to apply to all types of patentable subject matter, including 
     pharmaceutical products. Conforming amendments should have 
     been made to the Federal Food, Drug and Cosmetic Act and 
     section 271 of the U.S. Patent Act, but were inadvertently 
     overlooked.

  One other quote from Ambassador Kantor:

       We intended to apply this grandfather provision to the 
     pharmaceutical area. S. 1277 would result in a level of 
     protection that is consistent with our original intent.

  Mr. President, let me say, Senator Brown, Senator Chafee and myself 
have tried to proceed in good faith. There are Members on each side of 
the aisle that have stated their concern about, and in some cases their 
objection to, certain language that we had in this legislation. We have 
attempted to meet with them. We have attempted to compromise. We have 
certainly gone to the negotiating table and attempted to bargain in 
good faith and see what their concerns are.
  Truly, Mr. President, I believe that we now have come together and 
crafted an amendment that is acceptable to all those concerned with 
doing what is right for consumers, businesses which have relied upon 
the law in good faith and for our compliance with a very important 
treaty. The amendment represents the simplest and best means for us to 
correct the egregious flaw that persists today because of 
unconscionable delays and the efforts of special interests.
  Mr. President, I want to say in conclusion that I have thoroughly 
enjoyed working with Senator Brown of Colorado and Senator Chafee of 
Rhode Island, my colleagues on the other side of the aisle. I hope we 
can bring this matter to a resolution in the very near future.
  The PRESIDING OFFICER (Mr. Gorton). The Senator from Colorado.
  Mr. BROWN. Mr. President, the vote on this measure was close, as has 
been noted. Since that time, I believe we have persuaded others to join 
us in advocating this amendment. The amendment has been compromised to 
the point that specifically we have spelled out in the compromise 
version that is before the Senate right now a very clear, bright-line 
test of what substantial investment is. It is easy and clear to work 
with. I think we have addressed the problems. I am confident we have 
the votes.
  However, because of the urgency of the particular underlying measure 
that is here, some Members whose votes we need and count on are unable 
to support this amendment because they fear

[[Page S3583]]

it would bring controversy to the bill. It is, therefore, necessary for 
me to reluctantly withdraw this measure.
  I must mention, Mr. President, it does seem to me this is the 
appropriate kind of thing that ought to be considered on a prompt 
basis. Literally, to fail to act costs consumers $5 million or more a 
day, and literally if we fail to act very promptly, the issue becomes 
moot because the time simply runs out. I believe in fairness to 
companies that have reinvested, and, in fairness to consumers, we 
should and must act quickly.
  I simply want to serve notice that we will be looking for other 
vehicles to offer on this floor in a rather prompt fashion.
  With that, I reluctantly withdraw the amendment.
  The PRESIDING OFFICER. The Senator has the right to withdraw the 
amendment.
  So the amendment (No. 3678) is withdrawn.
  Mrs. KASSEBAUM. Mr. President, I very much appreciate the sponsors of 
the amendment withdrawing it. Senator Brown and Senator Pryor are very 
persuasive in their arguments, as Senator Chafee was as well. I am 
sympathetic to the purpose of the amendment.
  As was noted by the sponsors, it is controversial. For that reason, 
we would have to oppose it on the health insurance reform bill. I 
appreciate the thoughtfulness in their withdrawal.


                      Unanimous-Consent Agreement

  Mrs. KASSEBAUM. Mr. President, I put forward on behalf of the 
majority leader a unanimous-consent agreement.
  I ask unanimous consent during the remainder of the Senate's 
consideration of S. 1028, the following amendments be the only first-
degree amendments in order, that they may be subject to relevant 
second-degree amendments, and following the disposition of the listed 
amendments and the committee substitute, the bill be advanced to third 
reading, and the Senate then proceed to the House companion bill, that 
all after the enacting bill be stricken, the text of the Senate bill be 
inserted, the bill be advanced to third reading and the Senate proceed 
to vote on passage of H.R. 3103, as amended, without any intervening 
action or debate.
  The list that I have of the amendments would be: Nickles, relevant; 
Jeffords, lifetime caps; Thomas, rural health; McCain, biological 
medical devices; Gramm, relevant; Coats, medical volunteer liability 
coverage; Domenici, mental health; Specter, public health; pecter, 
public health; Specter, public health; Gregg, choice care; Helms, study 
of access by HHS; Senator Brown has withdrawn his amendment; McConnell, 
medical malpractice; Bond, administration simplification; Pressler, 
CRNAS; D'Amato, fair tax treatment; Kassebaum, relevant; Dole, 
relevant; Roth, relevant; Simpson, commission; Bennett relevant; Burns, 
telemedicine; Boxer, ban HMO gag rules; Conrad, nurse practitioner, 
nurse anesthetists, advance nurse practitioner; Feinstein, nonprofit 
insurance; Graham-Baucus, Medicare fraud; Harkin, fraud and abuse; 
Harkin, fraud and abuse; Kennedy, relevant; Pryor relevant; Wellstone, 
two domestic violence; Simon is a sense-of-the-Senate resolution; 
Dorgan, organ donations; Lieberman, MM data banks; Kennedy, nursing 
care; Daschle, relevant; Boxer, biomed devices.
  Mr. KENNEDY. Would the Senator add Wellstone, relevant, sense of the 
Senate.
  The PRESIDING OFFICER. Is there objection to the unanimous consent 
request?
  Without objection, it is so ordered.
  Mrs. KASSEBAUM. Mr. President, I believe Senator Jeffords has been 
waiting, and I believe he is next to be recognized.
  Mr. JEFFORDS. Mr. President, I yield to the Senator from Arkansas.
  Mr. PRYOR. Mr. President, if we could ask a question, Mr. President, 
while the two distinguished managers are on the floor. It is 6:15; I 
did not realize there were quite as many amendments.
  Mrs. KASSEBAUM. Neither did we.
  Mr. PRYOR. Are we planning to go on into the evening?
  Mrs. KASSEBAUM. Yes, Mr. President, I say to the Senator from 
Arkansas, I think it is the hope not only of the managers but also of 
the minority leader and the majority leader that we finish tonight.
  Mr. PRYOR. Good night, Mr. President, thank you.


                           Amendment No. 3679

   (Purpose: To establish a minimum amount that may be applied as an 
  aggregate lifetime limit with respect to coverage under an employee 
              health benefit plan or a group health plan)

  Mr. JEFFORDS. Mr. President, I have an amendment at the desk.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Vermont [Mr. Jeffords] proposes an 
     amendment numbered 3679.

  Mr. JEFFORDS. Mr. President, I ask unanimous consent reading of the 
amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.

       At the end of section 103, add the following new 
     subsection:
       (g) Limitation on Lifetime Aggregate Limits.--
       (1) In general.--Except as provided in paragraph (2), an 
     employee health benefit plan or a health plan issuer offering 
     a group health plan may not impose an aggregate dollar 
     lifetime limit of less than $10,000,000 (such amount to be 
     adjusted for inflation in fiscal years subsequent to the 
     fiscal year in which this subsection becomes effective) with 
     respect to coverage under the plan.
       (2) Small employers.--Paragraph (1) shall not apply to a 
     group health plan offered to or maintained for employees of a 
     single employer that employs 25 or fewer employees.
       (3) Rule of construction.--Paragraph (1) shall not be 
     construed as prohibiting the application by an employee 
     health benefit plan or a health plan issuer offering a group 
     health plan of any limits, exclusions, or other forms of cost 
     containment mechanisms with respect to coverage under the 
     plan other than the aggregate limit permitted under paragraph 
     (1).
       (4) Disclosure.--Any limits, exclusions, or other cost 
     containment mechanisms permitted under paragraph (3) shall be 
     disclosed as provided for in section 105(c).
       (5) Application of subsection.--This subsection shall not 
     apply to a health maintenance organization that meets the 
     requirements of title XIV of the Public Health Service Act.
       (6) Effective date.--This paragraph shall become effective 
     with respect to health plans on the date that is 2 years 
     after the date of enactment of this Act.
       At the end of section 105, add the following new 
     subsection:
       (c) Disclosure of Limits and Exclusions.--An employee 
     health benefit plan or a health plan issuer offering a group 
     health plan shall disclose, as part of its solicitation and 
     sales materials and in a form and manner that is conspicuous 
     and understandable to a reasonable individual, any limits, 
     exclusions, or cost containment mechanisms with respect to 
     coverage provided under the plan.
       Section 3711 of title 31, United States Code, is amended by 
     adding at the end the following new subsections:
       ``(g)(1) If a nontax debt or claim owed to the United 
     States has been delinquent for a period of 180 days--
       ``(A) the head of the executive, judicial, or legislative 
     agency that administers the program that gave rise to the 
     debt or claim shall transfer the debt or claim to the 
     Secretary of the Treasury; and
       ``(B) upon such transfer the Secretary of the Treasury 
     shall take appropriate action to collect or terminate 
     collection actions on the debt or claim.
       ``(2) Paragraph (1) shall not apply--
       ``(A) to any debt or claim that--
       ``(i) is in litigation or forelosure;
       ``(ii) will be disposed of under an asset sales program 
     within 1 year after the date the debt or claim is first 
     delinquent, or a greater period of time if a delay would be 
     in the best interests of the United States, as determined by 
     the Secretary of the Treasury;
       ``(iii) has been referred to a private collection 
     contractor for collection for a period of time determined by 
     the Secretary of the Treasury;
       ``(iv) has been referred by, or with the consent of, the 
     Secretary of the Treasury to a debt collection center for a 
     period of time determined by the Secretary of the Treasury; 
     or
       ``(v) will be collected under internal offset, if such 
     offset is sufficient to collect the claim within 3 years 
     after the date the debt or claim is first delinquent; and
       ``(B) to any other specific class of debt or claim, as 
     determined by the Secretary of the Treasury at the request of 
     the head of an executive, judicial, or legislative agency or 
     otherwise.
       ``(3) For purposes of this section, the Secretary of the 
     Treasury may designate, and withdraw such designation of debt 
     collection centers operated by other Federal agencies. The 
     Secretary of the Treasury shall designate such centers on the 
     basis of their performance in collecting delinquent claims 
     owed to the Government.
       ``(4) At the discretion of the Secretary of the Treasury, 
     referral of a nontax claim may be made to--
       ``(A) any executive department or agency operating a debt 
     collection center for servicing, collection, compromise, or 
     suspension or termination of collection action;

[[Page S3584]]

       ``(B) a contractor operating under a contract for servicing 
     or collection action; or
       ``(C) the Department of Justice for litigation.
       ``(5) nontax claims referred or transferred under this 
     section shall be serviced, collected, or compromised, or 
     collection action thereon suspended or terminated, in 
     accordance with otherwise applicable statutory requirements 
     and authorities. Executive departments and agencies operating 
     debt collection centers may enter into agreements with the 
     Secretary of the Treasury to carry out the purposes of this 
     subsection. The Secretary of the Treasury shall--
       ``(A) maintain competition in carrying out this subsection;
       ``(B) maximize collections of delinquent debts by placing 
     delinquent debts quickly;
       ``(C) maintain a schedule of contractors and debt 
     collection centers eligible for referral or claims; and
       ``(D) refer delinquent debts to the person most appropriate 
     to collect the type or amount of claim involved.
       ``(6) Any agency operating a debt collection center to 
     which nontax claims are referred or transferred under this 
     subsection may charge a fee sufficient to cover the full cost 
     of implementing this subsection. The agency transferring or 
     referring the nontax claim shall be charged the fee, and the 
     agency charging the fee shall collect such fee by retaining 
     the amount of the fee from amounts collected pursuant to this 
     subsection. Agencies may agree to pay through a different 
     method, or to fund an activity from another account or from 
     revenue received from the procedure described under section 
     3720C of this title. Amounts charged under this subsection 
     concerning delinquent claims may be considered as costs 
     pursuant to section 3717(e) of this title.
       ``(7) Notwithstanding any other law concerning the 
     depositing and collection of Federal payments, including 
     section 3302(b) of this title, agencies collecting fees may 
     retain the fees from amounts collected. Any fee charged 
     pursuant to this subsection shall be deposited into an 
     account to be determined by the executive department or 
     agency operating the debt collection center charging the fee 
     (in this subsection referred to in this section as the 
     `Account'). Amounts deposited in the Account shall be 
     available until expended to cover costs associated with the 
     implementation and operation of Governmentwide debt 
     collection activities. Costs properly chargeable to the 
     Account include--
       ``(A) the costs of computer hardware and software, word 
     processing and telecommunications equipment, and other 
     equipment, supplies, and furniture;
       ``(B) personnel training and travel costs;
       ``(C) other personnel and administrative costs;
       ``(D) the costs of any contract for identification, 
     billing, or collection services; and
       ``(E) reasonable costs incurred by the Secretary of the 
     Treasury, including services and utilities provided by the 
     Secretary, and administration of the Account.
       ``(8) Not later than January 1, of each year, there shall 
     be deposited into the Treasury as miscellaneous receipts an 
     amount equal to the amount of unobligated balances remaining 
     in the Account at the close of business on September 30 of 
     the preceding year, minus any part of such balance that the 
     executive department or agency operating the debt collection 
     center determines is necessary to cover or defray the costs 
     under this subsection for the fiscal year in which the 
     deposit is made.
       ``(9) To carry out the purposes of this subsection, the 
     Secretary of the Treasury may prescribe such rules, 
     regulations, and procedures as the Secretary considers 
     necessary.
       ``(h)(1) The head of an executive, judicial, or legislative 
     agency acting under subsection (a)(1), (2), or (3) of this 
     section to collect a claim, compromise a claim, or terminate 
     collection action on a claim may obtain a consumer report (as 
     that term is defined in section 603 of the Fair Credit 
     Reporting Act (15 U.S.C. 1681a)) or comparable credit 
     information on any person who is liable for the claim.
       ``(2) The obtaining of a consumer report under this 
     subsection is deemed to be a circumstance or purpose 
     authorized or listed under section 604 of the Fair Credit 
     Reporting Act (15 U.S.C. 1681b).''.
  Mr. JEFFORDS. Mr. President, I know that we have had a difficult day 
today. We are having a difficult time trying to face the facts of life 
that the bill we are amending is a very important one, one which I have 
been an original cosponsor and one which part of the bill is mine. It 
is something that I worked very hard on. I believe it is an excellent 
job.
  However, I also believe that it has a very serious flaw in it. Thus, 
at the time the committee was meeting--and I want to point out that we 
have already made an exception today--the Finance Committee came and 
said, ``Hey, we have a bunch of amendments.'' Most of them have been 
accepted. So we have already made several exceptions to the 
nonamendment rule. I want to remind people of that.
  Now, I submitted this amendment, which I have before this body, at 
the committee. I am a member of the committee, ranking Republican on 
the committee. At that time it was said, ``Hey, we want to get out of 
here a unanimous bill. We may have problems.'' So I said, ``OK, I will 
wait until the floor.'' So I come to the floor to offer an amendment, 
which I think about everybody agrees ought to be on it, and they said, 
``No. No amendments--except for the Finance Committee amendments.''
  I understand that the ranking Republican and the chairman of the 
committee are bound by their commitment to no amendments, but nobody 
else is. Nobody else is in this body. So I hope Members would say he 
deserves to be heard. He has told me I could raise this amendment on 
the floor, and here it is.
  Now we will talk about what the amendment is and why we are here. The 
bill is one which provides, if a person is working for a business and 
changing jobs, or whatever else, has a health problem, that they are 
guaranteed an issuance of a policy or a continuance of a policy, 
notwithstanding the fact that they are sick. That is very important. 
This is an important breakthrough. That is why I supported the bill.
  However, what we were not aware of at the time and I brought to the 
committee's attention, but perhaps there was too little time to 
consider it, is the fact that there is no requirement now under the 
Federal law for any kind of a certain level of cap.
  Now, what could happen to us is, OK, we require the insurance company 
to take a sick person, but then the insurance company has the right to 
change its benefits, or it can say, ``OK, we will lower the lifetime 
cap. So when we take you on, as soon as we pay whatever level of funds 
we reduce the limit to, you are gone, finished, you have no more 
coverage.''
  Well, this amendment would rectify that and say we have to put--as a 
nationwide standard, with the exception, we admit it could cause some 
problems with small businesses, so we exempt 25 and under. We say you 
have to have $10 million of coverage. Why the $10 million? The $10 
million lifetime cap is because the standard for the industry for many 
years was a million dollars. But that was 20 years ago. That million 
dollars is worth about $100,000 now. So we say, let us go back to the 
standard of 20 years ago and put on that cap.
  I want to point out that when we do this, we are obviously going to 
cause some costs. I will explain that later. But let us take a look at 
who we are talking about when we are talking about those covered under 
this provision. We are talking about those that are working for 
businesses, as I say, that get sick. All of a sudden they have some 
pretty big bills. Remember, some of the lifetime caps out there on 
these insurance plans are $50,000. That is one day in a hospital 
sometimes. So you go in there sick, and all of a sudden you have no 
coverage. We are trying to correct that.
  Now, let me point out to you, again, what we are talking about from a 
national policy perspective. What happens now to that sick person? That 
person is sick. They have been allowed to be covered and then chopped 
off because they have reached the lifetime limit of, say, $50,000. What 
happens? Under the law right now, in order for them to qualify for 
Medicaid, they cannot have resources beyond a certain level. So what we 
are talking about--and I will give some examples in a minute--is middle 
income people, or even higher income people, who suddenly are placed in 
a position where the only way they can get care for their loved one is 
to get rid of all of their assets and then they will qualify for 
Medicaid. So the household has to go through that--getting rid of its 
assets--and then they qualify for Medicaid. Should our policy in this 
Nation do that? I say no, and I am sure you will, too. This is not good 
policy.
  Let me talk a little about some of the people involved. I think all 
of you have probably heard the ads of Christopher Reeve, or watched 
them on television, or read the editorials in the newspapers and the 
stories that have covered this. If you want an example as to whether or 
not it could happen to you, here is ``Superman,'' who was involved in a 
very serious accident. He was thrown off his horse and he becomes a C-
2, which is a broken neck. He has lost the functions below the neck 
level, without some assistance. He has a cap of $1.2 million, and it is 
costing him $400,000 a year. In 3 years, he will be past that cap.

[[Page S3585]]

  Let us take Jim Brady, who is another one--not an example of the 
lifetime cap, because he is on worker's compensation, but he had a head 
injury caused by a bullet when he was with President Reagan. He would 
be far beyond a million-dollar cap, to say nothing of a $50,000 cap at 
this time.
  Let me talk about some of the people that do not have the resources 
of a Christopher Reeve, or the protection of the law with respect to 
worker's comp, like Jim Brady. Let me go through some of these so that 
you understand better what kind of people we are talking about.
  This story is about Donelle and Kyle Meniketti, from the Washington 
Post. For 4 years, Donelle Meniketti waged a tremendous fight to save 
her son Kyle from suffering death or severe brain damage as a result of 
a rare breathing disorder that struck when he was 18 days old. It says:

       When he sleeps, said the Livermore, CA, woman, his airway 
     collapses and his brain does not tell him to breathe. 
     He needs a breathing machine at night and an oxygen 
     monitor. When he sleeps, he must have someone there all 
     the time to make sure he is breathing.
  Home nursing care costs alone can be $10,000 a month, and even though 
Mrs. Meniketti has spent sleepless nights watching over her son rather 
than pay for a nurse, his medical care is making constant claims on the 
health insurance plan of her husband Keith. As these claims mounted, 
they face the terrible prospect of the child's expenses soon reaching 
the million-dollar cap.
  He is 4 years old. So far he has escaped it. But they will be forced 
into Medicaid if this amendment does not succeed.
  Then there is Heather Fraser. I wish you would have seen her. She 
appeared at our press conference the other day. She is 23 years old and 
suffers from cystic fibrosis. She has suffered already many times. She 
does not know from one day to the next whether she is going to have one 
of these respiratory infections. She has had chronic problems of all 
different kinds and will continue to do so. She graduated from college, 
is 23, and is looking forward to the future. What is going to happen? 
The average cost per year to treat a moderate case of cystic fibrosis 
is $46,000. More severe cases cost roughly $79,000. To date, Heather's 
medical expenses have exceeded $800,000. Research is going on, but 
right now she will be beyond the cap and on Medicaid.
  Another one is Lauren Yandell of Williston, VT. Her policy has a cap 
of $1 million. Lauren has a son who has suffered from a chronic and 
very rare neurological disease since birth. Because of medications and 
frequent surgery and personal care, his medical expenses are extremely 
high--last year alone, over $70,000. He is only 5 years old. At this 
rate, Lauren believes her son will exhaust the limit within 10 years.
  Barbara Church, in Shelburne, VT--these are Vermonters, but there are 
people like this all over the Nation. Barbara has a 12-year-old son who 
was in a car accident 3 years ago. He has a very similar condition to 
Christopher Reeve. Since the accident, medical expenses have ranged 
from $20,000 to $50,000 annually. Her policy through her employer does 
not have a cap, and she is wary because if she loses her job, as it is 
under this law now, and she tries to go somewhere, she will not have 
the cap, or it may be only $50,000. There is no protection for her.
  These are the kinds of real-life situations. Is it appropriate for us 
to say that the way these people should get their continuous care is to 
get rid of all their assets and live in poverty for the rest of their 
lives, as long as their child survives? No, that is not what the policy 
of this Nation ought to be. This amendment would make sure that those 
occurrences do not occur.
  I hope that people will take into consideration that this is an 
amendment which will correct the deficiencies in the bill before us by 
saying that there will be a cap out there, which will be sufficient to 
take care of the expenses of these people to whom we are saying, ``You 
have a good deal because you can continue your coverage.'' Right now, 
the expectations are not there, and they can be changed at any moment.
  So I want to urge you to consider that this is something that is 
important to the bill before us. It is an amendment to the bill before 
us. It is to correct the serious problem in the bill before us. What we 
are talking about here, as far as the impact, is, obviously, if 
somebody is paying some money, somebody is going to have to shell out 
some money somewhere else. If they are being paid to have their health 
taken care of--first of all, let me review for a moment the kinds of 
costs involved with these actions.
  Look at this chart. It will show you about children with hemophilia. 
There are about 7,000 children with hemophilia, not many in terms of 
250 million. The average cost per year per person is $100,000. Life 
expectancy is 40 years. Lifetime cost per person for hemophilia is $4 
million. Do you want to put them all under Medicaid?
  Cystic fibrosis, the case I talked about earlier; the prevalence is 
about 4,000 in this country. That is not many relative to the huge 
population. It is easy to spread around the cost. The average cost per 
person per year is $18,000, and the average life expectancy is 30 
years; $2.5 million.
  This is the kind of situation which we are talking about.
  Let us take a look. There are other examples. Spinal injury and head 
trauma, you can also see where the costs are--around $5 million for a 
lifetime situation.
  Now let us review the question of why this is going to be a 
reasonable cost with respect to the existing situation. Again, 
insurance--the main purpose of insurance is to spread costs over a 
larger population so that the cost is small to the employer and to the 
employee with the insurance policy. But because of the huge number for 
which we spread it, it makes it reasonable for a family to afford.
  Let me remind all of my colleagues that we all have no lifetime cap. 
None of the Federal employees have anything to worry about. We are all 
covered, whatever the costs are. In addition to that, as this chart 
shows, we are one of the 20 percent in this country that have no limits 
whatsoever. There are those that have more than $1 million, about 6 
percent. The biggest group is that one that has been carrying the $1 
million forward for the last 20 years as long they have been in 
business. That is 46 percent. So already we are at over 70 percent. 
Then we go on down.
  I will be candid with you. The lower, of course, your lifetime caps, 
especially when you get to the really low levels, you obviously start 
covering more things than normally, and you end up with more cost. But 
the thing I am trying to make sure you understand is the cost that is 
spread around is not that high.
  Let us take a look at what some of the people say about what those 
costs would be. First of all, let me run through some of these that 
have given us some costs.
  The American Academy of Actuaries, for instance, has given us a cost 
analysis which demonstrates what we are talking about. Let me go to 
Price Waterhouse first. Price Waterhouse is a noted accounting firm, 
which we often look to give us accurate information, estimates that the 
Jeffords amendment would save $7 billion in Medicaid costs--$7 
billion--over 7 years. And more importantly, the cost to businesses 
would be somewhere in the area of--especially those in the larger 
areas--would be somewhere around 1 percent of their premiums.
  Let us go to another one. We have several on this.
  Also the National Taxpayers Union; let me tell the people on my side 
of the aisle what the National Taxpayers Union says. They are 
supporting it. They say it will be scored as a direct spending 
reduction in the Medicaid Program by approximately $2.8 billion over a 
5-year period. In addition, $2.1 billion may be saved through State and 
local Medicaid Programs.
  How can you say that this is not something that should be done when 
we know what it is going to do to help us address the budget problems 
which we have? Do you know what that amount of money means? That is 
going to be replaced by the insurance premiums? But it does not even 
cover the money that is drained out of all those families that went out 
for expenditures on health care.
  The Consumers Union, the other side of the aisle usually looks 
forward to the lifetime cap amendment which would significantly benefit 
consumers. The Consumers Union agrees that, if

[[Page S3586]]

health insurance policies have lifetime caps, it would be no lower than 
$10 million to the people exposed. They say it is important and 
essential.
  Then, of course, we have to look to the Congressional Budget Office 
and we have CBO's estimates. This came to us today. The Congressional 
Budget Office says the amendment would increase the Federal deficit. 
They are the only ones who say it is a cost after you balance out the 
deductions for taxes--$120 million. So by the worst-case scenario we 
have an offset for this. You could have a tiny, itty-bitty negative 
impact of $120 million over 5 years.
  So it is almost a no-brainer. It is hard to find out why anybody is 
against it.
  This is the Congressional Budget Office again. The proposal would 
initially raise private insurance premiums by 0.4 percent. You want to 
keep in mind that, if you are an employer, you have options. You can 
increase your premiums, or you can increase your deductibles.
  So it may not even cost the businessman anything. So again, the 
Congressional Budget Office says that we have something here which 
either costs nothing or something which is going to save the Treasury 
billions of dollars over 7 years.
  So it is just hard for me to figure out why there can be any 
opposition to do this. Not only that. But Senator Kennedy, and I think 
Senator Kassebaum, have suggested that this is a great amendment and 
that it ought to be on some other bill. What other bill? Why not the 
one it is most relevant to? Why not on the one with which we are trying 
to make sure is helping people with their transfer from job to job?
  I understand the complexity of trying to get a bill through without 
any amendments on it. But I remind everyone that we have already 
granted exceptions to the Finance Committee, and I asked the committee 
that be one of those exemptions because I offered it at the committee 
level, and they said, ``No way. Take it to the floor.'' I come to the 
floor. They say, ``Sorry. No amendments even though it is relevant to 
the bill.'' It will save the middle-income people billions of dollars. 
It will not cost employers hardly anything, and it will establish for 
the first time a good policy in this situation so that we do not drive 
people through poverty to qualify for Medicaid.
  Mr. President, I yield the floor.
  Mr. SIMON addressed the Chair.
  The PRESIDING OFFICER. The Senator from Illinois.


                         Privilege of the Floor

  Mr. SIMON. Mr. President, I ask unanimous consent that Jayson 
Slotnik, a fellow on my staff, be permitted to be on the floor during 
the action on S. 1028.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. SIMON. Mr. President, I rise in support of Senator Jeffords' 
amendment. I am blessed to be a cosponsor of that. He mentioned the 
case of Christopher Reeves. Christopher Reeves and an actor named Robin 
Williams, when they were students, made a pact that they would support 
one another if they ever faced this kind of an emergency. Robin 
Williams, as an actor who makes a great deal of money, is able to help 
Christopher Reeves. But what about the thousands of Americans who do 
not have a Robin Williams?

  It is very interesting. Senator Jeffords talked about the cost. We 
changed the Federal insurance. In other words, all Federal employees, 
including everyone here in the Senate right now--all of us--had some 
changes. We had two major changes. The most costly was adding mental 
health coverage for all Members--not only Members but all Federal 
employees. Do you know what that cost? It costs 27 cents each pay 
period. That is the additional mental health coverage cost. Twice a 
month we pay 27 cents. I tried to find out what taking the $1 million 
cap off cost us, and nobody knows what it cost. It is such a small 
amount.
  My guess is, if you took that chart that Senator Jeffords has there 
of companies that have a $1 million limit and the 22 percent that do 
not have any limit, that you would find really no difference in the 
rates charged; no pattern of difference. You are talking about 
something that does not affect very many Americans. So the total cost 
is very limited.
  I talked earlier today--four reporters stopped me out here, as they 
stop all of us. I said to the reporters, when they were asking me about 
this, ``Do you know what kind of limits you have on your insurance?'' 
Well, Adam Clymer of the New York Times knew, but the other three 
reporters did not know. I think very few Americans have any idea what 
kind of limit they have. They just know they are covered by insurance 
or they are not.
  We should not impoverish people before we protect them. That is what 
we do with Medicaid. I think the Jeffords amendment makes a great deal 
of sense, and I am proud to support it and proud to be a cosponsor.
  Mr. KENNEDY addressed the Chair.
  The PRESIDING OFFICER. The Senator from Massachusetts.
  Mr. KENNEDY. Mr. President, it grieves me greatly to rise to indicate 
my reservation about this amendment on this particular bill. I know how 
hard the Senator has worked on this project, and in any other forum I 
would be a strong supporter. I am very familiar with Chris Reeves. He 
is a resident of my State out in the Berkshires. He was a strong 
supporter of mine in the last campaign, a personal friend as well. I am 
very familiar with the real challenges--first of all, the extraordinary 
courage of this absolutely incredible human being. It is what I think 
of first when I think of Christopher Reeves. As he has pointed out so 
well, the human tragedy of others who are facing these kinds of 
situations is incredible and incredibly difficult, and all of us are 
familiar with stories of families being bankrupt because of these 
ceilings which are out there. Most of them were about $1 million just 
until very recently, some of them as high as $2 million.
  I agree with the Senator, and it pains me to oppose him on this 
particular measure. I was mindful of that during his presentation.

  I ask the Senator what his disposition is, whether he might take a 
voice vote here. Does he prefer that we make a tabling motion, or is he 
willing to take----
  Mr. JEFFORDS. That, of course, is the Senator's option. I cannot 
stand here representing 100 groups who support this amendment and 
taking into consideration the tremendous effort that Christopher Reeves 
has put into this personally to try and convince this body to do this 
reasonable thing, and not, unfortunately, from the Senator's 
perspective, ask for a recorded vote. I do not mean to embarrass the 
Members on this, but I just remind them that I was told I could come to 
the floor and offer it, and I am being precluded. But I understand that 
all got changed as we went along the way, and I do not hold any grudges 
against anybody. I understand you have to stand by that no amendment 
outside of the Finance Committee. I just would suggest to my colleagues 
that they are not bound by any such thing and would urge them to vote 
in favor of the amendment.
  Incidentally, I have now heard something which occurs when you get 
people nervous here, that there has been a rush to find a new cost from 
CBO, and apparently they are ready to rush over and claim I do not have 
enough money.
  Well, I am always ready for those circumstances, and we are rushing 
over with an amendment which will put a sufficient amount of money in 
it so I do not get into a budget problem. If they are not around, if we 
can just get the yeas and nays without going through the necessity of 
me amending the amendment, that is fine, too.
  Mr. SIMON. Will my colleague yield?
  The PRESIDING OFFICER. The Senator from Massachusetts has the floor.
  Mr. KENNEDY. I want to be very clear. I had joined with the chairman 
of the committee in indicating I would oppose amendments on this that 
virtually were not unanimously accepted. I should like very much to 
accept it.
  As I mentioned earlier in the day, there are many different features 
which I should like to add.
  I can remember very well I had a son who was in an NIH program, and 
they terminated the NIH support. It was $3,200 for the treatment they 
had to give those children every 3 weeks for 3 days for 2 years, and I 
was able to afford it. Mothers and families were out there saying, 
well, my child only gets 5 months, 6 months. What chance does that 
child have to live?
  I am very mindful of these situations. I feel very strongly about 
them,

[[Page S3587]]

and I feel very sympathetic, too. But I am also mindful that we need 
this legislation, and we have made a commitment at the time which I 
hope the Senator from Vermont will understand. I joined with the 
chairman of the committee to that effect. But I will be glad to join 
with him at another time. But we are going to abide at least by the 
assurances we gave to the other members of the committee. At the 
appropriate time I will, or the chairman of the committee can, make a 
motion to table.
  Mr. SIMON. Will the Senator from Massachusetts yield?
  Mr. KENNEDY. I will be glad to yield.
  Mr. SIMON. I cannot speak for the chief sponsor, but when you ask for 
a voice vote, the Senator from Massachusetts has a strong voice. If he 
will be fairly silent in that voice vote, I would be willing to take a 
voice vote, but I cannot speak for the Senator from Vermont.
  Mrs. KASSEBAUM. Mr. President, if I may, I, too, am very sympathetic 
to the issue that Senator Jeffords is addressing. I think we all 
recognize--I believe the figures are almost 1,500 Americans at least 
that would benefit from this legislation. It is more than just the 
enormous financial cost. It is an emotional and difficult issue.
  However, our agreement was not just with the Finance Committee. 
Unless there is a consensus of support on both sides of the aisle, then 
we have to oppose the amendments. I think the Senator from Vermont 
knows there are many in the business community, particularly the small 
business community, that have been opposed to this, who worry a great 
deal about the implications of it and have said they would oppose the 
whole bill if amendments like this one would be added. We felt that the 
underlying amendment offered so much that we then had to also oppose 
those other amendments which I think have much merit, and it is with 
regret that I would, too, have to oppose it. I certainly am willing to 
have a rollcall vote. I think it will be up to the sponsor of the 
legislation to determine that.

  Mr. KENNEDY. I make a motion to table the Jeffords amendment.
  Mr. JEFFORDS. I would like to amend my amendment first to have plenty 
of money in there so nobody can----
  Mr. KENNEDY. I am not going to make that argument. That is fine.
  Mr. JEFFORDS. All right.
  Mr. KENNEDY. If it is all right with Senator Kassebaum. I have no 
objection to either doing it--we are not making a point of order on the 
money or questioning it at this time.


                Amendment No. 3680 to Amendment No. 3679

   (Purpose: To reduce delinquencies and to improve debt-collection 
          activities government-wide, and for other purposes)

  Mr. JEFFORDS. I want to preclude that objection from being 
registered, so, Mr. President, I have an amendment to my amendment.
  The PRESIDING OFFICER. The Senator has the right to modify his 
amendment.
  Is this an amendment to the amendment?
  Mr. JEFFORDS. Mr. President, it is an amendment to the amendment. I 
will ask to have it reported.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Vermont [Mr. Jeffords] proposes an 
     amendment numbered 3680 to amendment No. 3679.

  Mr. JEFFORDS. Mr. President, I ask unanimous consent that reading of 
the amendment be dispensed with or we will be here the rest of the 
evening.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (The text of the amendment is printed in today's Record under 
``Amendments Submitted.'')
  Mr. JEFFORDS. What this does, Mr. President, is take an amount of 
money which has been verified by CBO, which has yet to be utilized and 
also verified by OMB, that will cover any conceivable cost of this 
bill, to make sure someone does not come back and say I failed to cover 
any cost of that.
  I understand there will be maybe a motion to table. Let me just urge 
my colleagues to please remember what we are trying to do here. You 
have 100 disability groups of people who are in favor of this 
amendment. You have estimates which indicate that we have eliminated 
all the small businesses 25 or under. We have not pulled lifetime caps. 
We have gone to $10 million, which is exactly the value of what they 
were many years ago when the million dollar cap was in fashion.
  What we are trying to do is prevent people going into bankruptcy in 
order to qualify for Medicaid in order to take care of their sick ones. 
It also improves this bill because this bill would allow an insurance 
company--although they are forced to take somebody on the policy, they 
can lower the lifetime caps and chop them off after a year again, and 
then they are back out on the street looking for care and back onto 
Medicaid.
  With that, I would suffer the indulgence of a tabling motion at this 
time.
  The PRESIDING OFFICER. If there be no further debate, the question is 
on agreeing to the amendment.
  The amendment (No. 3680) was agreed to.
  Mrs. KASSEBAUM. Does any Senator wish further debate on the 
amendment, as amended?
  If not, I move to table the amendment of the Senator from Vermont.
  The PRESIDING OFFICER. The Senator from Kansas has moved to table the 
amendment of the Senator from Vermont, as amended.
  Mr. JEFFORDS. Mr. President, I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The yeas and nays were ordered.
  Mrs. KASSEBAUM. Mr. President, I ask if there could be about a 5-
minute delay to notify everybody to come.
  Mr. JEFFORDS. 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.
  Mrs. KASSEBAUM. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER (Mr. Bennett). Without objection, it is so 
ordered.
  Mrs. KASSEBAUM. Mr. President, I ask that we now proceed to vote on 
the motion to table the amendment of the Senator from Vermont. The yeas 
and nays have been ordered.
  The PRESIDING OFFICER. The question is on agreeing to the motion to 
lay on the table the amendment of the Senator from Vermont, No. 3679.
  The yeas and nays have been ordered. The clerk will call the roll.
  The bill clerk called the roll.
  Mr. LOTT. I announce that the Senator from Colorado [Mr. Campbell] 
and the Senator from Florida [Mr. Mack] are necessarily absent.
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 56, nays 42, as follows:

                      [Rollcall Vote No. 74 Leg.]

                                YEAS--56

     Abraham
     Akaka
     Ashcroft
     Bennett
     Bond
     Bradley
     Breaux
     Brown
     Bryan
     Chafee
     Coats
     Cochran
     Cohen
     Coverdell
     Craig
     Daschle
     Dodd
     Exon
     Faircloth
     Ford
     Frist
     Gorton
     Gramm
     Grassley
     Gregg
     Hatch
     Hatfield
     Heflin
     Hollings
     Hutchison
     Inhofe
     Inouye
     Johnston
     Kassebaum
     Kempthorne
     Kennedy
     Kerrey
     Kohl
     Kyl
     Lieberman
     McCain
     Mikulski
     Moseley-Braun
     Moynihan
     Murkowski
     Murray
     Nickles
     Nunn
     Pressler
     Reid
     Rockefeller
     Sarbanes
     Simpson
     Thomas
     Thompson
     Thurmond

                                NAYS--42

     Baucus
     Biden
     Bingaman
     Boxer
     Bumpers
     Burns
     Byrd
     Conrad
     D'Amato
     DeWine
     Dole
     Domenici
     Dorgan
     Feingold
     Feinstein
     Glenn
     Graham
     Grams
     Harkin
     Helms
     Jeffords
     Kerry
     Lautenberg
     Leahy
     Levin
     Lott
     Lugar
     McConnell
     Pell
     Pryor
     Robb
     Roth
     Santorum
     Shelby
     Simon
     Smith
     Snowe
     Specter
     Stevens
     Warner
     Wellstone
     Wyden

                             NOT VOTING--2

     Campbell
     Mack
       
  So the motion to lay on the table the amendment (No. 3679) was agreed 
to.
  Mr. KENNEDY. Mr. President, Senator Domenici has been seeking 
recognition, and I believe he is willing to enter into a time 
agreement.
  Mr. DOMENICI. Senator Wellstone, how much time?
  Mr. WELLSTONE. I think I need about 15 minutes.

[[Page S3588]]

  Mr. DOMENICI. From the standpoint of proponents, we will settle on 35 
minutes. You all can take whatever you would like.
  Mr. KENNEDY. Mr. President, I ask that we have 40 minutes on the 
Domenici-Wellstone amendment, 35 minutes to be under the control of 
Senators Domenici and Wellstone, and 5 minutes under the control of 
Senator Kassebaum.
  Mr. JOHNSTON. Does the Senator from Massachusetts know how many 
amendments and when we might expect to finish tonight?
  Mr. KENNEDY. On our side there would probably be--we have Senator 
Boxer's amendment, which I think will take a very short period of time. 
We have Senator Conrad on visa, which I think we can work out. We are 
waiting for the report of the chairman on the immigration control. 
Senator Simon, a sense-of-the-Senate which I think will be very short. 
We are on the Domenici-Wellstone now. There is one by Senator Dorgan on 
the organ cards, which hopefully we can accept.
  I do not think we have any amendments here that would require very 
much time to deal with.
  Mrs. KASSEBAUM. Mr. President, if the Senator from Massachusetts 
would yield, there may be some amendments offered that will be 
withdrawn--not all have been agreed to or cleared. I think we are 
moving forward. We wish to complete this by 9:30 or 10 o'clock tonight 
at the latest. We need to know exactly who will be wanting a rollcall 
vote on their amendments. I think that is what everyone would like to 
know.
  Senator Domenici's amendment will be next. There will be a rollcall 
vote I believe. At that point, we should know how many more votes would 
actually be ahead of us.

  Mr. JOHNSTON. Will the Senator yield for a question?
  Mrs. KASSEBAUM. I am happy to.
  Mr. JOHNSTON. Would it be out of the question to stack some votes 
tonight?
  Mrs. KASSEBAUM. We thought not. We thought it best to move forward. 
After the next vote, we will be able to tell you exactly how many more 
rollcall votes there will be.
  Mr. DOMENICI. When you ask the Senator from Kansas a direct question, 
she gives you a direct answer, right?
  The PRESIDING OFFICER. There is no unanimous-consent agreement before 
the Senate. The Senator from Massachusetts was propounding one, but it 
was not formally propounded.


                      Unanimous-Consent Agreement

  Mr. KENNEDY. Mr. President, I ask unanimous consent that on the 
Domenici amendment that there be 40 minutes, with 35 minutes under the 
control of Senators Domenici and Wellstone, 5 minutes under the control 
of Senator Kassebaum and the Senator from Massachusetts, and that there 
be no second-degree amendments in order to the Domenici amendment.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  Mr. DOMENICI. Mr. President, I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The yeas and nays were ordered.


                           Amendment No. 3681

  (Purpose: To ensure that parity is provided under health plans for 
                    severe mental illness services)

  Mr. DOMENICI. Mr. President, I send an amendment to the desk and ask 
for its immediate consideration.
  The PRESIDING OFFICER. The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from New Mexico [Mr. Domenici], for himself and 
     Mr. Wellstone, proposes an amendment numbered 3681.

  Mr. DOMENICI. Mr. President, I ask unanimous consent that reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (The text of the amendment is printed in today's Record under 
``Amendments Submitted.'')
  Mr. DOMENICI. Mr. President, I yield myself 10 minutes and ask that I 
be advised when I have used 9 minutes of that time.
  Mr. President, it is with a degree of regret that I have to bring 
this amendment to the floor on this bill because I understand that 
Senators Kassebaum, Kennedy, and the committee of jurisdiction have 
worked very hard on the basic bill that is before us. They have made 
some commitments, which I gather, based on the last vote, that they 
take very seriously. They are going to try to keep this bill clean.
  I have to say to my fellow Senators that when you are involved and 
understand what is going on out there in America with reference to the 
mentally ill people and their inability to get adequate insurance 
coverage, which I will explain in a little more detail to the Senate, 
you have to take every opportunity you can to try to effect some major 
change.
  The country, in terms of insuring people for various physical 
disabilities has come a long way. But this country, in terms of 
insuring mentally ill people, is going backward instead of forward, 
because as insurance costs go up, insurance company after insurance 
company is finding a way to try to write cheaper and cheaper insurance, 
and they look for ways to drop groups of people from coverage by saying 
they are not covering them, or are covering them so inadequately that 
they are left back in the arms of their parents or relatives. So this 
is happening dramatically across America. When it comes to mental 
illnesses, I submit that I know a little bit more about severe mental 
illnesses because I have worked actively in committees on that issue 
for a long time.
  But if you happen to be a parent of somebody who has schizophrenia, a 
very serious mental disease, and not some figment--it did not come 
because somebody's mother did not take care of them properly; it is a 
severe disease of the brain. If you happen to have one of those kinds 
of persons in your family and you have an insurance policy that is 
typical in America, it will, for the most part, not cover very much, it 
will have a cap that is very insignificant, and it will be very 
distinct from the rest of the policy coverage. In other words, they 
will go out of their way to cover mental illness differently and with 
less coverage than the basic coverage they are giving to physical 
ailments, diseases that we all understand.
  The time has come--and we can wait once again, but I believe it is 
tonight--to send a signal that while we have a bill before us that is 
going to alter some serious shortcomings in insurance coverage in 
America--and we understand what they are and we compliment the 
committee for taking one good bite at this problem--but those of us who 
are worried about the problem of mental health and mental illness, 
including severe mental illnesses, like manic depression, severe 
depression, bipolar or serious depression, we understand that there is 
medication available, there is treatment available. But, occasionally, 
they have to be treated in an atmosphere that costs a lot of money, in 
an environment that costs a lot of money.

  This amendment is very simple. I am offering it with my friend, 
Senator Wellstone. Essentially, Mr. President, it prohibits insurers 
and health plans from imposing treatment restrictions or financial 
requirements on services for the mentally ill that it does not impose 
on services for the physically ill.
  We offer this today, although this country has come a long way in 
understanding and recognizing the special problems of people suffering 
from mental illness. We understand that structural and institutional 
discrimination continues and persists in our society. Stigmas are 
rampant in this area, and I am referring to another kind of 
discrimination--that is, the way health insurers and health plans treat 
these individuals, and I believe this situation represents one of the 
real continuing injustices in America today.
  Although we now understand that mental illnesses are, in fact, for 
the most part, physical illnesses, they are still treated differently 
than other physical conditions. The only difference between the other 
physical ailments and mental illness is that mental illness is a 
disease of the brain, and it may be more complicated, but we are making 
excellent strides at understanding it. Because this disease manifests 
itself in our centers of thought, reason, and emotion, many find it 
easy to deride those problems and to deride those who are afflicted, or 
turn their back on the problem, or act as if the problem does not 
exist. Mental illness is not due to sinful behavior. It is not due to a 
weakness, or frail character. These illnesses are real, and they are

[[Page S3589]]

debilitating, and there are many who suffer from them. Nearly 5 million 
Americans suffer from severe forms of mental illness. I will repeat 
just a few of them.

  Schizophrenia affects about 2 million adults a year. And I repeat, 
nobody is at fault because somebody has schizophrenia and acts 
differently and reasons differently. They are just as sick as your 
neighbor who has cancer.
  Yet only 2 percent of all individuals with mental illnesses are 
covered by insurance which provides benefits equal to the coverage for 
physical illnesses. I stated that in generalities a while ago. Now, 
here is the objective number. Through narrowing down the definitions 
through caps that are irresponsible but save money so insurance 
companies do it in their own self-interest, only 2 percent of Americans 
with mental illness are covered with the same degree of coverage as if 
they got tuberculosis or cancer instead of manic-depression or 
schizophrenia.
  You can walk down any street in urban America and you will find them. 
It is time to give these people access to care they need, and as you 
see them in urban America sleeping on grates and other things, you 
should realize that they probably started out as wonderful teenage 
children in some beautiful family. And when the costs got prohibitive 
and the behavior uncontrollable, they are abandoned. In fact, you find 
more of them in jails than in the institutions which we ought to have 
to help them. Most studies reveal that most of the severely mentally 
ill are in prisons or county or city jails because of misbehavior than 
in places we put together to treat them. Part of that is because 
resources are not applied, and part of the reason resources are not 
applied is because the insurance companies--I am not here angry at 
them, I am not here fighting with insurance companies. Because what 
they say is, ``How do we make money? So if we lessen the coverage for 
mental health, we get a better bargain for people who want coverage for 
the other things.'' But I am submitting that sooner or later we have to 
say to them that you all have to cover them. If you are covering 
physical illness and they get 6 months of hospitalization, you have to 
do the same for mentally ill people. If not, nobody is going to care 
for them.
  Let me tell you, I have seen purposely and intentionally how this 
destroys families. I have been to the National Alliance for the 
Mentally Ill meetings with 1,000 of the finest people in America who 
are there talking about their children, and in many cases they are lost 
because they could not afford to pay for them when they were 19 and 20, 
and they do not even know where they are. Somebody in this society is 
paying for that. For the most part, the ill are paying for it, for they 
are not getting taken care of right.

  I thought a bill that was aimed at correcting the lack of coverage in 
the private insurance industry of America--because you choose and pick 
insurance companies to cover what you want and what you do not want you 
do not cover--we came today to the Senate and in 1 day or 2 are going 
to pass a marvelous bill that says, in two areas, you are all going to 
cover something. I am just asking tonight that, in three areas, you say 
you are going to cover something.
  I know the motion to table will be made, and the argument will be 
made that this is not the right time. And, of course, I am taking a 
gamble, because with that kind of power, I might lose this amendment. 
But let me suggest, if we do--and I hope we do not--you can count on 
it, we are going to be back here, and we are going to find and look 
until we find a vehicle that sets this thing straight.
  Mr. President, when that bill was sent to the desk, I saw some 
Senators watch it go up there and they saw this very thick bill. I do 
not want you to think there is all kinds of language in there about 
mental illness. What we have to do is pay for this.
  So much of that bill is to defer the cost in the first 5 years of 
this bill, and we have used offsets that are acceptable, which Senator 
Wellstone and I have used at other times here but have not become law. 
So we have offset it as best we could. That is what most of that is.
  It is a rather simple bill. We could narrow it down. We chose not to. 
We talk about mental illness. That includes all of the severe ones, but 
it includes more, and it says as part of treatment, no more 
discrimination, no more treating them differently.
  We have cost estimates. If it was done across the board in all 
policies, it would add about 1.6 percent net to the insurance coverage 
across the land. It obviously would not happen overnight. It would take 
some time. But, essentially, we want to give the Senate an opportunity 
to vote on this tonight.
  That is my explanation for now. I want to say thanks to Senator 
Wellstone. He has been kind of my friend working on this for a long 
time. There are some other Senators on board.

  I want to yield to him now 7 minutes of my time for him to tell us 
his version of why we ought to do that.
  Thank you very much.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Mr. WELLSTONE. Mr. President, I am very pleased to be here with my 
colleague, Senator Pete Domenici, to introduce an amendment on an issue 
that I feel very strongly about. Our amendment deals with one issue, 
and we hope that we have our colleagues' vote tonight: equitable health 
care coverage for mental illness services.
  Mr. President, let me say it has been a real honor to work with 
Senator Domenici on this issue. He has been a real leader, as has his 
wife, Nancy, and I personally appreciate all of their efforts.
  I am proud to cosponsor this amendment, which would require that 
health plans to provide coverage for mental health services 
commensurate with what is provided for other physical illnesses.
  For too long, mental health has been put in parenthesis; we did not 
want to talk about it, and we did not take it seriously as a country. 
The stigma of mental illness has kept many in need from seeking help, 
and it has prevented policymakers from providing it. And for too long, 
persons in need of mental health services who reach private coverage 
discriminatory limits have been dumped onto Government-funded programs.
  Mr. President, I support a universal health coverage plan, and 
comprehensive benefits for mental health services. While we failed to 
enact legislation to achieve this during the 103d Congress, we did 
increase awareness. But now we are talking about parity, and awareness 
is not enough.
  Our amendment would require health plans to provide parity in their 
coverage of physical and mental health. Plans would be prohibited from 
requiring copays, or deductibles, for mental health benefits, or 
establishing lifetime limits for mental health benefits, or 
establishing visit limitations for mental health services unless the 
same restrictions apply to other health services.
  All we ask for is equitable treatment. That is all this amendment 
does. All this amendment does is say, please let us stop this 
discrimination.
  Mr. President, many people, or most people's instinctive reaction is 
to assume that this amendment would be expensive. This is not the case. 
As a matter of fact, in my State of Minnesota, where we have already 
passed legislation requiring full parity for mental health and 
substance abuse services, this was implemented August 1, 1995, and the 
cost of the parity mandate was estimated to be 26 cents per member 
provided. Minnesotans who were unable to work full time either because 
they were too sick or they were forced to impoverish themselves in 
order to qualify for Medicaid benefits, are now able to work and pay 
taxes and be productive. Because of this discrimination, all too often 
people cannot work so that they can receive medical assistance. People 
are forced to impoverish themselves in order to qualify for the medical 
assistance they need.

  Now, in Minnesota--this is what we propose to do for our Nation, 
because we have parity and we have ended this discrimination--these 
same Minnesotans are now able to work, to live a life with dignity, and 
to pay their taxes.
  Mr. President, we have a tremendous body of evidence, new evidence, 
proving that, without a doubt, mental health disorders can be diagnosed 
and treated in a cost-effective manner.
  In fact, we can show that within a very short period of time it costs 
less

[[Page S3590]]

to treat those disorders directly and appropriately than not treat them 
at all. We can say that this is true based upon studies of every sector 
of our population--insured and employed, uninsured and unemployed, 
people who now use the private system and those who now use the public 
system.
  Mr. President and colleagues, there are several arguments for 
requiring parity for mental health services. First, we now have cost-
effective treatments for mental illnesses and high rates of success are 
being achieved across the spectrum of diagnosis. For example, 80 
percent of individuals with depression respond to treatment. Second of 
all, mental illness results in physical illness, inability to work, 
impaired relationships, and sometimes crime and homelessness.
  Would it not be better to end the discrimination and have less of the 
homelessness? Would it not be better to end the discrimination and 
enable people to work and be productive citizens? And finally, Mr. 
President, mental health services are already part of health delivery 
in the United States.
  Let us have no doubt about it, this amendment leaves all decisions 
about the delivery of services to the private marketplace. The 
amendment does not require the provision of mental health services to 
employees, specify what care should be provided, interfere with the 
discretion of employers and health plans to negotiate reimbursement 
rates as they see fit, or mandate the use of any particular kind of 
delivery of needed care.
  What this amendment calls for is just parity. Mental illness has 
touched many of our families and many of our friends. It is for this 
reason and many others that it is not a partisan issue. Mental illness 
is a problem affecting all sectors of American society. It shows up in 
both the rural and urban areas. It affects men and women, teenagers and 
the elderly, every ethnic group and people in every tax bracket. It can 
be effectively treated just like heart disease or diabetes. Treatment 
not only saves lives but it also saves dollars. That is why this 
amendment is so important.
  I look forward to the adoption of this amendment and to continuing to 
work with Senator Domenici to end discrimination against this very 
vulnerable population and their families. It is only old data and old 
ideas that keep us from covering mental health, the same way we cover 
any other real illness, whether it is acute or chronic.
  I know there has been some agreement on amendments, but I plead and 
implore my colleagues to please vote for this amendment. Senator 
Domenici is right. Tonight is just the beginning. If we do not win 
tonight--and I hope we get a very significant vote, and I hope we do 
win--then, of course, we will come back.
  Colleagues, please support us. Please end the discrimination. That is 
what this amendment is all about.
  I do not usually do this on the floor of the Senate, but I would like 
to dedicate my remarks to my brother who has struggled with mental 
illness almost his whole life. He is doing great now.
  I yield the floor.
  Mr. DOMENICI addressed the Chair.
  The PRESIDING OFFICER. The Senator from New Mexico.
  Mr. DOMENICI. How much time does the Senator from New Mexico have?
  The PRESIDING OFFICER. The Senator has 13 minutes and 5 seconds.
  Mr. DOMENICI. My good friend, Senator Simpson, desires to speak, and 
I yield him 5 minutes. And then, I say to the Senator from North 
Dakota, I will yield him some time.
  The PRESIDING OFFICER. The Senator from Wyoming.
  Mr. SIMPSON. Mr. President, I hope that all Members will read the 
amendment. I know sometimes we forget to do that from time to time, it 
is perhaps one of our failings. It is a very simple amendment. It is 
described as ``parity.'' I think the Senator from New Mexico and the 
Senator from Minnesota have covered it very well.
  The important thing that you want to hear regarding it is about the 
rule of its construction. It is just one construction because people 
say that it is going to be tremendously costly; or that this is going 
to ``open the doors'' or that this is the first step toward incurring 
tremendous cost. But what the amendment says is this:

       Nothing in [the subsection previous] shall be construed as 
     prohibiting an employee health benefit plan, or a health plan 
     issuer offering a group plan, or an individual health plan 
     from requiring preadmission screening prior to the 
     authorization of services covered under the plan or from 
     applying other limitations that restrict coverage for mental 
     health services to those services that are medically 
     necessary.

  I think that is a very important thing. That is a very critical part 
of this.
  Let me just tell you that about 4 years ago a most beautiful girl in 
our family, the niece of my wife--my wife's twin sister's daughter, 
whom we had watched grow and mature from her birth--left our midst. She 
was a dancer; she was an artist; she was a poet; she was a guitarist; 
she was a singer; she was the rainbow of life.
  We did not get or understand the signals in time, and the signals 
were very clear as we all look back now out of sheer guilt and anguish. 
She was tough minded, independent, loving, strong, and forceful. She 
would come into your kitchen and just cook up a batch and leave the 
stuff in the sink, and family would say, ``Why doesn't Susan clean up 
afterwards?'' And then, ``Why doesn't Susan work? How old will she be 
before she ever works?''
  She began to withdraw, and then she went into some religious and 
almost cultish activities, and she had a child. And that is a beautiful 
child. I know that child. That is the wonderful part of it now--because 
Susan is gone. And after years of reaching out to us in her way and us 
not hearing and us not knowing, she one day decisively purchased a 
pistol and a few hours later purchased the ammunition and went to an 
isolated field, removed her shoes, sat in a the crouched position in 
Bowling Green, KY, and blew her chest away.
  That is what sometimes happens to these people, and we think, 
``well, but they should have tried to do something for themselves.

  We thought we were doing something for her. We thought she was 
finally doing it for herself. She was taking medication, and it was 
working. But then something, something unknown, entered her mind and 
her life and she decided not to take the medication --knowing what 
would happen if she did not--and then her tragic plan of ultimate 
rejection came to pass.
  There is a group of humans--a particular vulnerable group in society 
that the mental health workers and professionals tell us about who now 
are in their 37th to their 45th year, who somewhere along the line were 
perhaps those involved in the early experimentation with drugs, yes. 
Yes, of course, but that penalty should not be something visited upon 
them forever. So I say there is not a soul in this Chamber that has not 
been grievously affected in some way by these things. It is time for 
healing. It is time for understanding more than anything. It is time to 
minister. It is time to love and to be compassionate and time to learn 
so much more about these tragic things. For these are the people who 
you know and see every day, and they are making it, and they never did 
before, but they are now. If we can put this in this bill in this way 
with this language, I think it would be a tremendous benefit to them--
and they are our first charge--and to the rest of us in society.
  I thank the Chair.
  Mr. DOMENICI. How much time do we have remaining, Mr. President?
  The PRESIDING OFFICER. The Senator has 8 minutes and 50 seconds.
  Mr. DOMENICI. Mr. President, I yield 5 minutes to Senator Conrad.
  Mr. CONRAD. Mr. President, I personally thank Senators Domenici and 
Wellstone for bringing this amendment to the Chamber tonight.
  I rarely take the time of my colleagues, in the evening hours, to 
speak, because I often feel that it is an imposition on their time. 
Tonight, I think this amendment is so important that it requires all of 
us to speak. This amendment simply asks that mental illnesses be 
treated on a parity basis with other illnesses. It is inescapable: An 
illness is an illness. There should be no differentiation between how 
we treat those who have a mental illness and a physical illness.
  When I was the assistant tax commissioner in North Dakota, Senator 
Dorgan was the tax commissioner. We had a young woman who was our 
receptionist. She was a beautiful and vibrant young woman. She was 
somebody

[[Page S3591]]

who absolutely lit up an office. One day, she just went off the deep 
end with a mental illness that none of us knew that she had. Pictures 
were speaking to her. She had all kinds of aberrant thoughts. It led to 
her institutionalization. It led to her attempting to take her own 
life. That was a young woman, because of a suicide attempt, who did 
enormous damage to herself from which she will never fully recover.
  That young woman had a mental illness, and that illness deserved to 
be treated like any other illness. She is not alone. There are millions 
like her all across America. As we sought to reach out and help this 
young woman, I became somewhat educated about what was happening in our 
communities. One thing I learned is that we actually treat differently 
those with a physical illness and those with a mental illness, and it 
is a tragedy.
  In our State, we have taken the step to recognize that there should 
not be discrimination between illnesses. What we have found is it does 
not cost more money. Oh, it does as you begin, but as you go forward, 
it does not cost more money, and it does not cost more money because, 
if you fail to treat, the physical ailments mount and become much more 
expensive.
  I would say to my colleagues, we passed this amendment. We passed 
this in the Finance Committee on Medicaid, during reconciliation. I 
offered the amendment. It was adopted. It passed here on the floor of 
the U.S. Senate. It was only taken out in conference.
  We passed it in the Finance Committee based on the best evidence that 
shows over time this will not cost money. I submitted detailed studies 
from North Dakota that demonstrate that.
  I hope my colleagues will vote for this amendment tonight. It is the 
right thing to do. I hope my colleagues will agree to the Domenici-
Wellstone amendment. They will be proud the rest of their lives that 
they did.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Massachusetts.
  Mr. KENNEDY. Mr. President, I yield myself 2\1/2\ minutes.
  I have difficulty in not commending, which I do, my good friends and 
colleagues with whom I have worked over a very considerable time on the 
issues of mental health. This is obviously an awkward position for me 
to have these amendments come up and to be fighting these issues. One 
of the first pieces of legislation passed during President Kennedy's 
administration was the community health programs which got people out 
of institutions, and into the community. I worked with Senator Domenici 
and Senator Wellstone in 1990 to move the whole mental health research 
out to NIH, against strong opposition at that time. In the health 
insurance bill that we passed last year, we had effective equivalence 
between mental health and physical health, though there were some 
aspects of hospitalization that were phased in over a period of time.
  So I am strongly sympathetic. I just regret this. Hopefully, it will 
be defeated. Maybe we are going to continue to have these votes so 
people are able to speak to them. Once again, I can understand the 
frustration because we have not gone ahead on it.
  It is painful for many of us who are strongly committed to the whole 
issue of eliminating preexisting condition and our strong commitment to 
that, to have to go on record in opposition to these amendments. But if 
that is the cost, and Members of the Senate feel that is what they want 
to do to many of us who have been out there working on precondition 
year in and year out, we are prepared to do it.
  I will join in urging that the Senate table this at the first 
opportunity.
  The PRESIDING OFFICER. The Senator from New Mexico.
  Mr. DOMENICI. Mr. President, how much time do I have left?
  The PRESIDING OFFICER. The Senator from New Mexico has 4 minutes 26 
seconds.
  Mr. DOMENICI. Mr. President, I certainly do not intend by my action 
tonight to make it painful for Senator Kennedy, who has been a staunch 
advocate. I hope that is not what he said tonight. I just believe very, 
very sincerely that the time is now to get something done.
  I want to explain one more time in just a brief, few words what this 
amendment does not do, because I think there could be some confusion. 
Let me clear up what it does not do. It does not provide an open-ended 
entitlement to whatever mental health services an individual wants. It 
does not limit the ability of an insurer or health plan to limit 
services to only those who are medically necessary. It does not 
institute a service-by-service equivalency between physical and mental 
illness. It does not mandate a benefit package.
  It simply makes the following common situations illegal. Let me cite 
a few:
  Policies that allow 365 days in-patient care for physical illness 
allow only 45 days for in-patient psychiatric care.
  Policies that provide a lifetime cap of $1 million for physical care 
have a $50,000 cap for mental illness.
  Policies providing unlimited outpatient visits for physical care 
allow only 20 outpatient visits for mental illnesses.
  Mr. President, 90 percent of employer-sponsored plans impose such 
limits, despite the proven efficacy of treatments for mental illness. 
Treatment for schizophrenia has a 60 percent success rate; manic 
depression, 80 percent; major depression, 65 percent. Yet commonly 
reimbursed procedures such as angioplasty and arthrectomy have only a 
41-percent and a 52-percent ratio, and nobody seeks to treat them with 
limitations that are imposed on mental illnesses.
  The era of managed care is upon us, making tight management of 
patient care the norm, and artificial cost measures to reduce 
utilization are a thing of the past.
  I have a number of examples of companies that have covered with 
parity of treatment and, believe it or not, they have saved money and 
added to their work force in ways that are measurable and objectively 
beneficial to the companies that have so seen fit.
  So, from my standpoint, from the standpoint of the Senator from New 
Mexico, I do not seek to kill this bill. I think it is a marvelous step 
in the right direction. But I ask my fellow Senators when, if not 
tonight, will we ever get around to this issue? If I thought there was 
another bill coming down this year, I would probably have made an 
agreement so that I could have the full support of my friend from 
Massachusetts and my colleague and friend from Kansas, Senator 
Kassebaum. But I do not see that coming.

  I believe there is plenty of evidence that the discrimination 
continues. It grows more rampant. The stigma, since that discrimination 
is rampant, is growing instead of diminishing, in an era when knowledge 
is beginning to grow almost exponentially.
  So, now is the time. Tonight is the time to send this to conference. 
Deny the motion to table. Let our Senate colleagues take this to 
conference. Let us work on the various interests that will be part of 
that conference and see if we cannot make this a better bill because it 
would have this amendment attached than it would if it fails tonight.
  I yield the floor.
  Mrs. KASSEBAUM addressed the Chair.
  The PRESIDING OFFICER. The Senator from Kansas.
  Mrs. KASSEBAUM. Mr. President, I know that many here would like to 
vote in favor of this amendment offered by Senator Domenici, and 
Senator Wellstone is one. It has been carefully crafted.
  There is no greater dedication to this legislation than from those 
who have spoken to us, as well as Senator Kennedy who, for a long time, 
has been a great supporter.
  So it is with real disappointment, if all debate is over, that I will 
have to move to table, as it is not an amendment that has consensus of 
support. And so for that reason, I only hope we can find some other 
avenue later through which we can address this.
  I move to table the Domenici-Wellstone amendment, and I ask for the 
yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The yeas and nays were ordered.
  Mr. DOMENICI. Has all time expired?
  The PRESIDING OFFICER. The Senator from New Mexico has 14 seconds 
remaining. The Senator from Kansas has 2 minutes.

[[Page S3592]]

  Mr. DOMENICI. I yield back my time.
  Mrs. KASSEBAUM. I yield back my time.
  The PRESIDING OFFICER. The question is on agreeing to the motion to 
lay on the table amendment No. 3681.
  The yeas and nays have been ordered.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. LOTT. I announce that the Senator from Colorado, [Mr. Campbell] 
and the Senator from Florida [Mr. Mack] are necessarily absent.
  The PRESIDING OFFICER (Mr. Jeffords). Are there any other Senators in 
the Chamber desiring to vote?
  The result was announced--yeas 33, nays 65, as follows:

                      [Rollcall Vote No. 75 Leg.]

                                YEAS--33

     Ashcroft
     Bond
     Breaux
     Brown
     Bryan
     Chafee
     Coats
     Cohen
     Craig
     Daschle
     Dodd
     Faircloth
     Ford
     Frist
     Gorton
     Gramm
     Grams
     Gregg
     Hollings
     Inhofe
     Johnston
     Kassebaum
     Kempthorne
     Kennedy
     Kohl
     Kyl
     McCain
     Nickles
     Reid
     Rockefeller
     Roth
     Smith
     Thompson

                                NAYS--65

     Abraham
     Akaka
     Baucus
     Bennett
     Biden
     Bingaman
     Boxer
     Bradley
     Bumpers
     Burns
     Byrd
     Cochran
     Conrad
     Coverdell
     D'Amato
     DeWine
     Dole
     Domenici
     Dorgan
     Exon
     Feingold
     Feinstein
     Glenn
     Graham
     Grassley
     Harkin
     Hatch
     Hatfield
     Heflin
     Helms
     Hutchison
     Inouye
     Jeffords
     Kerrey
     Kerry
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lott
     Lugar
     McConnell
     Mikulski
     Moseley-Braun
     Moynihan
     Murkowski
     Murray
     Nunn
     Pell
     Pressler
     Pryor
     Robb
     Santorum
     Sarbanes
     Shelby
     Simon
     Simpson
     Snowe
     Specter
     Stevens
     Thomas
     Thurmond
     Warner
     Wellstone
     Wyden

                             NOT VOTING--2

     Campbell
     Mack
       
  So the motion to lay on the table the amendment (No. 3681) was 
rejected.
  Mr. DOLE. Mr. President, I move to reconsider the vote.
  Mr. SANTORUM. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.
  Mr. DOLE. Mr. President, I think we are making progress. I wonder if 
the managers might be able to identify those amendments that would 
require rollcall votes and have the debate on those amendments, and 
then we can advise our other colleagues that did not have amendments 
that we would probably be voting, say, at 10 o'clock or 9:30, or 
whatever it might be. That would save everybody from having to stay on 
the floor. When you stay on the floor, sometimes you get excited and 
talk.
  Mrs. KASSEBAUM. Mr. President, I say to the majority leader, on our 
side, I understand that Senator Specter would like to have a vote. He 
has two amendments.
  Mr. DOLE. En bloc?
  Mrs. KASSEBAUM. I would assume we could vote en bloc.
  Mr. SPECTER. I am right here and ready to go, madam manager.
  Mrs. KASSEBAUM. All right. I am not sure about Senator Thomas, 
whether he will want a vote on his, and Senator Gramm. I believe those 
are the only amendments that I have listed that would require--Senator 
Burns, I believe, has one on telemedicine.
  Mr. COATS. I have one, also.
  Mrs. KASSEBAUM. I thought we were going to try to work that out.
  Mr. COATS. We are not able to work that out, so we are going to have 
to have a vote on it.
  Mr. DOLE. How many from the Senator from Massachusetts?
  Mr. KENNEDY. We have the Conrad amendment on J-1 visas, which is 
acceptable. We have one other amendment where somebody wants to 
introduce it, speak, and withdraw it. Senator Dorgan's amendment on 
organ donor, which, I believe, has been accepted, with Senator Frist. 
We have Senator Harkin's, and we are waiting to see whether Senator 
Wellstone wants to work out an exchange of language or a vote. And 
there is a Senator Boxer sense of the Senate.
  Some of those, as I mentioned--the Conrad visa amendment, and the 
organ donor amendment--have been worked out. I think they will just 
take very brief comments.
  Mr. DOLE. So that will be two votes?
  Mr. KENNEDY. Potentially, four. I hope we get it down to three.
  Mr. DOLE. Let me encourage my colleagues, if there is an opportunity 
to work these out on either side, we hope we can do that and not 
require a rollcall vote. If you are going to work out your amendment 
and it is accepted without rollcall votes, I will look very kindly on 
those amendments. I will be a conferee.

  Mr. DOMENICI. Mr. President, I ask that the yeas and nays be vitiated 
on the Domenici amendment.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is agreed to.
  So the amendment (No. 3681) was agreed to
  Mr. DOMENICI. Mr. President, I move to reconsider the vote.
  Mr. EXON. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.
  Mr. DOLE. Mr. President, I think the distinguished Democratic leader 
wanted to add a word.
  Mr. DASCHLE. Mr. President, I ask the majority leader whether or not, 
to accommodate a couple of our colleagues, who, I think, were working 
under the understanding that we might be able to stack votes, whether 
or not it may be possible to stack the next two or three votes so as to 
accommodate some of those who may have left with that understanding. 
Would that be possible?
  Mr. DOLE. I am satisfied with that. I think it is a good idea.
  Mrs. KASSEBAUM. As long as there are so few left.
  Mr. DOLE. We can stack three or four votes back to back, accept the 
rest of them, and have final passage.
  Mr. LEAHY. Will the majority leader yield for a question?
  Mr. DOLE. Yes.
  Mr. LEAHY. If we are going to stack them, do we know approximately 
when the votes will start?
  Mr. DOLE. How much time will the Senator from Pennsylvania take?
  Mr. SPECTER. Mr. President, responding to the majority leader's 
question, I think it can be disposed of in 20 minutes, 10 minutes a 
side.
  Mr. DOLE. Each amendment, or both?
  Mr. SPECTER. I am going to start with the first amendment.
  Mr. KENNEDY. We would take 5 minutes.
  Mr. DOLE. Let us say an hour from now.
  Mr. LEAHY. Votes will start then, an hour from now?
  Mr. DOLE. Yes.


                           Amendment No. 3682

(Purpose: To reauthorize and expand the healthy start program to target 
 areas in need and to implement community driven strategies to reduce 
                           infant mortality)

  Mr. SPECTER. Mr. President, I send an amendment to the desk and ask 
for its immediate consideration.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Pennsylvania [Mr. Specter] proposes an 
     amendment numbered 3682.

  Mr. SPECTER. Mr. President, I ask unanimous consent that reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:
       At the appropriate place in title III, insert the following 
     new section:

     SEC.   . REAUTHORIZATION OF HEALTHY START PROGRAM.

       (a) Authorization of Appropriations.--To enable the 
     Secretary of Health and Human Services to carry out the 
     healthy start program established under the authority of 
     section 301 of the Public Health Service Act (42 U.S.C. 241), 
     there are authorized to be appropriated $100,000,000 for each 
     of the fiscal years 1997 through 2001.
       (b) Existing Projects.--
       (1) In general.--Of the amount appropriated under 
     subsection (a) for a fiscal year, the Secretary of Health and 
     Human Services shall reserve $30,000,000 for such fiscal year 
     among demonstration projects that received funding under the 
     healthy start program for fiscal year 1996.
       (2) Eligibility.--To be eligible to receive funds under 
     paragraph (1), an existing demonstration projects shall 
     demonstrate to the satisfaction of Secretary of Health and 
     Human Services that such project has been successful in 
     serving needy areas and reducing infant mortality.
       (3) Use of projects.--A demonstration project that receives 
     funding under paragraph (1) shall be utilized as a resource 
     center to assist in the training of those individuals to be 
     involved in projects established

[[Page S3593]]

     under subsection (c). It shall be the goal of such projects 
     to become self-sustaining within the project area.
       (c) New Projects.--Of the amount appropriated under 
     subsection (a) for a fiscal year, the Secretary of Health and 
     Human Services shall allocate the remaining amounts for such 
     fiscal year among up to 35 new demonstration projects. Such 
     projects shall be community-based and shall attempt to 
     replicate healthy start model projects that have been 
     determined by the Secretary of Health and Human Services to 
     be successful.

  Mr. SPECTER. Mr. President, this is an amendment which provides for 
reauthorization of Healthy Start. This amendment would reauthorize the 
Healthy Start program for an additional 5 years at $100 million a year. 
It is important that the reauthorization occur on this bill because, 
given the Senate calendar, it is highly doubtful that this issue will 
be raised on any other bill.
  In my capacity as Chairman of the Appropriations Subcommittee for 
Health and Human Services, I can say with some authority that we need 
the authorization so that we are prepared to make the appropriate 
appropriations.
  Healthy Start is a program which is designed to provide prenatal care 
to infants. I saw my first 1-pound baby more than a decade ago at the 
Alma Ellery Clinic in Pittsburgh and, at that time, I saw a baby about 
as big as my hand, weighing a pound. Some babies weigh as little as 12 
ounces, and they are human tragedies, carrying scars for a lifetime, 
and they are very expensive for our society, costing as much as 
$250,000 each.
  In my position on the Appropriations Committee, I worked to start 
this program of Healthy Start, and it has had a really remarkable 
success. It has been in existence for 5 years, which is a relatively 
short period of time. But we already have statistics available that 
show the success of the program.
  The 1994 statistics received from the projects demonstrated that from 
1984 to 1988, baseline statistics in Philadelphia show that infant 
mortality had decreased some 28 percent. In Pittsburgh, the infant 
mortality rate decreased 20 percent since the start of the Healthy 
Start Program in 1993.
  The Maternal and Child Health Bureau reports that for the State of 
New York, between 1990 and 1994, infant mortality rates decreased by 38 
percent in the Healthy Start project area, compared to a 22 percent 
decline citywide.
  Without going into any greater demonstration of statistics, Mr. 
President, I think it is apparent that Healthy Start is an important 
program. Dr. Koop commented that with these minimal four prenatal 
visits, women carrying children would not give birth to low-birthweight 
babies. It, obviously, has been a very important program. It exists in 
some 22 cities at the present time: Boston; New York; Philadelphia; 
Pittsburgh; Baltimore; Washington, the DCPD region; South Carolina; 
Birmingham, AL; Cleveland, OH. I read these listings so that my 
colleagues will know how many of these units are in existence in their 
locales. Troy, IN; Chicago, IL; New Orleans; the Northern Plains Indian 
Reservations; communities in South Dakota, North Dakota, Iowa; Oakland, 
CA; and special projects in Dallas, TX; Essex County, NJ; the Florida 
Panhandle; Milwaukee, WI; the Mississippi Delta; Richmond, VA; and 
Savannah, GA.

  The plan is to expand these projects from the 17 projects which are 
now--from the 22 projects which are now in existence, to an additional 
35 projects.
  Mr. President, I think the value of this program is apparent on its 
face. It has been in existence for 5 years. It has been very successful 
and does not encumber or impede this bill in any way.
  It is a little hard to understand why it is not accepted, but I think 
it ought to command the attention of this House and the House of 
Representatives. And I urge its adoption.
  The PRESIDING OFFICER. Is there further debate?
  Mr. SPECTER. Mr. President, I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The yeas and nays were ordered.
  Mrs. KASSEBAUM. Mr. President, is the Senator from Pennsylvania going 
to offer a second-degree amendment at this time?
  Mr. SPECTER. I am not.
  Mrs. KASSEBAUM. Is the Senator going to wait until quarter of 10 to 
speak on that? We are stacking the votes.
  Mr. SPECTER. I understand we are stacking the votes. At this time I 
am offering this amendment and speaking about this amendment.
  Mr. HARKIN addressed the Chair.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. HARKIN. I understand the floor is open for amendments.
  The PRESIDING OFFICER. There is a pending amendment which needs to be 
set aside by unanimous consent.
  Mr. HARKIN. I understand, if I am not mistaken, that we are going to 
stack these votes. Is the Senator getting a vote right now under the 
regular order? The yeas and nays were ordered.
  Mr. SPECTER. As I understand it, we are stacking the amendments. But 
I am not prepared to set the amendment aside at this point. I would 
like to see if the managers have contrary argument.
  Mrs. KASSEBAUM. Mr. President, yes. This is not acceptable. The 
reason is that it is authorizing legislation which I believe needs to 
come through committee and the committee procedure before we would 
authorize this on this bill regarding health insurance reform.
  That would be the objection of the managers of the bill.
  Mr. SPECTER addressed the Chair.
  The PRESIDING OFFICER. The Senator from Pennsylvania is recognized.
  Mr. SPECTER. Mr. President, in response to the comments of the 
Senator from Kansas, it is my strong view that a healthy start program 
is directly germane and directly relevant to the pending legislation on 
health care and that it is a jurisdictional question. I do not quite 
understand the argument. This program has been in existence, has been a 
success, and there has been no denial by the managers that it is in 
existence and has been a success. It is hardly the kind of program 
which is going to require additional hearings. It seems to me that it 
is right for disposition. That is why I am offering the amendment.
  The PRESIDING OFFICER. Is there further debate on the amendment?
  Mrs. KASSEBAUM. Mr. President, I stated the reasons why we have an 
objection. It is a program that has had some success. That is very 
true. And healthy start is very important. It is part of other programs 
in the public health sector to which that is directed. As I say, I 
think it should be really reviewed in oversight so we can analyze what 
is being done and what should be done. I just feel strongly that in 
this instance it needs to be handled through the authorizing process 
rather than an amendment.
  The PRESIDING OFFICER. For clarification, there is no unanimous 
consent to stack the votes at this time. So the pending business is the 
amendment of the Senator from Pennsylvania.
  Mrs. KASSEBAUM. Mr. President, just so I understand, I thought the 
majority leader asked that votes would be stacked until 9:45. Did I 
misunderstand?
  The PRESIDING OFFICER. My understanding is that it was not posed as a 
unanimous consent request.
  Mr. DOLE. I now make that request.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  Mr. HARKIN addressed the Chair.
  The PRESIDING OFFICER. The Senator from Iowa is recognized.


 Amendment No. 3683 to the Committee Substitute, as Amended by No. 3675

        (Purpose: To reduce health care fraud, waste, and abuse)

  Mr. HARKIN. Mr. President, I send an amendment to the desk.
  The PRESIDING OFFICER. The clerk will report.
  The bill clerk read as follows:

       The Senator from Iowa [Mr. Harkin], for himself and Mr. 
     Baucus, proposes an amendment numbered 3683.

  Mr. HARKIN. Mr. President, I ask unanimous consent that reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (The text of the amendment is printed in today's Record under 
``Amendments Submitted.'')
  Mr. HARKIN. Mr. President, this is offered on behalf of myself and 
Senator Baucus.
  Mr. President, this amendment deals with the continuing problem of 
waste,

[[Page S3594]]

fraud, and abuse in the Medicare system. Over the last several years we 
have had numerous IG investigations, reports, GAO investigations, and 
GAO reports. The data is overwhelming. No one can dispute the findings. 
The Director of HCFA himself has testified before the Labor, Health and 
Human Services Appropriations Subcommittee as to the validity of these 
findings. No one disputes that there is tremendous waste, fraud, and 
abuse in Medicare. The GAO has estimated that up to 10 percent of 
Medicare funds are lost to waste, fraud, and abuse every year.
  Out of a $180 billion program, 10 percent, that is up to $18 billion 
lost to waste, fraud, and abuse. That is $500 per beneficiary per year.
  I know that we are not going to be able to get all of it out. I 
understand that. But at least we can make some important strides in 
saving a lot of this money. The amendment that was adopted earlier--the 
Dole-Roth amendment--had some provisions in it to combat fraud and 
abuse that I have pushed and supported for a long time, including 
increased resources for the HHS Inspector General and increased 
resources for Medicare contractors to fight fraud and abuse, and 
tougher penalties for fraudulent activities. These were in the 
amendment adopted.
  I say that these are positive and long overdue steps. As I said, they 
are steps that I have pushed and promoted for years. However, they are 
inadequate. There is much, much more that needs to be done and can be 
done right now to really make a dent in the massive amounts of waste 
and abuse in the system.
  Mr. President, every time I go to town meetings in Iowa and I meet 
with the elderly--or just basically anyone that has been involved in 
the Medicare system, like people who have had parents or grandparents 
who have received Medicare help and assistance--whenever you talk about 
waste and abuse you get an immediate response. They know it exists all 
too well. When you talk about looking at their bills and ask if they 
ever look at a bill and see an item on there that they did not really 
think they received, or maybe paid too much for--you watch the heads 
nod--they all have, and they are outraged about it. But what they will 
show you is they will hold up the form that they got from Medicare, and 
it will have stamped on the front of it, ``This is not a bill.''
  A couple of years ago a woman by the name of Shirley Pollock from 
Atlantic, IA, got hold of me. She had received one of these for her 
mother-in-law who had been in a nursing home.
  For something short of 5 weeks' time, she was billed over $5,000 for 
bandages. She was outraged, because she knew there was no way her 
mother-in-law had used that many bandages. But on the front it said, 
``This is not a bill.'' So Shirley Pollock complained to the Medicare 
payor about this and was told: Do not worry about it. You do not have 
to pay it anyway.
  Well, as Shirley later told me, ``I got so mad because I knew 
somebody's got to pay it. Obviously taxpayers or people paying into 
Medicare are paying for it. Someone is paying for it. I know we didn't 
receive $5,000 in bandages, and I want to do something about it.''
  So she contacted my office, and we worked it through and found out, 
indeed, that she was absolutely right. Her mother-in-law had never 
received $5,000 in bandages--maybe $500 worth but not $5,000, and yet 
the bill was paid. The bill was just paid as if nothing had happened.
  So we know this is going on. And like I said, you can ask any person 
in a town meeting about this, especially those who have been in 
Medicare, and they will tell you that they know what we are talking 
about, too.
  So I am offering this amendment to add what I believe are a few more 
important commonsense weapons in this fight against waste and abuse.
  Now, I will for the benefit of my colleagues state at the outset that 
there is one provision I have been pushing for for some time that I do 
not have in this amendment because I know there is opposition to it on 
the floor. I have offered it before. And that is the idea of 
competitive bidding. I am not offering that as part of this package 
because I know they want to get the bill through, and I am for this 
bill; I am a cosponsor of it. I wish to get it through. But, obviously, 
unbelievable as it may seem to me and to others, there are some who do 
not believe that Medicare should adopt competitive bidding when it 
comes to medical supplies so that seniors and the taxpayers get the 
best price possible.
  So I did not include it. I took it out because I know that that some 
have said it's too controversial. But I am going to be offering that 
again to get us to competitive bidding, just like the Veterans 
Administration has been doing for years. It's an outrage Medicare is 
losing millions because its payment system is prone to abuse and waste. 
Over a period of years I've compared like bills, like items between 
Medicare and the Veterans Administration, same city, same supplier. 
Medicare is often paying 30 to 50 percent more than what the Veterans 
Administration is. Why is that? Because the Veterans Administration 
engages in competitive bidding and Medicare does not. But as I said, I 
have not included that in this amendment. I wanted to make that clear.
  All of the provisions in this amendment that I have offered are the 
result of extensive hearings held by the Labor, Health and Human 
Services Appropriations Subcommittee over the past several years. They 
are all recommendations of the General Accounting Office, the inspector 
general of the Department of Health and Human Services or other private 
sector medical experts. All of them are commonsense steps, and I just 
want to review very briefly what they are.
  First, this would provide for improved information to seniors to 
allow them to better help in the fight against Medicare fraud, waste, 
and abuse. Seniors would be guaranteed the right to receive itemized 
bills instead of a summarized report from which it may be difficult to 
detect billing errors or abuses. Every Medicare payment statement would 
also have to include a toll-free hotline number to report suspected 
cases of fraud, waste, or abuse.
  Now, to those who may say this is a burden, let me just point out 
that those who are sending in the bills have to keep an itemized 
record. But when they send it to the beneficiary, they can just 
summarize it. So the beneficiary can look at it, and a lot of times not 
even know what they are paying for and a lot of times Medicare does not 
know what it is paying for. They just pay it, but they really do not 
know what the itemized bill is.
  The reason I know that you can go back and find the itemized bills is 
that the investigations we have done by the General Accounting Office 
have gone after some of these summarized bills, gone back to the 
claimant, back to the hospital or the nursing home or the doctor or 
whoever it might be and said, OK, what made up this summarized 
statement? Well, they had to produce the itemized bill so that the 
General Accounting Office could look at it. So they do have that 
itemized bill. I am saying it is no more of a problem for them just to 
print that out on the bill they send to Medicare. This amendment would 
guarantee seniors that they could get an itemized bill so that they 
know exactly what they were being charged for and how much they were 
being charged for it. And, as I said, it would also require Medicare to 
put on each explanation of Medicare benefits a toll-free hotline number 
so that a person could report any suspected case of fraud or abuse.
  That is the first part of my amendment. The second part of my 
amendment establishes rewards of up to $10,000 for those providing 
information that leads to a health care fraud conviction. Again, it is 
to get people to step forward, to provide the information that we need, 
and if it leads to a health care fraud conviction they would be 
entitled to a reward up to $10,000.
  The third part of my amendment prohibits Medicare payments for 
wasteful and unnecessary items such as sports cars for corporate 
executives, lucrative gifts to executive families and friends, tickets 
to sporting and other entertainment events, and other items not related 
to medical care.
  In one of the most infuriating cases of abuse we found that health 
care executives were padding Medicare bills with all sorts of 
outrageous items identified as indirect costs. For example, we found 
the following items charged to Medicare: $2,433 for a trip to Italy to 
inspect a piece of sculpture; $10,215 billed to Medicare for clocks, 
watches,

[[Page S3595]]

and bowls for employees and friends; thousands of dollars for a golf 
tournament that was only held for executives; a $4,200 bill for a 
sporting event, all billed to Medicare as indirect costs. That is 
outrageous.
  Now, Medicare did take one step after I prodded them at hearings. No 
longer will they pay for alcohol or for lobbying expenses as indirect 
costs. Well, that was a good first step, but they still have not 
specifically excluded these other items. My amendment would change 
that.
  Next, my amendment says that we would reduce Medicare waste by giving 
the private companies that administer Medicare the authority to reduce 
payments for items they identify as grossly overpriced. Currently this 
can only be done on a national basis by HCFA and has only been done 
once, a process that took HCFA 3 years.
  I am familiar with that because I initiated it several years ago. We 
found a blood glucose monitor, a little device that you can buy at 
Kmart or any discount store; it is for people who have diabetes. They 
can get an accurate check on what their blood glucose level is. It is a 
little pocket device with a battery in it. We found that Medicare was 
reimbursing up to $200 for each one of those. I sent my staff down to 
the local Kmart. They bought one for $49.99--50 bucks. Medicare was 
reimbursing up to $200 for it.
  So I went to Medicare, to HCFA. I said, ``Okay, we have to stop it. 
You can go down and buy it for 50 bucks. Why are you paying $200?"
  Believe it or not, from that moment to the day that they actually 
reduced the price to $50 took 3 years--3 years for them to do that. 
Well, this amendment would give a private company that administers 
Medicare the authority to reduce payments on items that they identify 
as grossly overpriced. So if they found something like a blood glucose 
monitor that they were reimbursing $200 for and they could buy it for 
50 bucks, they could reduce the price down themselves. Again, right 
now, it takes HCFA over 3 years just to do one simple thing like that. 
This is a change that has been praised both by Medicare and the HHS 
Inspector General.
  Next, my amendment would better assure that rapidly growing home 
health services are not subject to abuse by requiring that Medicare 
payments are not inflated by bills being filed in a higher payment area 
outside of where the service was provided, by establishing a fine for 
knowingly providing a false certification that a patient meets Medicare 
home health coverage criteria and by requiring that bills submitted for 
surgical dressings are itemized.

  I will just read a little bit from this GAO report that covered 
excessive payments for medical supplies. Here is what happens. It says:

       Fiscal intermediaries pay medical supply claims without 
     knowing specifically what they are being asked to pay for on 
     behalf of beneficiaries. The claims submitted by providers 
     have no detailed information that would allow fiscal 
     intermediaries to assess the claims' reasonableness. This 
     lack of detail exists because HCFA guidance allows providers 
     to bill all medical supplies under 10 broad codes. Billed 
     items are not listed by type or amount. A code frequently 
     used to record medical supplies is code 270, that is medical/
     surgical supplies, which we found included many different 
     items such as a $21,437 pacemaker, a 75 cent sterile sponge, 
     and even daily rental charges of $59 for an aqua pad. 
     Consequently, unless fiscal intermediaries identify these 
     claims for review and request additional documentation before 
     payment, they will pay for the claims without knowing what 
     the specific purchase was or whether it was covered or 
     medically necessary.

  Again, my amendment would address that and allow them to get that 
necessary information so that they would know exactly what they were 
paying for. That change was recommended and drafted by the General 
Accounting Office.
  Next, my amendment would require Medicare to replace its outdated 
computer systems with state-of-the-art private sector computer software 
to detect and stop billing abuse. The General Accounting Office found 
that this simple change would save about $600 million a year. Again, 
this provision carries out their recommended changes to save seniors 
and taxpayers money.
  GAO found, in fact, that a number of the private companies that 
process Medicare claims use the more sophisticated computer software on 
their private sector business but are not allowed to use it on their 
Medicare claims. They actually have to have two computer systems. They 
have their own that they submit claims to. Then they have another set 
that they have to have and another set of software just for Medicare.
  As I said, the General Accounting Office said that just by making 
this one change, this one change would save $600 million a year, and 
the cost for doing that was about $20 million. So, again, it would 
require Medicare to replace its computer systems with state-of-the-art 
private sector computer technology, just what most private companies 
are using today to detect and stop billing abuse. As the GAO said, the 
private sector ones were so much better at detecting fraud and abuse 
than the Medicare ones were. We have been after Medicare. They say they 
are going to do this; maybe by the end of 1999 they might have it 
changed. We could change it right now and, as GAO said, save up to $600 
million a year.
  Last, my amendment saves money and reduces hassle by cutting 
excessive Medicare and Medicaid paperwork. There would be a uniform 
application and benefit claims form that would be established and would 
eliminate duplicative forms.
  Mr. President, these are really modest steps. Again, these are all 
steps that the GAO, the inspector general's office, and other private 
sector health care experts have said are necessary to at least stem 
this tremendous hemorrhaging of waste and abuse that we have in 
Medicare. When you are talking about up to $18 billion a year, even if 
we cannot get all of it, if we could just get half of it, that is $9 
billion a year. That is a lot of money. I see no reason why we could 
not get at least half of it with these modest steps that I am proposing 
here.
  As I said, I did not include the one on competitive bidding. We will 
revisit that at another time. But I thought in the spirit of moving 
this legislation along and offering something that I thought was 
modest, that would move us in the right direction, that is why I took 
out competitive bidding.

  I offer this amendment to enhance this bill and hopefully make it a 
better bill for health care in America. That is what this bill is 
about, is to help us in health care reform. You cannot have real health 
care reform until you stop the waste, fraud and abuse in Medicare. It 
is in that spirit I offer this amendment.
  I thank the Senator from Montana for his strong support over the 
years, trying to weed out this waste, fraud and abuse in Medicare. He 
has been a leader on this subject. I am happy to have him as a 
cosponsor on this amendment.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I hope my colleagues listened very closely 
to the Senator from Iowa. The big debate here is how to save Medicare. 
Senators on one side of the aisle say we have to cut Medicare to save 
it. We had this big debate over whether we should cut $270 billion out 
of Medicare in the next 7 years. We spent a lot of time debating this 
issue. Unfortunately, the majority Members in this body ended up 
deciding that, yes, we should cut that much money out of Medicare over 
7 years. I think every Member on this side of the aisle voted against 
that.
  Obviously, if we are going to save Medicare, we ought to first look 
at waste. It is clear there is waste in Medicare. We all know there is 
waste in Medicare. The General Accounting Office has documented the 
waste. The Senator from Iowa has listed all the Federal agencies that 
documented the millions of dollars lost to waste. Each of us, at home, 
talks to senior citizens, to providers and others who, on an anecdotal 
basis, tell us about waste in Medicare. We all know there is waste in 
Medicare.
  We also know it takes a long time to get something done around here, 
way too long. Too many times we debate issues, not months but years. It 
takes way too long to get something meaningful accomplished around 
here. I think tonight we are debating a very important bill. We are 
going to pass this bill, hopefully tonight, that will take solid steps 
to provide better insurance coverage for millions of Americans and 
thousands of Montanans. This

[[Page S3596]]

is important and I strongly support this bill. At the same time, we 
have the chance to take the steps necessary to cut some of the waste in 
Medicare.
  Tonight, let us pass this amendment. It is not perfect. There will be 
a lot of opportunities to work with it, during the conference 
committee, but let us get started. Let us pass this. We all know we 
should. Let us just do it. It might not be perfect, but we should not 
let perfection be the enemy of the good. Every Senator here tonight 
knows that this is a good amendment. We all know it is on the right 
track. I, for the life of me, do not understand why we just do not 
accept it tonight, work on it in the conference committee, maybe fix it 
up a little bit, get it enacted into law, and begin to attack a lot of 
the waste that exists in Medicare.
  I hope Senators listened to the examples the Senator gave tonight. 
There are many more. They are outrageous--trips to Italy, sports cars. 
You would be amazed what waste, fraud, and abuse occurs in our Medicare 
program. It is outrageous. So, let us begin to do something about it; 
just begin. We heard the figures. GAO says up to 10 percent. That is 
$18 billion.
  Let us be honest, we are not going to get a full $18 billion 
recovered. We know that. But, as the Senator from Iowa says, let us at 
least make a start. Let us not say we are not going to do it tonight 
because we have a no-amendments policy. We have already adopted one 
amendment, and another one, already tonight. Certainly this is in the 
category of amendments that we know should be passed. Otherwise, we run 
the risk that nothing will happen to fight fraud and abuse in the 
Medicare program this year.
  What is going to happen next year? We do not know, as we attempt to 
address the waste that exists in Medicare.
  I am not going to belabor the issue. It is getting late tonight. The 
Senator from Iowa has listed all the various provisions of his 
amendment. I just hope we can leave the partisan fighting and political 
rhetoric behind and do something which we know the people at home whom 
we represent want. Let us begin to take some very critical and concrete 
steps to address the waste and fraud that does exist in Medicare. That 
is where we should begin, rather than just cutting Medicare. First, let 
us cut the waste out of Medicare and the fraud out of Medicare before 
we cut Medicare services and programs that help millions of seniors 
nationwide.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Kansas, the majority manager, 
is recognized.
  Mrs. KASSEBAUM. Mr. President, I am speaking somewhat on behalf of 
Senator Cohen from Maine. He has worked many years on this issue, and 
has worked with Senator Harkin as well, trying to address the issues of 
fraud and abuse.
  The language that Senator Cohen had worked on is now part of the 
bill. It is an important issue, and the very things that Senator Harkin 
raised are issues Senator Cohen raised. But there have also been some 
concerns, and we have to be careful, if there are some problems, to see 
if we cannot get them worked out or else it poses a problem for the 
underlying bill.
  I yield time to the Senator from Maine.
  Mr. KENNEDY. Mr. President, I wonder if we can possibly get a time 
understanding. We have several Members here. I know people want to 
address this, and Senator Cohen wants to speak on it. I am wondering if 
the proponents of the amendment are willing to agree to a time limit.
  Mrs. KASSEBAUM. There is very little time we need, Mr. President. My 
guess is, if Senator Cohen says 5 minutes, that is fine.
  Mrs. BOXER. I am sorry, this is a time agreement?
  Mr. KENNEDY. Just with regard to the Harkin amendment, can we agree 
that there be 10 minutes evenly divided? I ask unanimous consent that 
there be 10 minutes equally divided.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The Senator from Maine.
  Mr. COHEN. Mr. President, if I can be as brief as I can within the 5-
minute limitation, the fraud and abuse provisions that we adopted in 
the leadership amendment is something that I have worked on now for 
over 3 years. It passed both the House and the Senate last year as part 
of the budget reconciliation act. It was included in the 
administration's budget reconciliation proposal.
  So the legislation we have passed and adopted is something that has 
been completely vetted; it has been negotiated through a lengthy 
process; it has been through the hearing process; it has been on the 
floor on several occasions--in fact, numerous times.
  Additionally, it has received the endorsement of the administration, 
the Attorney General, Secretary of Health and Human Services, the 
Finance Committee of the House and Senate, as well as many private 
groups. The Harkin legislation has not gone through any such review or 
scrubbing; it has not received these endorsements, to my knowledge. In 
fact, I am sure we do not know of all the objections to his provisions. 
I do believe that there are several that are the subject of 
controversy.
  I am not here to argue the merits of each of the items I am about to 
raise, but I know that both Health and Human Services and HCFA, the 
Health Care Financing Administration, object to the section that 
requires HCFA to acquire commercial software technology for Medicare 
claims processing. I know HCFA has concerns with the Harkin section 
that requires Medicare payments for certain items.

  Again, I am not here to argue the merits of these particular items 
tonight. I merely say to my colleagues, they are not without 
controversy. If our objective is to pass the Kassebaum-Kennedy bill 
because we want to see legislation that guarantees access, 
affordability and portability, it seems to me the best thing we can do 
is stay with the legislation we adopted. That is why it was included in 
the leadership amendment.
  So we have adopted it on several occasions. There may be some merit 
to Senator Harkin's proposal, but I think because of the items that are 
in controversy, it is only going to jeopardize the legislation. I 
believe the fraud and abuse provisions we have adopted are an enormous 
step forward. CBO has scored the amendment we adopted as saving some $3 
billion, and that is going to pay for a number of items in the bill 
itself.
  So, Mr. President, I hope that my colleagues, when the appropriate 
time comes, will move to table the Harkin amendment, that we will enjoy 
the support of our colleagues, because I believe the Harkin amendment 
does raise controversial issues, and the last thing we need at this 
time is more controversy on this bill.
  Mr. KENNEDY. I yield myself 2 minutes.
  Mr. President, I have worked very closely with the Senator from Iowa, 
and I admire all of his extraordinary work in all of this area. I think 
it is very commendable, and I do not think we have really ensured that 
a number of the recommendations have been enacted. So I am, again, very 
sympathetic and supportive of the concept.
  This is a matter really for the Finance Committee, and there has been 
an objection raised on that vote in support of tabling the amendment. 
But I give assurances to the Senator, as a member of the conference and 
given the fact the whole issue of fraud will be a matter of conference, 
I will do the best I can to see that we are able to include some of 
those measures in the conference. That is the best at least I can do, 
but I admire his work and look forward to joining with him on another 
occasion.
  Mr. HARKIN addressed the Chair.
  The PRESIDING OFFICER. The Senator from Iowa is recognized.
  Mr. HARKIN. Mr. President, I appreciate Senator Kennedy's comments, 
and I hope we can get some of these adopted in conference. I say, 
again, I appreciate what the Senator from Maine has done over the last 
few years. He has done a great job of going after these issues of waste 
and abuse. I have no major objections to what was adopted earlier. 
Overall, I think it is a great step in the right direction.
  We probably have been working along parallel paths. I am on the 
Appropriations Committee and the Senator is on another committee, but I 
first started having hearings on this 6 years ago, so we have been 
working on parallel tracks. I do not think there is any need to debate 
that.
  I was just saying I do not know that it is necessary before we pass 
anything

[[Page S3597]]

around here that we have to have the approval of the administration. I 
find that kind of an odd concept at this time in the Senate that we 
have to have that kind of approval. We are the legislative branch.
  I point out that every single item I just mentioned has gone through 
a process of hearings. We have had numerous hearings on this. We have 
had the approval of the inspector general's office and the GAO.
  The Senator from Maine did mention one item. Out of all of these, 
there is only one item that HCFA opposes, and that is the provision in 
there that mandates they use state-of-the-art computer technology. That 
is because HCFA has been trying to develop its own. I have had some 
pretty fair battles with HCFA on this. I guarantee the Senator from 
Maine is right that they do not want that provision.
  I am going to tell you they are wrong. There is high quality computer 
software out in the private sector that Medicare can adopt right now. 
They are wasting money developing their own. And I'm afraid by the time 
that the system they are developing won't solve the problem. The GAO 
study and investigation showed that. I have had Medicare intermediaries 
say that they have the software that Medicare could adopt, and, in 
fact, I say to the Senator from Maine that Medicare did adopt some 
changes of the type I've advocated in January of this year. They 
adopted a little bit of it. It will save some money, but much more 
could be saved.
  Lastly, let me just say the amendment of the Senator from Maine does 
save $3 billion over 7 years. We do not have an estimate on how much 
this would save. All I know is, just on the computer software alone, 
that was $600 million in savings. I believe this amendment would save 
much, much more.
  Again, I do not see anything here that is controversial but for that 
one item where HCFA says they are opposed to adopting private sector 
computer technology. As I said every single item in this amendment is a 
direct recommendation from the Inspector General, the General 
Accounting Office or other experts as effective methods to stop waste, 
fraud and abuse in Medicare.
  This should be a completely noncontroversial amendment. I hope, 
again, as the Senator from Montana said, that we will not get caught up 
in jurisdictions.
  Let us do what is right. What is right is to adopt this and start 
saving some money in the Medicare system. The amendment of the Senator 
from Maine is going to save some money. Darn right it is going to save 
some money. But we can save much more by adopting these other 
provisions.
  The PRESIDING OFFICER. The Senator's time has expired. The minority 
manager is recognized
  Mr. KENNEDY. I was going to make the tabling motion and then set that 
aside. What we had tried to do before is have the few amendments that 
we have here incorporated.
  But I am reminded by my chairman that we had one over here and that 
it would be reasonable and fair to do one over there, and then we would 
come back to try and do all three of these here.
  Mr. CONRAD. I wonder if we can get at least an order that would be 
acceptable so that those of us who have been waiting for an extended 
period might get a timeframe so that we will not just be waiting around 
and then find the list somehow gets altered and we wait some more.
  Mr. KENNEDY. I was prepared to accept Senator Conrad's amendment. It 
is going to take a minute.
  Mr. KASSEBAUM. We are accepting it. So if the Senator wants to 
proceed--Senator Coats has been waiting too, but that is fine. It is 
acceptable.
  Mr. KENNEDY. Mr. President, I make a motion to table the Harkin 
amendment and ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second? There is 
sufficient second.
  The yeas and nays were ordered.
  Mr. KENNEDY. Mr. President, I ask that the Harkin amendment be 
temporarily set aside.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                           Amendment No. 3684

  (Purpose: To extend State requested waivers of the foreign country 
residence requirement with respect to international medical graduates, 
                        and for other purposes)

  Mr. CONRAD. Mr. President, I send an amendment to the desk and ask 
for its immediate consideration.
  The PRESIDING OFFICER. The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from North Dakota [Mr. Conrad] proposes 
     amendment numbered 3684.

  Mr. CONRAD. Mr. President, I ask unanimous consent that further 
reading of the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

       At the appropriate place in the bill, insert the following:

     SEC.   . WAIVER OF FOREIGN COUNTRY RESIDENCE REQUIREMENT WITH 
                   RESPECT TO INTERNATIONAL MEDICAL GRADUATES.

       (a) Extension of Waiver Program.--Section 220(c) of the 
     Immigration and Nationality Technical Corrections Act of 1994 
     (8 U.S.C. 1182 note) is amended by striking ``June 1, 1996'' 
     and inserting ``June 1, 2002''.
       (b) Conditions on Federally Requested Waivers.--Section 
     212(e) of the Immigration and Nationality Act (8 U.S.C. 
     1184(e)) is amended by inserting after ``except that in the 
     case of a waiver requested by a State Department of Public 
     Health or its equivalent'' the following: ``or in the case of 
     a waiver requested by an interested United States Government 
     agency on behalf of an alien described in clause (iii)''.
       (c) Restrictions on Federally Requested Waivers.--Section 
     214(k) (8 U.S.C. 1184(k)) is amended to read as follows:
       ``(k)(1) In the case of a request by an interested State 
     agency or by an interested United States Government agency 
     for a waiver of the two-year foreign residence requirement 
     under section 212(e) with respect to an alien described in 
     clause (iii) of that section, the Attorney General shall not 
     grant such waiver unless--
       ``(A) in the case of an alien who is otherwise 
     contractually obligated to return to a foreign country, the 
     government of such country furnishes the Director of the 
     United States Information Agency with a statement in writing 
     that it has no objection to such waiver; and
       ``(B)(i) in the case of a request by an interested State 
     agency--
       ``(I) the alien demonstrates a bona fide offer of full-time 
     employment, agrees to begin employment with the health 
     facility or organization named in the waiver application 
     within 90 days of receiving such waiver, and agrees to work 
     for a total of not less than three years (unless the Attorney 
     General determines that extenuating circumstances exist, such 
     as closure of the facility or hardship to the alien would 
     justify a lesser period of time); and
       ``(II) the alien's employment continues to benefit the 
     public interest; or
       ``(ii) in the case of a request by an interested United 
     States Government agency--
       ``(I) the alien demonstrates a bona fide offer of full-time 
     employment that has been found to be in the public interest, 
     agrees to begin employment with the health facility or 
     organization named in the waiver application within 90 days 
     of receiving such waiver, and agrees to work for a total of 
     not less than three years (unless the Attorney General 
     determines that extenuating circumstances exist, such as 
     closure of the facility or hardship to the alien would 
     justify a lesser period of time); and
       ``(II) the alien's employment continues to benefit the 
     public interest;
       ``(C) in the case of a request by an interested State 
     agency, the alien agrees to practice medicine in accordance 
     with paragraph (2) for a total of not less than three years 
     only in the geographic area or areas which are designated by 
     the Secretary of Health and Human Services as having a 
     shortage of health care professionals; and
       ``(D) in the case of a request by an interested State 
     agency, the grant of such a waiver would not cause the number 
     of waivers allotted for that State for that fiscal year to 
     exceed 20.
       ``(2)(A) Notwithstanding section 248(2) the Attorney 
     General may change the status of an alien that qualifies 
     under this subsection and section 212(e) to that of an alien 
     described in section 101(a)(15)(H)(i)(b).
       ``(B) No person who has obtained a change of status under 
     subparagraph (A) and who has failed to fulfill the terms of 
     the contract with the health facility or organization named 
     in the waiver application shall be eligible to apply for an 
     immigrant visa, for permanent residence, or for any other 
     change of nonimmigrant status until it is established that 
     such person has resided and been physically present in the 
     country of his nationality or his last residence for an 
     aggregate of at least two years following departure from 
     the United States.
         ``(3) Notwithstanding any other provisions of this 
     subsection, the two-year foreign residence requirement under 
     section 212(e) shall apply with respect to an alien in clause 
     (iii) of that section who has not otherwise been accorded 
     status under section 101(a)(27)(H)--
         ``(A) in the case of a request by an interested State 
     agency, if at any time the alien practices medicine in an 
     area other than an area described in paragraph (1)(C); and

[[Page S3598]]

         ``(B) in the case of a request by an interested United 
     States Government agency, if at any time the alien engages in 
     employment for a health facility or organization not named in 
     the waiver application.''.

  Mr. CONARD. Mr. President, this is very simple. It is an extension of 
the popular J-1 visa program for 6 years. If we fail to do this, the 
authority runs out June 1. Mr. President, the J-1 visa waiver permits 
each of our States to extend 20 waivers a year. And 21 of our States 
have already done it. More are interested in doing it. They will not 
have a chance if the authority runs out June 1.
  Mr. President, the amendment I am sponsoring would extend what has 
become known by some as the ``Conrad State 20 Program.'' In 1994, I 
added a provision to the visa extension bill that allows state health 
departments or their equivalents to participate in the process of 
obtaining J-1 visa waivers. This process allows a foreign medical 
graduate (FMG) who has secured employment in the United States to waive 
the J-1 visa program's 2 year residency requirement.
  As a condition of the J-1 visa, FMGs must return to their home 
countries for at least 2 years after their visas expire before being 
eligible to return. However, if the home countries do not object, FMGs 
can follow a waiver process that allows them to remain and work here in 
a designated health professional shortage area or medically underserved 
area. Before my legislation became law, that process exclusively 
involved finding an ``interested federal agency'' to recommend to the 
United States Information Agency (USIA) that waiving the 2 year 
requirement was in the public interest. The law now allows each State 
health department or its equivalent to make this recommendation to the 
USIA for up to 20 waivers per year.
  This law as necessary for several reasons. Despite an abundance of 
physicians in some areas of the country, other areas, especially rural 
and inner city areas, have had an exceedingly hard time recruiting 
Americans doctors. Many health facilities have had no other choice but 
turn to FMGs to fill their primary care needs. Unfortunately, obtaining 
J-1 visa waivers for qualified FMGs through the federal program is a 
long and bureaucratic process that not only requires the participation 
of the ``interested federal agency'' but also requires approval from 
both the USIA and the Immigration and Naturalization Service.
  Finding a federal agency to cooperate is difficult enough, 
considering that the Department of Health and Human Services does not 
participate. States who are not members of the Appalachian Regional 
Commission, which is eligible to approve its own waivers, have had to 
enlist any agency that is willing to take on these additional duties. 
These agencies, such as the Department of Agriculture or the Department 
of Housing and Urban Development, often have little or no expertise in 
health care issues. Once an agency does agree to participate, the word 
spreads quickly and soon that agency can be flooded with thousands of 
waiver applications from across the country.
  Because states can clearly determine their own health needs far 
better than an agency in Washington, DC, my legislation now allows 
states to go directly to the USIA to request a waiver. It also is 
relieving some of the burden that participating federal agencies have 
incurred in processing waiver applications.
  The Conrad State 20 Program is still very new, and not every state 
has yet elected to use it. But the program is beginning to work exactly 
as I had hoped. At least 21 States have reported using it to obtain 
waivers. More states are expected to participate in the coming months. 
Unfortunately, the Conrad State 20 program is scheduled to sunset on 
June 1, 1996, unless Congress approves an extension. The amendment I am 
offering would extend the program for 6 more years. This is not a 
permanent extension. The amendment would sunset the program on June 1, 
2002.
  My amendment also puts new restrictions and conditions on FMGs who 
use the federal program. As a condition of using the Conrad State 20 
program to acquire a waiver, FMGs must contract to work for their 
original employer for at least 3 years. Otherwise, their waiver will be 
revoked and they will be subject to deportation. My amendment would 
apply the same 3-year contractual obligation for those who obtain a 
waiver through the Federal program.
  We all know that State empowerment has been a major issue of the 
104th Congress. The Conrad State 20 Program is one way of giving States 
more control over their health care needs. States that are using the 
program want to keep it operating for a few more years. They understand 
that this program does not take away jobs from American doctors, but 
instead is one more valuable tool to help serve the health care needs 
of rural and inner city citizens. The Senate passed my original 
legislation with strong bipartisan support. I am hopeful the Senate 
will agree that creating the Conrad State 20 program was very 
worthwhile, and will agree to accept this modest, 6-year extension.
  I hope we can accept this amendment.
  Mr. KENNEDY. Mr. President, we have talked to the chairman of the 
Immigration Committee, Senator Simpson. And I, as the ranking minority 
member on that committee, say this makes sense. It is targeting doctors 
in underserved areas. We welcome this. This is effective. It is time 
sensitive in terms of the reauthorization. We urge the adoption of the 
amendment.
  The PRESIDING OFFICER. Is there further debate?
  The question occurs on agreeing to the amendment.
  The amendment (No. 3684) was agreed to.
  Mr. SIMON. Mr. President, I recognize Senator Coats is going to have 
his amendment next. But Senator Conrad's point that we would like some 
kind of knowledge as to what order we are going to come in here--some 
of us have been waiting a long time. And it will take a few minutes. I 
wonder if there can be some agreement following the Coats amendment as 
to who is going to be up here with their amendments.
  Mrs. KASSEBAUM. After the Coats amendment there are only two 
amendments I know of at this point that will require votes on this 
side, one is a Gramm amendment and, I believe, perhaps a Burns 
amendment.
  Mr. KENNEDY. Mr. President, I ask Senator Coats, how long does he 
expect to take?
  Mr. COATS. There are one or two people that may want to speak on it. 
They are not on the floor. I do not intend to take all that long, 15 
minutes or so, 10, 15 minutes.
  Mr. KENNEDY. All right. The Senator from Illinois was just trying to 
get through this. He has been here and has been prepared, and Senator 
Boxer. I ask unanimous consent that at the conclusion of the 
consideration of Senator Coats' amendment, Senator Boxer be recognized, 
and at the conclusion of Senator Boxer, Senator Simon be recognized.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. KENNEDY. Could we get a time, for the benefit of our colleagues 
here? Could we set a time for the Senator's amendment?
  Mr. COATS. Well, it is difficult for me to determine how much 
opposition there will be to this amendment.
  Mr. KENNEDY. I think the opposition will not take very much time. We 
would request maybe 4 minutes for the opposition.
  Mr. COATS. I think we can do this then in a total of 15 minutes 
equally divided.
  Mr. KENNEDY. Mr. President, I ask unanimous consent that there be an 
allocation of 20 minutes, 15 minutes for the Senator from Indiana, and 
5 minutes for this Senator.

  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. COATS addressed the Chair.
  The PRESIDING OFFICER. The Senator from Indiana is recognized.
  Mr. COATS. I thank the Chair.
  Mr. KENNEDY. Mr. President, I ask unanimous consent that we vitiate 
that unanimous consent request until I get agreement on our side.
  The PRESIDING OFFICER. Without objection, it is so ordered. The 
request is vitiated.


                           Amendment No. 3685

 (Purpose: To encourage the provision of medical services in medically 
  underserved communities by extending Federal liability coverage to 
                          medical volunteers)

  Mr. COATS. Mr. President, I send an amendment to the desk and ask for 
its immediate consideration.

[[Page S3599]]

  The PRESIDING OFFICER. The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from Indiana [Mr. Coats] proposes amendment 
     numbered 3685.

  Mr. COATS. Mr. President, I ask unanimous consent that further 
reading of the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

       At the appropriate place in title III, insert the following 
     new section:

     SEC.   . MEDICAL VOLUNTEERS.

       (a) Short Title.--This title may be cited as the ``Medical 
     Volunteer Act''.
       (b) Tort Claim Immunity.--
       (1) General rule.--A health care professional who provides 
     a health care service to a medically underserved person 
     without receiving compensation for such health care service, 
     shall be regarded, for purposes of any medical malpractice 
     claim that may arise in connection with the provision of such 
     service, as an employee of the Federal Government for 
     purposes of the Federal tort claims provisions in title 28, 
     United States Code.
       (2) Compensation.--For purposes of paragraph (1), a health 
     care professional shall be deemed to have provided a health 
     care service without compensation only if, prior to 
     furnishing a health care service, the health care 
     professional--
       (A) agrees to furnish the health care service without 
     charge to any person, including any health insurance plan or 
     program under which the recipient is covered; and
       (B) provides the recipient of the health care service with 
     adequate notice (as determined by the Secretary) of the 
     limited liability of the health care professional with 
     respect to the service.
       (c) Preemption.--The provisions of this section shall 
     preempt any State law to the extent that such law is 
     inconsistent with such provisions. The provisions of this 
     section shall not preempt any State law that provides greater 
     incentives or protections to a health care professional 
     rendering a health care service.
       (d) Definitions.--For purposes of this section:
       (1) Health care professional.--The term ``health care 
     professional'' means a person who, at the time the person 
     provides a health care service, is licensed or certified by 
     the appropriate authorities for practice in a State to 
     furnish health care services.
       (2) Health care service.--The term ``health care service'' 
     means any medical assistance to the extent it is included in 
     the plan submitted under title XIX of the Social Security Act 
     for the State in which the service was provided.
       (3) Medically underserved person.--The term ``medically 
     underserved person'' means a person who resides in--
       (A) a medically underserved area as defined for purposes of 
     determining a medically underserved population under section 
     330 of the Public Health Service Act (42 U.S.C. 254c); or
       (B) a health professional shortage area as defined in 
     section 332 of such Act (42 U.S.C. 254e);
     and who receives care in a health care facility substantially 
     comparable to any of those designated in the Federally 
     Supported Health Centers Assistance Act (42 U.S.C. 233 et 
     seq.), as shall be determined in regulations promulgated by 
     the Secretary.
       (4) Secretary.--The term ``Secretary'' means the Secretary 
     of the Department of Health and Human Services.

  Mr. COATS. Mr. President, the amendment I offer extends the Federal 
tort claim coverage to a health care professional if that health care 
professional volunteers his or her medical services to a medically 
underserved person. This is the same type of coverage--this is not new. 
We are not breaking new ground here. We extend that same type of 
Federal tort coverage for medical services provided in Indian health 
care facilities, in Federal community, migrant, homeless, and public 
housing health centers.
  What I am attempting to do here is extend it to those volunteer 
efforts--not paid--but volunteer efforts on the part of health care 
professionals if those medical services are provided to people from 
underserved areas that are deemed by the Secretary of Health and Human 
Services as medically underserved or medically needy.
  We have built into this significant patient protection, indicating 
that the patient must receive notice before providing the care, and 
that the provider has agreed not to charge the party for any health 
care that is provided, and that the medical malpractice liability is 
shifted to the Federal Tort Claims Act.
  We are not in any way limiting the plaintiff's right to receive 
compensation for negligence or for a successful award in a suit. We are 
just simply shifting it from the provider's insurance coverage to the 
Federal Tort Claims Act. The provider is deemed, for the purposes of 
providing that voluntary service, an employee of the Federal Government 
and therefore covered under the act.
  The providers have to be licensed in the State in which the care is 
provided. The care must be covered under Medicaid in that State. In 
addition, the patient must receive the care in a health care facility 
that is substantially comparable in nature to the Federal migrant and 
community health centers that provide care to underserved populations. 
This is the protection that is needed in order to ensure that the care 
is provided in adequate facilities. So those facilities that are deemed 
by the Secretary of Health and Human Services as federally certified--
if they are provided in substantially comparable facilities--the 
coverage will qualify.
  What we are attempting to do here is to provide a way that medical 
personnel can provide medical services to people who otherwise cannot 
afford them, people who are uninsured but where doctors and 
professionals and providers in the community come together and 
volunteer their time.
  We all know the horrendous cost of medical liability insurance. In 
many instances these medical providers cannot pay or do not choose to 
pay the additional liability cost. One of the primary reasons for this 
is that many of these individuals are retired. They are retired doctors 
or dentists or health care providers. So they do not have umbrella 
liability policies because they are not necessarily practicing on a 
full-time basis. But we want to encourage these individuals--as many of 
them already do--to engage in providing medical services.

  I think the amendment is pretty straightforward. There has been a 
question about the cost. It is interesting to note that when we 
provided this liability coverage for community health centers, the 
Congress set aside $10 million a year to cover potential liability 
costs. It is important to note that none of this money has been used in 
the 2 years that this has been in operation.
  People receiving free health care from professional providers 
generally are very grateful for the care and obviously are not looking 
to sue, yet we have protected their rights to do so if negligence 
occurs or if any liability occurs under the services. That is provided. 
It just simply is that the coverage comes under the Federal tort claims 
procedure rather than under the private insurance liability coverage of 
the medical provider.
  Again, the purpose here is to encourage the provision of free medical 
services to people who either live in underserved areas--and who of us 
do not represent a State that has underserved areas--or to those people 
of such income level that do not have insurance or do not have the 
personal wherewithal to purchase the medical service that is needed.
  This is widely supported. The American Medical Association supports 
this, the Catholic Health Association, the Christian Medical and Dental 
Society. Senators Frist and Kassebaum have been cosponsors of this 
bill. And it is supported by professionals throughout our States and 
throughout our communities.
  I have seen some marvelous examples of efforts where community 
medical professionals gather together, provide an acceptable clinic, 
volunteer their time and provide very needed services to people that 
need these free services in order to receive medical care.
  I hope that our colleagues could support this amendment. I thought 
this was something that we might be able to work out. We were not able 
to do that. I will address any questions that might be raised in 
opposition to this. I reserve the balance of my time.
  Mr. KENNEDY. Mr. President, I yield myself 2 minutes.
  This idea is a good idea. As the author of the community health 
centers, we had the Tort Claim Act covering all the medical personnel 
in there. Then there was a downsizing of service corps, we had other 
doctors that came in there, and we had an increase in the insurance 
costs for the neighborhood health centers as a result of that.
  About 4 years ago, again, we worked out with the Treasury and the 
administration an indemnification program for those doctors in the 
neighborhood health centers. It has worked very well. The reason that 
has worked well

[[Page S3600]]

is because there is supervision and accountability at the neighborhood 
health centers.
  That aspect is missing in this program. That is why I will vote to 
table this measure. Then we will come back, one, on the issue of what 
the funding level would be in terms of it; and second, whether an 
overall program can be worked in terms of the accountability. Without 
an accountability, without some ideas of funding, this is not the 
place, the time. It is a good idea.
  I commit to working with my friend from Indiana to try and see if we 
cannot make it a reality in the very near future.
  Mr. COATS. Mr. President, I appreciate the offer of the Senator from 
Massachusetts to work with us on this. I hardly think this needs 
additional work.
  First of all, it is important to understand that the bill itself 
addresses the issue that the Senator raised. In the definition of 
``medically underserved person'' it says the term ``medically 
underserved person'' means a person who receives care in a health care 
facility substantially comparable to any of those designated in the 
federally-supported Health Centers Assistance Act as shall be 
determined in regulations promulgated by the Secretary. The Secretary 
of Health and Human Services has a sufficient amount of control by the 
promulgation of regulations to certify the types of facilities, and 
there is accountability.
  If you feel that you need to have a Federal agency or a Federal 
supervisor standing over the shoulder of a health care professional, a 
doctor who might be earning $200 or $300 an hour performing services 
but who volunteers his time for free, if you say we cannot trust this 
person to provide adequate medical care, I think we are selling the 
medical profession very, very short and we are crediting the Government 
with an ability to supervise that it does not have.
  We do not need a Government agency to oversee the efforts of nurses 
and doctors who volunteer their time--volunteer their time--to provide 
needed free medical services to underserved and low-income individuals. 
Again, we are not limiting the liability of anybody that is served 
here. We are not saying they cannot bring a claim. We are simply saying 
that claim, if brought and if successfully brought, will be paid for 
under the Federal Tort Claims Act and not paid for under the liability 
insurance of the professional.
  Why do we need to do that? We need to do that so we can encourage 
these people to provide the care. Why is it necessary for most? Because 
many of these people are retired and they are not able or in a position 
to continue to pay the exorbitant medical liability insurance, 
sometimes running $50,000, $60,000, or $80,000, depending on the 
specialty, in order to cover themselves for the volunteer service they 
get. The last thing we need is more Federal oversight in a program that 
does not need oversight.
  The PRESIDING OFFICER. Under the previous order the hour of 9:45 
having arrived the question is on agreeing to the Specter amendment No. 
3682.
  Mrs. KASSEBAUM. Mr. President, I ask if we could delay this for 15 
minutes. There are a couple more amendments that need to be offered.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mrs. BOXER. Reserving the right to object, Mr. President, I do not 
wish to object, but I would like to know how much time is left and what 
the order will be. As I understand it, Senator Kennedy mentioned I 
would go next, but if you are just going to finish everything up in 15 
minutes, that would leave virtually no time for Senator Simon and 
virtually no time for me.
  I am confused about whether we will continue after the vote, I guess 
is the point. I only wish to take 5 minutes on my amendment.

  Mr. SPECTER. Mr. President, while we are doing the order here, I 
think it might be appropriate to spend just a minute on a discussion 
which I had with the distinguished manager, the Senator from Kansas, 
talking about hearings before the Labor Committee, hopefully, by the 
end of May, looking for reauthorization or authorization of the healthy 
start program.
  Mrs. KASSEBAUM. Mr. President, I wish the Senator from Pennsylvania 
might wait until we worked out the order here.
  Mr. SPECTER. I am glad to do that.
  Mrs. KASSEBAUM. I suggest at this point perhaps we could go an extra 
half hour, which I think will then take care of every amendment that is 
there to everyone's satisfaction.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mrs. KASSEBAUM. I respond, if I may, Mr. President, to the Senator 
from Indiana. I am a cosponsor, as a matter of fact, of the Senator's 
Medical Volunteer Act. I think it is a very positive step forward. It 
encourages medical voluntarism and brings some small measure of relief 
to the current liability system. There are objections that have been 
raised to this on the Democratic side, principally, and because of our 
need to try and get as strong a consensus as possible for the 
underlying measure I have to object.
  At the appropriate time, after all debate is concluded, I would move 
to table the amendment of the Senator from Indiana.
  Mr. KENNEDY. As a matter of order, I think we request to conclude 
with Senator Boxer and Senator Simon and then come back to the other 
side. I think that is what is the order.
  The PRESIDING OFFICER. Is there further debate on the Coats 
amendment?
  Mrs. KASSEBAUM. If not, I ask for the yeas and nays and ask that the 
amendment be set aside.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The yeas and nays were ordered on the motion to table the Coats 
amendment.
  The PRESIDING OFFICER. Under the previous order, the Senator from 
California is recognized.


                           Amendment No. 3686

  Mrs. BOXER. Thank you very much, Mr. President. I would like to be 
advised when I have utilized 4 minutes and then I will wrap up my side 
of the argument.
  I send an amendment to the desk and ask for its immediate 
consideration as a sense of the Senate.
  The PRESIDING OFFICER. The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from California [Mrs. Boxer], proposes an 
     amendment numbered 3686.
       The Senate finds that:
       Patients deserve to know the full range of treatments 
     available to them and,
       Patients should know if doctors receive bonuses for 
     withholding treatment from them.
       It is the sense of the Senate that Congress should 
     thoughtfully examine these issues to ensure that all patients 
     get the care they deserve.

  Mrs. BOXER. Mr. President, this is such a straightforward and simple 
sense-of-the-Senate. It is rather shocking to me that Members on the 
other side of the aisle have objected to it. I have to thank the 
chairwoman of the committee and Senator Kennedy, who were quite willing 
to accept such a sense-of-the-Senate resolution. I do not know what 
Members oppose this. I cannot imagine why they have not identified 
themselves to me, Mr. President. I just hope that Members will read the 
sense-of-the-Senate.
  Let me tell you a little story about why it is so important.
  This is an L.A. Times story, entitled ``HMO `Gag Clauses' on Doctors 
Spur Protests.'' I will read just a few paragraphs:

       The Santa Monica oncologist thought she was being a strong 
     advocate for her patient.
       In May, she referred the patient--a Los Angeles woman in 
     her forties, who was rapidly losing her battle with 
     metastatic colon cancer--to a Johns Hopkins University 
     specialist using an experimental drug that had proven 
     effective with similar cancers. It was, in the doctor's view, 
     perhaps the best chance of extending the woman's life.
       But the patient's managed care group had a different view 
     of the oncologist. It saw a doctor who said too much and 
     broke the rules. She received a reproachful letter from the 
     managed care group, stating that the Johns Hopkins specialist 
     was not ``in network'' and that the patient should not have 
     been referred there.
       ``This occurrence,'' the letter warned, ``had been noted in 
     the computer, and a future occurrence may result in 
     suspension of referral privilege or, in an extreme case, a 
     recommendation for termination.''

  Mr. President, this is what is happening across the country in HMO's. 
Doctors, who refer patients to specialists are being warned that they 
may be fired. Doctors are receiving bonus payments from the HMO's for 
not giving care to patients.

[[Page S3601]]

  Now, all I am asking in this sense-of-the-Senate is that we look into 
this. Already, we have looked into this in Medicare and, thank 
goodness, something is being done. Last month, the Department of HHS 
announced a regulation mandating that managed care plans serving 
Medicare and Medicaid patients reveal any arrangements in which doctors 
may face financial pressures to limit services or referrals to 
specialists.
  What about those who are not on Medicare, who are not on Medicaid? Do 
they not deserve the same protections, at a minimum? Doctors across the 
country are protesting managed care companies' practices that they 
contend impede their ability to have candid discussions with patients 
about treatment options.

  In this time of shifting health care needs and our attempt to 
restructure the health care delivery system, we must not lose sight of 
the valuable doctor-patient relationship. We should revere it, we 
should honor it. We should not allow the HMO's, because of the almighty 
bottom line, to interfere in this relationship and gag our physicians 
from telling their patients that there are other treatments for cancer, 
or whatever other condition it might be.
  I really do not understand why we cannot get a simple sense of the 
Senate through this body.
  In closing, I am going to read it to you one more time:

       The Senate finds that patients deserve to know the full 
     range of treatments available to them, and patients should 
     know if doctors receive bonuses for withholding treatment 
     from them. It is the sense-of-the-Senate that Congress should 
     thoughtfully examine these issues to ensure that all patients 
     get the care they deserve.

  Mr. President, we have a very good bill here. We can make it better, 
I believe, by just pledging to look into this situation and making sure 
that all of our people throughout this Nation are told all of the 
options, because if they are not told, they may lose their lives. I do 
not think we ought to have that on our hands.
  Thank you, Mr. President. I reserve whatever time I have remaining.
  Mr. KENNEDY. Mr. President, I ask unanimous consent that the Boxer 
amendment be temporarily set aside.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. SIMON addressed the Chair.
  The PRESIDING OFFICER. The Senator from Illinois is recognized.


                           Amendment No. 3687

  (Purpose: To express the sense of the Senate regarding the need to 
  ensure adequate health care coverage for all children and pregnant 
                                 women)

  Mr. SIMON. Mr. President, I send an amendment to the desk and ask for 
its immediate consideration.
  The PRESIDING OFFICER. The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from Illinois [Mr. Simon] proposes an amendment 
     numbered 3687.

  Mr. SIMON. Mr. President, I ask unanimous consent that reading of the 
amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

       At the appropriate place in the bill insert the following 
     new section:

     SEC.   . SENSE OF THE SENATE REGARDING ADEQUATE HEALTH CARE 
                   COVERAGE FOR ALL CHILDREN AND PREGNANT WOMEN.

       (a) Findings.--The Senate finds the following:
       (1) The health care coverage of mothers and children in the 
     United States is unacceptable, with more than 9,300,000 
     children and 500,000 expectant mothers having no health 
     insurance.
       (2) Among industrial nations, the United States ranks 1st 
     in wealth but 18th in infant mortality, and 14th among such 
     nations in maternal mortality.
       (3) 22 percent of pregnant women do not have prenatal care 
     in the first trimester, and 22 percent of all poor children 
     are uninsured, despite the medicaid program under title XIX 
     of the Social Security Act.
       (4) Of the 1,100,000 net increase in uninsured persons from 
     1992 to 1993, 84 percent or 922,500 were children.
       (5) Since 1987, the number of children covered by 
     employment based health insurance has decreased, and many 
     children lack health insurance despite the relative 
     affordability of providing insurance for children.
       (6) Health care coverage for children is relatively 
     inexpensive and in 1993 the medicaid program spent an average 
     of $1,012 per child compared to $8,220 per elderly adult.
       (7) Uninsured children are generally children of lower 
     income workers, who are less likely than higher income 
     workers to have health insurance for their families because 
     they are less likely to work for a firm that offers 
     insurance, and if such insurance is offered, it is often too 
     costly for lower income workers to purchase.
       (8) In 1993, 61 percent of uninsured children were in 
     families with at least one parent working full time for the 
     entire year the child was uninsured, and about 57 percent of 
     uninsured children had a family income at or below 150 
     percent of the Federal poverty level.
       (9) If Congress eliminates the Federal guarantee of 
     medicaid, an estimated 4,900,000 children may lose their 
     guarantee of health care coverage, and those same children 
     may be added to the currently projected 12,600,000 children 
     who will be uninsured by the year 2002.
       (10) Studies have shown that uninsured children are less 
     likely than insured children to receive needed health and 
     preventive care, which can affect their health status 
     adversely throughout their lives, with such children less 
     likely to have routine doctor visits, receive care for 
     injuries, and have a regular source of medical care.
       (11) The families of uninsured children are more likely to 
     take the children to an emergency room than to a private 
     physician or health maintenance organization.
       (12) Children without health insurance are less likely to 
     be appropriately immunized or receive other preventive care 
     for childhood illnesses.
       (13) Ensuring the health of children clearly increases 
     their chances to become productive members of society and 
     averts more serious or more expensive health conditions later 
     in life, and ensuring that all pregnant women receive 
     competent prenatal care also saves social costs.
       (14) Although the United States has made great improvements 
     in health care coverage through the medicaid program, it is 
     still the only developed nation that does not ensure that all 
     of its children and pregnant women have health care coverage.
       (15) The United States should not accept a status quo in 
     which children in many neighborhoods are more likely to have 
     access to drugs and guns than to doctors, or accept a status 
     quo in which health care is ensured for all prisoners but not 
     for all children.
       (b) Sense of the Senate.--It is the sense of the Senate 
     that the issue of adequate health care for our mothers and 
     children is important to the future of the United States, and 
     in consideration of the importance of such issue, the Senate 
     should pass health care legislation in the 105th Congress 
     that will ensure health care coverage for all of the United 
     States's pregnant women and children.
  Mr. SIMON. Mr. President, all this does, very simply, is say it is 
the sense of the Senate that in the next congressional session, 
starting in 1997, the 105th Congress pass health care legislation that 
protects pregnant women and children. That is all it does.
  It is very interesting. Two years ago, we were discussing health care 
legislation, and virtually everyone in this body, including the 
majority leader, said, ``We are going to work out some kind of health 
care for all Americans.'' I have to say, in fairness to Senator Phil 
Gramm, he said right from the start, ``Over my dead body. We are not 
going to have any national health care program.''
  We are the only western industrialized nation that does not protect 
all of our citizens. Listen to this, Mr. President. I ask my colleagues 
on the other side to listen to this.

       In accepting the Republican nomination for President in 
     1928, Herbert Hoover said, ``The greatness of any nation, its 
     freedom from poverty and crime, its aspirations and ideals 
     are the direct quotient of the care of its children. . .There 
     should be no child in America that is not born and does not 
     live under sound conditions of health.''

  That was in 1928, and we have not achieved Herbert Hoover's dream yet 
in 1996.
  Let me add, providing coverage for children is the least expensive 
part of health insurance. As we get older, it is more demanding in 
terms of expense. But still we do not provide it for all children.
  All women and children in Italy have health care coverage, but not in 
the wealthy United States of America.
  All women and children in France have health care coverage, but not 
in the wealthy United States of America.
  All women and children have health care coverage in Canada, but not 
in the wealthy United States of America.
  All women and children have health care coverage in Great Britain, 
but not in the wealthy United States of America.
  All women and children have health care coverage in Germany, but not 
in the wealthy United States of America.
  All women and children have health care coverage in Luxembourg, but 
not in the wealthy United States of America.
  All women and children have health care coverage in Belgium, but not 
in the wealthy United States of America.

[[Page S3602]]

  All women and children have health care coverage in The Netherlands, 
but not in the wealthy United States of America.
  All women and children have health care coverage in Portugal, but not 
in the wealthy United States of America.
  All women and children have health care coverage in Spain, but not in 
the wealthy United States of America.
  All women and children have health care coverage in Finland, but not 
in the wealthy United States of America.
  All women and children have health care coverage in Austria, but not 
in the wealthy United States of America.
  All women and children have health care coverage in Denmark, but not 
in the wealthy United States of America.
  All women and children have health care coverage in Norway, but not 
in the wealthy United States of America.
  All women and children have health care coverage in Sweden, but not 
in the wealthy United States of America.
  All women and children have health care coverage in Japan, but not in 
the wealthy United States of America.
  Mr. President, what we are just saying here is, let us in the next 
session of Congress--and I am not going to be here--at least protect 
pregnant women and children. That is all we ask. It is a sense of the 
Senate resolution.
  I regret that 2 years ago--and I blame myself as much as anyone--that 
we did not even get a vote on the floor of the U.S. Senate on the 
fundamental issue of health care. Today, my friends, we are going to 
get a vote. We do not say how it should be done; we just say it is the 
sense of the Senate that in the next session of Congress, we are going 
to at least protect pregnant women and children.
  I do not know how we can do anything less than that. That is what my 
amendment asks for.
  Mrs. KASSEBAUM. Mr. President, I recognize it is just a sense-of-the-
Senate resolution. But it is about 6 pages, and it is a fairly 
extensive direction for the next Congress. While there would be 
certainly a great deal of support for health care coverage for pregnant 
women and children, we are having a hard enough time in this Congress 
figuring out what we want to do, let alone applying some issues and 
directions to the next Congress.
  For that reason, Mr. President, I would have to oppose.
  Mr. KENNEDY. Mr. President, could we ask for the yeas and nays?
  Mr. SIMON. I ask for the yeas and nays.
  Mr. KENNEDY. That it would be in order to ask for the yeas and nays 
on the Boxer amendment.
  Mrs. KASSEBAUM. Mr. President, I move to table and ask for the yeas 
and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  Mr. SIMON. If the Senator from Kansas will withhold for 30 seconds 
for me to respond, she mentions a 5-page amendment. These are all 
whereases. The conclusion is that it is a sense of the Senate. If she 
wants to agree to this, I will knock out all of the whereases and we 
will just take the sense of the Senate that we ought to, next session 
of the Congress, pass health care legislation for pregnant women and 
children.
  Mrs. KASSEBAUM. Mr. President, I very much appreciate that Senator 
Simon is always very accommodating. The Senator from Illinois is a 
superb debater. I would still have to object. If there is no further 
debate, I will move to table the Simon amendment.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The yeas and nays were ordered.
  The PRESIDING OFFICER. Are there further amendments?
  Mr. KENNEDY. Mr. President, as I understand, the Senator is also 
asking for the yeas and nays on the tabling motion of the Boxer 
amendment.
  Mrs. KASSEBAUM. Yes. Mr. President, if I may just speak for a moment, 
this is objected to by the Finance Committee because it deals with 
Medicare. They would like to debate that at another time, even though 
it is just a sense-of-the-Senate resolution.
  Mrs. BOXER. Mr. President, if my friend will yield for a minute, we 
took out any reference to Medicare and Medicaid at the Senator's 
suggestion. It has nothing to do with Medicare and Medicaid. The way it 
reads now is simply that we should look to see whether patients are 
being denied the information they need. We deleted all reference to 
Medicaid and Medicare and asked just for the Congress to look at this 
matter.

  So I tried to be very accommodating, if my friend would try to help 
me. As I say, we do not have any reference in here at all. We simply 
ask that the Congress should thoughtfully examine the issue of 
patients, finding out the full range of their treatment, and patients 
should know if doctors are receiving bonuses from the treatment. It 
does not mention Medicare and Medicaid.
  Mr. BYRD. Mr. President, parliamentary inquiry.
  The PRESIDING OFFICER. The Senator will state his parliamentary 
inquiry.
  Mr. BYRD. Is not a motion to table now pending?
  The PRESIDING OFFICER. The Senator is correct.
  Mr. BYRD. There is no debate on a motion to table.
  The PRESIDING OFFICER. The Senator is correct.
  Mr. BYRD. Shall we vote?
  The PRESIDING OFFICER. We have a previous order to table the votes in 
sequential order and vote at 10:15.
  Mr. BYRD. Very well. I thank the Chair.
  Several Senators addressed the Chair.
  The PRESIDING OFFICER. The minority manager is recognized.


                           Amendment No. 3688

   (Purpose: To encourage organ and tissue (including eye) donation 
    through the inclusion of an organ and tissue donation card with 
       individual income refund payments, and for other purposes)

  Mr. KENNEDY. Mr. President, there are two amendments which have been 
agreed to dealing with the organ transplants and information on organ 
transplants, the Dorgan-Frist amendment, in terms of information on the 
organ transplants. I would like to send it to the table and ask for its 
immediate consideration.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Massachusetts [Mr. Kennedy], for Mr. 
     Dorgan, for himself and Mr. Frist, proposes an amendment 
     numbered 3688.

  Mr. KENNEDY. Mr. President, I ask unanimous consent that reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

       At the end of title III, add the following:

     SEC. 3  . ORGAN AND TISSUE DONATION INFORMATION INCLUDED WITH 
                   INCOME TAX REFUND PAYMENTS.

       (a) In General.--The Secretary of the Treasury shall 
     include with any payment of a refund of individual income tax 
     made during the period beginning on February 1, 1997, and 
     ending on June 30, 1997, a copy of the document described in 
     subsection (b).
       (b) Text of Document.--The Secretary of the Treasury shall, 
     after consultation with the Secretary of Health and Human 
     Services and organizations promoting organ and tissue 
     (including eye) donation, prepare a document suitable for 
     inclusion with individual income tax refund payments which--
       (1) encourages organ and tissue donation;
       (2) includes a detachable organ and tissue donor card; and
       (3) urges recipients to--
       (A) sign the organ and tissue donor card;
       (B) discuss organ and tissue donation with family members 
     and tell family members about the recipient's desire to be an 
     organ and tissue donor if the occasion arises; and
       (C) encourage family members to request or authorize organ 
     and tissue donation if the occasion arises.

  Mr. KENNEDY. Mr. President, I have described what it is. It is 
information on organ transplant in behalf of Senator Dorgan and Senator 
Frist.
  The PRESIDING OFFICER. Is there further debate on the amendment? If 
not, the question is on agreeing to the amendment of the Senator from 
North Dakota.
  The amendment (No. 3688) was agreed to.


                           Amendment No. 3689

    (Purpose: To prohibit the establishment of certain health plan 
    requirements based on information relating to domestic violence)

  Mr. KENNEDY. Mr. President, this amendment is in behalf of Senator 
Wellstone, and it is in regards to information relating to domestic 
violence. I send the amendment to the desk.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:


[[Page S3603]]


       The Senator from Massachusetts [Mr. Kennedy], for Mr. 
     Wellstone, proposes an amendment numbered 3689.

  Mr. KENNEDY. Mr. President, I ask unanimous consent that reading of 
the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

       On page 9, line 13 insert after evidence of insurability 
     ``(including conditions arising out of act of domestic 
     violence);''.

  The PRESIDING OFFICER. Is there further debate on the amendment? If 
not, the question is on agreeing to the amendment of the Senator from 
Minnesota.
  The amendment (No. 3689) was agreed to.
  Mr. WELLSTONE. Is it the Senators' understanding that this language 
that we have accepted from the House bill ensures that women covered in 
an employment-based health plan, will not be discriminated against 
because of a medical condition caused by domestic violence, because of 
a history of domestic violence, or because of their status as a victim 
of domestic violence?
  Mr. KENNEDY. Yes; that is my understanding.
  Ms. KASSEBAUM. Yes; that is my understanding.
  Mr. BURNS addressed the Chair.
  The PRESIDING OFFICER. The Senator from Montana is recognized.
  Mr. BURNS. Mr. President, I thank my friend from Kansas. We are 
redrafting different language where one committee says the first shall 
be the last and the last shall be first.
  I would like to yield the floor to my friend from West Virginia who 
has, I believe, an amendment to offer.
  The PRESIDING OFFICER. The Senator from West Virginia.
  Mr. ROCKEFELLER. Mr. President, the Senator from West Virginia would 
ask simply for 1 minute to make the following observation.
  Earlier this evening there was substantial nonpublic discussion as to 
nondiscrimination and long-term care. There was then a very helpful, 
constructive, and useful colloquy on the floor which agreed that in the 
tax preferential treatment of long-term care, that nondiscrimination 
would be completely treated. There was some disagreement as to what 
Treasury was saying constituted nondiscrimination and what the Finance 
Committee staff said constituted nondiscrimination. There seemed to be 
a difference.
  I simply, as a member of the Finance Committee, wanted to go on 
record as saying that the nondiscrimination aspect--this is not just 
racial, but we are talking just about the higher employer as opposed to 
the lowest employer--that nondiscrimination be done in the usual, 
customary, and effective manner for the tax preferential long-term care 
matters that we are now discussing.


                           Amendment No. 3690

  Mrs. KASSEBAUM. Mr. President, I have here a study request that I 
cosponsored with Senator Helms which would ask HHS to study options on 
point of service. It has been agreed to on both sides.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Kansas (Mrs. Kassebaum), for Mr. Helms, 
     for himself and Mrs. Kassebaum, proposes an amendment 
     numbered 3690.

  Mrs. KASSEBAUM. Mr. President, I ask unanimous consent that reading 
of the amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

       Amend Title III--Miscellaneous Provisions, Section 302 (a) 
     by striking ``two part study'' on line 19, and inserting 
     ``three-part study'' and adding Section 302 (d):
       ``(d) Evaluation of Access and Choice.--Not later than June 
     1, 1998, the Secretary of Health and Human Services shall 
     prepare and submit to the appropriate Committees of Congress 
     a report concerning--
       (1) an evaluation of the extent to which patients have 
     direct access to, and choice of, health care provider, 
     including specialty providers, within a network of providers, 
     as well as the opportunity to utilize providers outside of 
     the network, under the various types of coverage offered 
     under the provisions of this Act;
       (2) an evaluation of the cost to the insurer of providing 
     out-of-network access to providers, and the feasibility of 
     providing out-of-network access in all health plans offered 
     under provisions of this Act.
       (3) an evaluation of the percent of premium dollar utilized 
     for medical care and administration of the various types of 
     coverage offered, including coverage which permits out-of-
     network access and choice of provider, under provisions of 
     this Act.

  Mr. HELMS. Mr. President, one of the many reasons for my having 
opposed the Clinton health plan was the well founded fear that the 
American people would have been denied their right to choose their 
medical care. The enormous bureaucracy of the Clinton plan made that 
apprehension a certainty--which is why the American people rejected it.
  In the interest of time, I will not offer my amendment to guarantee 
patients the freedom to choose their health care provider.--This 
amendment was originally approved by the Senate last October by a vote 
of 79 to 20 when we considered Medicare reform.--I have no doubt that 
this provision continues to have strong bipartisan support in the 
Senate.
  However, instead of offering the original amendment I submit this 
amendment to require the Department of Health and Human Services to 
conduct a study to make certain that any changes in the health 
insurance market will not result in the loss of the American people's 
freedom to choose their health care provider.
  Whether Congress considers Medicare reform or health insurance 
reform, patients must not be deprived of the right to choose their own 
doctors. Even when Congress attempts to provide access to health 
insurance, that is only half of the equation. Equally important is that 
patients must not find themselves unknowingly thrown into health care 
coverage that limits their freedom to choose their own health care 
providers.
  The purpose of my provisions is to provide to Congress the 
information Congress may need to evaluate whether patients continue to 
have direct access to specialist and choice of health care provider, 
both in-network and out-of-network, as we make changes to the health 
insurance market place. It will also determine the cost to the insurer 
of providing this freedom to choose, and if the premium dollar 
collected is effectively going toward patient care.
  This study will not only go a long way to provide our Nation with 
useful information about health care delivery, but it will also 
emphasize the importance of preserving the patient's freedom of choice 
when it comes to their own doctor.
  The PRESIDING OFFICER. Is there further debate on the amendment? If 
not, the amendment is agreed to.
  The amendment (No. 3690) was agreed to.


                           Amendment No. 3691

    (Purpose: To direct the Health Care Financing Administration to 
        determine reimbursement rates for telemedicine services)

  Mr. BURNS. Mr. President, I ask unanimous consent that the pending 
amendment be set aside.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BURNS. I send an amendment to the desk.
  The PRESIDING OFFICER. The clerk will report the amendment.
  The assistant legislative clerk read as follows:

       The Senator from Montana [Mr. Burns], for himself and Mr. 
     Harkin, proposes an amendment numbered 3691.

  Mr. BURNS. Mr. President, I ask unanimous consent that reading of the 
amendment be dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

       On Page 71, line 19, add the following:

     ``SEC. 302.5. REIMBURSEMENT OF TELEMEDICINE.

       The Health Care Financing Administration is directed to 
     complete their ongoing study of reimbursement of all 
     telemedicine services and submit a report to Congress with a 
     proposal for reimbursement of fee-for-service medicine by 
     March 1, 1997. The report shall utilize data compiled from 
     the current demonstration projects already under review and 
     gather data from other ongoing telemedicine networks. This 
     report shall include an analysis of the cost of services 
     provided via telemedicine.

  Mr. BURNS. Mr. President, this amendment is sponsored also by my 
friend from Iowa Mr. Harkin.
  The Health Care Financing Administration has been reviewing 
telemedicine demonstration projects across the country. They have been 
studying them about 2 years now. They are analyzing the cost 
effectiveness of providing health services via telecommunications and 
how to reimburse health care providers.
  Telemedicine is a technology that is spreading--thankfully--because 
rural

[[Page S3604]]

areas and inner-city areas are in desperate need of health care. 
Getting health care services can be a challenge, especially if you are 
180 miles away from a specialist. But even if that specialist is 
willing and able to visit his patients via telemedicine, HCFA will not 
reimburse him for those services. And as you can imagine, many health 
care providers aren't too willing to give their time without being 
compensated.
  The study is already underway. But there is no anticipated deadline 
to finish the study and put the issue of reimbursement behind us. In 
fact, at a recent telemedicine conference, a HCFA representative stated 
that there would be no decision until Congress mandated one.
  My amendment basically instructs HCFA to decide on reimbursement of 
telemedicine services by March 1, 1997. That gives them almost an 
entire year--in addition to the time they have already spent studying 
the issue--to compile their data, gather data from other ongoing 
demonstrations, if they choose, and determine the fee-for-service 
reimbursement for services provided via telemedicine.
  There is no cost associated with this, since the study is already 
ongoing. I am simply asking that they finish the study and let rural 
areas and urban residents access the health care services that are 
currently out of their reach.
  The Health Care Financing Administration has been in this process now 
for a couple of years and we think it is about time that they bring 
this to a close and recommend to the Congress how they are going to 
deal with it. We have this new technology. We passed a telecom bill 
that allows a lot of things to happen in distance learning, 
telemedicine, and these kinds of things, and we think it is now time 
that we move into the next generation of providing health care to our 
rural areas via telecommunications.
  I appreciate my good friend from Iowa being a part of this.
  I yield the floor.
  Mr. KENNEDY addressed the Chair.
  The PRESIDING OFFICER. Is there debate on the amendment?
  Mr. HARKIN addressed the Chair.
  The PRESIDING OFFICER. The Senator from Iowa is recognized.
  Mr. HARKIN. Mr. President, I wish to congratulate the Senator from 
Montana for offering this amendment. I am proud to join with him in 
this.
  When I was chair of the Labor, Health and Human Services 
Appropriations Subcommittee, Senator Specter and I initiated the 
funding 3 years ago for the demonstration projects for telemedicine. I 
know Montana was one State, Iowa was another, and there were several 
other States, I think Georgia, West Virginia, others that were involved 
in the demonstration projects in telemedicine.
  One of the reasons that we had the demonstration projects was so that 
HCFA could develop a reimbursement means and determine how to 
reimburse.
  We have enough data. They know. We have had 3 years of these 
projects. The date the Senator has there, they can do that easily. They 
can actually do that a lot sooner than that. I think the Senator is 
generous in giving them that much time.
  Nonetheless, there is no doubt they have enough data--they have it 
now--that they can do this.
  To echo what the Senator from Montana said, telemedicine will improve 
access to care in rural areas. It will attract more doctors to rural 
areas because then they will have the necessary backup they need for 
correct diagnosis and treatment. It will lower costs in rural areas by 
cutting down on travel, and it will allow more services to be done like 
at our rural health clinics where they can reach out over a broader 
area.
  So this is a very good amendment and one that is going to help a lot 
in a lot of rural areas in the United States.
  I hope it will be adopted.
  The PRESIDING OFFICER. Is there further debate on the amendment?
  The vote now is on agreeing to the Burns amendment.
  The amendment (No. 3691) was agreed to.
  Mrs. KASSEBAUM addressed the Chair.
  The PRESIDING OFFICER. The majority manager is recognized.


                      Amendment No. 3682 Withdrawn

  Mrs. KASSEBAUM. I would like now to have a colloquy with the Senator 
from Pennsylvania. Senator Specter and myself and Senator Kennedy have 
discussed his amendment regarding healthy start and my objection had 
been it was authorization on this bill which I felt needed to go 
through the committee with some hearings, review what has always been 
an appropriations matter rather than an authorization, and I believe 
this has been agreed to by Senator Specter and we will have a hearing 
if possible by the end of May.
  Mr. SPECTER addressed the Chair.
  The PRESIDING OFFICER. The Senator from Pennsylvania is recognized.
  Mr. SPECTER. The distinguished Senator from Kansas expresses it 
accurately. I think that will accomplish the purpose and lead to 
authorization, or a reauthorization. That is acceptable, and I formally 
withdraw the amendment.
  The PRESIDING OFFICER. Is there objection? Without objection, it is 
so ordered.
  The minority manager is recognized.


                    Amendment No. 3686, as Modified

  Mr. KENNEDY. Mr. President, the Senator from California, Senator 
Boxer, proposed a sense-of-the-Senate. In her behalf, I have a revised 
sense-of-the-Senate and I ask unanimous consent that it be in order to 
send it to the desk and that it be in order for consideration at the 
appropriate time in the list of amendments.
  The PRESIDING OFFICER. Is the Senator modifying the underlying Boxer 
amendment?
  Mr. KENNEDY. The Chair is correct.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment as modified is as follows:

       At the appropriate place add:
       It is the sense of the Senate that patients deserve to know 
     the full range of treatments available to them.
       Congress should thoughtfully examine these issues to ensure 
     that all patients get the care they deserve.

  Mr. KENNEDY. I will ask for a vitiation of the yeas and nays on that 
particular amendment.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The PRESIDING OFFICER. The hour of 10:15 having arrived, the question 
is on agreeing to the motion to table amendment No. 3683. That is the 
amendment offered by the Senator from Iowa, Senator Harkin. The yeas 
and nays have been ordered.
  Mr. DOLE addressed the Chair.
  The PRESIDING OFFICER. The majority leader is recognized.
  Mr. DOLE. I wanted to get consent that votes occur in the order in 
which they were debated, with 1 minute of debate after the first vote 
to be equally divided for explanation; that all votes after the first 
vote be reduced to 10 minutes in length. I think that is satisfactory 
to the managers.
  The PRESIDING OFFICER. Is there objection? The Chair hears none, and 
it is so ordered.


                       Vote on Amendment No. 3683

  The PRESIDING OFFICER. The question is on agreeing to the motion to 
table the Harkin amendment No. 3683. The yeas and nays have been 
ordered. The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. LOTT. I announce that the Senator from Colorado [Mr. Campbell] 
and the Senator from Florida [Mr. Mack] are necessarily absent.
  The result was announced--yeas 62, nays 36, as follows:

                      [Rollcall Vote No. 76 Leg.]

                                YEAS--62

     Abraham
     Ashcroft
     Bennett
     Bond
     Breaux
     Brown
     Bryan
     Burns
     Chafee
     Coats
     Cochran
     Cohen
     Coverdell
     Craig
     D'Amato
     Daschle
     DeWine
     Dodd
     Dole
     Domenici
     Faircloth
     Ford
     Frist
     Gorton
     Gramm
     Grams
     Gregg
     Hatch
     Hatfield
     Helms
     Hutchison
     Inhofe
     Johnston
     Kassebaum
     Kempthorne
     Kennedy
     Kerrey
     Kohl
     Kyl
     Lott
     Lugar
     McCain
     McConnell
     Moynihan
     Murkowski
     Nickles
     Nunn
     Pressler
     Reid
     Robb
     Roth
     Santorum
     Shelby
     Simpson
     Smith
     Snowe
     Specter
     Stevens
     Thomas
     Thompson
     Thurmond
     Warner

                                NAYS--36

     Akaka
     Baucus
     Biden
     Bingaman
     Boxer
     Bradley

[[Page S3605]]


     Bumpers
     Byrd
     Conrad
     Dorgan
     Exon
     Feingold
     Feinstein
     Glenn
     Graham
     Grassley
     Harkin
     Heflin
     Hollings
     Inouye
     Jeffords
     Kerry
     Lautenberg
     Leahy
     Levin
     Lieberman
     Mikulski
     Moseley-Braun
     Murray
     Pell
     Pryor
     Rockefeller
     Sarbanes
     Simon
     Wellstone
     Wyden

                             NOT VOTING--2

     Campbell
     Mack
       
  So the motion to table the amendment (No. 3683) was agreed to.
  The PRESIDING OFFICER. Under the previous order there is a minute to 
be utilized by the sponsor of the bill and the opposition.
  Mr. DOLE addressed the Chair.
  The PRESIDING OFFICER. The majority leader.
  Mr. DOLE. Mr. President, I ask unanimous consent that after all the 
amendments are disposed of this evening, the vote occur on final 
passage of S. 1028, as amended, on Tuesday at a time to be determined 
by the majority leader after consultation of the Democratic leader. Let 
me indicate why I am doing that. Senator Mack's father passed away. He 
would like to make the final passage vote, unless there is some 
objection.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. KENNEDY. Is it the intention of the leader that we move to third 
reading tonight?
  Mr. DOLE. Oh, yes. I think there is only one additional vote. I 
believe this will be the last vote.
  The PRESIDING OFFICER. Does the sponsor of the amendment wish to 
debate the amendment? If not--
  Mr. SIMON addressed the Chair.
  The PRESIDING OFFICER. The Senator from Illinois, Senator Simon, is 
recognized.


                    Amendment No. 3687, as Modified

  Mr. SIMON. Mr. President, I ask unanimous consent to vitiate the vote 
on my amendment and to modify it by dropping 4 words that I have given 
to the clerk.
  The PRESIDING OFFICER. Is there objection? Without objection, it is 
so ordered.
  The amendment, as modified, follows:
         At the appropriate place in the bill insert the following 
     new section:

     SEC.  . SENSE OF THE SENATE REGARDING ADEQUATE HEALTH CARE 
                   COVERAGE FOR ALL CHILDREN AND PREGNANT WOMEN.

         (a) Findings.--The Senate finds the following:
         (1) The health care coverage of mothers and children in 
     the United States is unacceptable, with more than 9,300,000 
     children and 500,000 expectant mothers having no health 
     insurance.
         (2) Among industrial nations, the United States ranks 1st 
     in wealth but 18th in infant mortality, and 14th among such 
     nations in maternal mortality.
         (3) 22 percent of pregnant women do not have prenatal 
     care in the first trimester, and 22 percent of all poor 
     children are uninsured, despite the medicaid program under 
     title XIX of the Social Security Act.
         (4) Of the 1,100,000 net increase in uninsured persons 
     from 1992 to 1993, 84 percent or 922,500 were children.
         (5) Since 1987, the number of children covered by 
     employment based health insurance has decreased, and many 
     children lack health insurance despite the relative 
     affordability of providing insurance for children.
         (6) Health care coverage for children is relatively 
     inexpensive and in 1993 the medicaid program spent an average 
     of $1,012 per child compared to $8,220 per elderly adult.
         (7) Uninsured children are generally children of lower 
     income workers, who are less likely than higher income 
     workers to have health insurance for their families because 
     they are less likely to work for a firm that offers 
     insurance, and if such insurance is offered, it is often too 
     costly for lower income workers to purchase.
         (8) In 1993, 61 percent of uninsured children were in 
     families with at least one parent working full time for the 
     entire year the child was uninsured, and about 57 percent of 
     uninsured children had a family income at or below 150 
     percent of the Federal poverty level.
         (9) If Congress eliminates the Federal guarantee of 
     medicaid, an estimated 4,900,000 children may lose their 
     guarantee of health care coverage, and those same children 
     may be added to the currently projected 12,600,000 children 
     who will be uninsured by the year 2002.
         (10) Studies have shown that uninsured children are less 
     likely than insured children to receive needed health and 
     preventive care, which can affect their health status 
     adversely throughout their lives, with such children less 
     likely to have routine doctor visits, receive care for 
     injuries, and have a regular source of medical care.
         (11) The families of uninsured children are more likely 
     to take the children to an emergency room than to a private 
     physician or health maintenance organization.
       (12) Children without health insurance are less likely to 
     be appropriately immunized or receive other preventive care 
     for childhood illnesses.
       (13) Ensuring the health of children clearly increases 
     their chances to become productive members of society and 
     averts more serious or more expensive health conditions later 
     in life, and ensuring that all pregnant women receive 
     competent prenatal care also saves social costs.
       (14) Although the United States has made great improvements 
     in health care coverage through the medicaid program, it is 
     still the only developed nation that does not ensure that all 
     of its children and pregnant women have health care coverage.
       (15) The United States should not accept a status quo in 
     which children in many neighborhoods are more likely to have 
     access to drugs and guns than to doctors, or accept a status 
     quo in which health care is ensured for all prisoners but not 
     for all children.
       (b) Sense of the Senate.--It is the sense of the Senate 
     that the issue of adequate health care for our mothers and 
     children is important to the future of the United States, and 
     in consideration of the importance of such issue, the Senate 
     should pass health care legislation that will ensure health 
     care coverage for all of the United States' pregnant women 
     and children.

  Mr. DOLE. Mr. President, I urge that the amendment be agreed to.
  The amendment (No. 3687), as modified was agreed to.
  Mrs. KASSEBAUM addressed the Chair.
  The PRESIDING OFFICER. The majority manager is recognized.
  Mrs. KASSEBAUM. Parliamentary inquiry. Mr. President, I believe I 
moved to table the amendment of the Senator from Indiana, is that 
correct, and that I had asked for the yeas and nays at that time?
  The PRESIDING OFFICER. The Senator is correct.
  Mrs. KASSEBAUM. So this is a tabling motion.


                       Vote On Amendment No. 3685

  The PRESIDING OFFICER. There is no debate on the amendment. The 
question is on agreeing to the motion to lay on the table the amendment 
of the Senator from Indiana, [Mr. Coats]. The yeas and nays have been 
ordered. The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. LOTT. I announce that the Senator from Colorado [Mr. Campbell] 
and the Senator from Florida [Mr. Mack] are necessarily absent.
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 47, nays 51, as follows:

                      [Rollcall Vote No. 77 Leg.]

                                YEAS--47

     Akaka
     Biden
     Bingaman
     Boxer
     Bradley
     Breaux
     Bryan
     Bumpers
     Byrd
     Cohen
     Conrad
     D'Amato
     Daschle
     Dodd
     Feingold
     Feinstein
     Ford
     Gorton
     Graham
     Harkin
     Hatfield
     Heflin
     Hollings
     Inouye
     Johnston
     Kassebaum
     Kennedy
     Kerrey
     Kerry
     Kohl
     Leahy
     Levin
     Mikulski
     Moseley-Braun
     Moynihan
     Murray
     Pell
     Pryor
     Reid
     Robb
     Rockefeller
     Sarbanes
     Shelby
     Simon
     Snowe
     Wellstone
     Wyden

                                NAYS--51

     Abraham
     Ashcroft
     Baucus
     Bennett
     Bond
     Brown
     Burns
     Chafee
     Coats
     Cochran
     Coverdell
     Craig
     DeWine
     Dole
     Domenici
     Dorgan
     Exon
     Faircloth
     Frist
     Glenn
     Gramm
     Grams
     Grassley
     Gregg
     Hatch
     Helms
     Hutchison
     Inhofe
     Jeffords
     Kempthorne
     Kyl
     Lautenberg
     Lieberman
     Lott
     Lugar
     McCain
     McConnell
     Murkowski
     Nickles
     Nunn
     Pressler
     Roth
     Santorum
     Simpson
     Smith
     Specter
     Stevens
     Thomas
     Thompson
     Thurmond
     Warner

                             NOT VOTING--2

     Campbell
     Mack
       
  The motion to lay on the table the amendment (No. 3685) was rejected.
  Mr. COATS. Mr. President, I move to reconsider the vote.
  Mrs. KASSEBAUM. Mr. President, I move to lay that motion on the 
table.
  The motion to lay on the table was agreed to.


                             Change of Vote

  Mr. FORD. Mr. President, on amendment numbered 3681, I am recorded 
voting ``yea.'' Since it will not change the outcome of the vote, I ask 
unanimous consent to be changed from ``yea'' to ``nay.''
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. KENNEDY. I understand that Senator Boxer's amendment is ready for 
final disposition.

[[Page S3606]]

  Mr. REID. Mr. President, would my friend yield for a unanimous 
consent request?
  Mr. KENNEDY. I think I will get acceptance for the Boxer amendment.


                           Amendment No. 3686

  The PRESIDING OFFICER. The question is on agreeing to the Boxer 
amendment, Amendment 3686, as modified.
  The amendment (No. 3686), as modified, was agreed to.
  Mrs. BOXER. I move to reconsider the vote.
  Mr. REID. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.


                             Change of Vote

  Mr. REID. Mr. President, on rollcall vote 75, it was my intention to 
vote ``nay.'' Therefore, I ask unanimous consent that I be permitted to 
change my vote. This will in no way affect the outcome.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                             Change of Vote

  Mr. BRYAN. Mr. President, on rollcall vote 75, I voted ``yea'' and 
intended to vote ``nay.'' I ask unanimous consent that I be permitted 
to change my vote. This will in no way change the outcome.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. LEAHY. Mr. President, today over 62,000 Vermonters are included 
in the 39.7 million Americans without health insurance. Unfortunately, 
this number is increasing every year. Health insurance has simply 
become less available and affordable, especially for small businesses 
and individuals. I am proud to cosponsor S. 1028, the Health Insurance 
Reform Act, that will address some of the issues blocking access to 
coverage that the uninsured face today.
  This bill is a good bill and a step in the right direction. The bill 
increases the availability of insurance by ensuring that anyone who 
wants it, and can afford it, will be able to buy it. I am hopeful that 
provisions to encourage small employers to form voluntary purchasing 
pools will give some relief from rising health insurance premiums by 
giving them more leverage to negotiate lower premiums and better 
conditions of coverage.
  To be clear, however, this bill does not address the larger issue of 
the skyrocketing cost of health care which will continue to be a 
looming problem that Americans face.
  What the bill does do is end insurance practices that restrict the 
availability of insurance to people with preexisting medical 
conditions, or avoid enrolling or renewing coverage for older or sicker 
individuals and groups. The GAO estimates that up to 21 million 
Americans a year would benefit from federal laws waiving preexisting 
condition exclusions for persons who had prior coverage.
  What these reforms add up to is portability of health insurance--an 
end to ``job lock.'' Currently, some employees are ``locked'' into 
their current jobs because changing jobs might subject them to periods 
without comprehensive coverage while preexisting condition limitations 
were met. Under this bill, a person with previous group coverage would 
receive credit from this coverage toward any new limitation period. 
These portability provisions do not guarantee that an individual 
currently insured would be covered after a job change--the new employer 
must offer coverage for this guarantee to exist. The GAO estimates that 
ending job lock will benefit as many as 4 million Americans who have 
stayed in their jobs due to concerns about their preexisting 
conditions.
  The individuals who will benefit from this bill are real people who 
have preexisting conditions that they were born with or people who 
become sick or have had a severe accident. Without the Kassebaum/
Kennedy bill, insurance companies can continue to impose restrictions 
on the coverage they offer to these people whose health conditions are 
beyond their control. Even worse, someone seeking insurance who has an 
adverse health condition can be denied insurance altogether. These are 
children, teenagers, young people trying to get jobs for the first 
time, our brothers, sisters, parents, and our grandparents. We cannot, 
in good conscience, risk the well being of people whose health could be 
dramatically affected if denied coverage for the care they need.
  I am proud to say that Vermont has already addressed many of the 
health insurance reforms included in S. 1028. In 1991, Vermont was the 
first state in the nation to prohibit insurance companies from denying 
coverage or charging excessive rates to high-risk groups. In 1992, the 
state extended this to the individual market. Today in Vermont, no one 
can be denied health insurance at a reasonable cost from a carrier 
doing business in the state.
  However, there is a large exception to this rule. Due to a Federal 
law, the Employee Retirement Income Security Act [ERISA], the State of 
Vermont's insurance reforms do not apply to businesses that self-insure 
their health benefits programs.
  For example, during the health reform debate in 1994, I was contacted 
by a Vermont woman who shared with me her husband's experience of 
losing health coverage due to a preexisting condition. This gentleman 
had worked for the same business for over 20 years. He had a heart 
condition, but had always been covered under his employer's health 
insurance plan. When his employer was bought out by a self-insured 
company from another state, the new employer deemed the heart condition 
a preexisting condition and denied insurance coverage.
  Because of stories like this, I have sought to address the issue of 
self-insured employer plans being exempt from State regulation because 
of ERISA in past Congresses. I am very pleased that a key component of 
S. 1028 extends these nondiscrimination and portability requirements to 
self-insured plans. The GAO has estimated that about 44 million 
Americans are in self-insured health plans that states cannot regulate.
  S. 1028 is long overdue. Nearly 2 years ago, Congress was engaged in 
a great battle over how to get health care costs under control and make 
health care services available to all Americans. That battle heeded few 
results and left millions of Americans frustrated and disappointed that 
health care would continue to be out of their reach. The obstacles that 
prevented Americans from buying health insurance have not gone away and 
Congress now owes it to Americans to pass the Kassebaum/Kennedy bill to 
address some of the issues that these individuals face.
  We must pass this bill and make the modest changes that will make it 
easier for people to get the health care coverage they need. I hope in 
the future we will be able to come to agreement on further health 
reforms that will address the skyrocketing cost of health care--simply 
requiring access to health insurance coverage does not address this 
looming issue.
  Mr. WARNER. Mr. President, at the close of debate during the series 
of rollcall votes, I was prepared to vote in favor of the amendment 
offered by the distinguished Senator from California, Senator Boxer, 
proposing a Senate Resolution that the Congress fully examine 
administrative practices of Health Maintenance Organizations [HMO's] in 
which physicians may be precluded from providing full and complete 
medical counsel, or referral for specialized care.
  I am pleased that Senator Boxer's amendment was accepted but wish to 
take this opportunity to indicate that had there been a rollcall vote, 
I would have voted in favor of the Boxer Amendment.
  No physician should feel that they are being subjected to a ``gag 
rule'' in the course of their professional practice. Patients are 
entitled to a full and open discussion of all medical options and 
physicians should not feel restrained in the process.


                       liability for biomaterials

  Mr. McCAIN. Mr. President, I had planned to offer an amendment which 
would ensure the availability of raw materials and component parts for 
implantable medical devices. This provision is necessary if Americans 
are to have continued access to a wide variety of life-saving devices, 
such as brain shunts, heart valves, artificial blood vessels, and 
pacemakers. Unfortunately, we were unable to obtain agreement for this 
amendment from my colleagues on the other side of the aisle.
  Currently, the manufacturers and suppliers of materials used in 
implantable medical devices are subject to substantial legal liability 
for

[[Page S3607]]

selling relatively small amounts of materials to medical device 
manufacturers. These sales generate relatively small profits and are 
often used for purposes beyond their direct control. Due to their small 
profit margins and large legal vulnerability for these sales, some of 
the manufacturers and suppliers of these materials are now refusing to 
provide them for use in medical devices.
  It is absolutely essential that a continued supply of raw materials 
and component parts is available for the invention, development, 
improvement and maintenance of medical devices. Most of these devices 
are made with materials and parts that are not designed or manufactured 
specifically for use in implantable devices. Their primary use is in 
non-medical products. Medical device manufacturers use only small 
quantities of these raw materials and component parts, and this market 
constitutes a small portion of the overall market for such raw 
materials.
  While raw materials and component parts suppliers do not design, 
produce or test the final medical implant, they have been sued in cases 
alleging inadequate design and testing of, or warnings related to use 
of, permanently implanted medical devices. The cost of defending these 
suits often exceeds the profits generated by the sale of materials. 
This is the reason that some manufacturers and suppliers have begun to 
cease supplying their products for use in permanently implanted medical 
devices.
  Unless alternative sources of supply can be found, the unavailability 
of raw materials and component parts will lead to unavailability of 
life-saving and life enhancing medical devices. The prospects for 
development of new sources of supply for the full range of threatened 
raw materials and component parts are remote, as other suppliers around 
the world are refusing to sell raw materials or component parts for use 
in manufacturing permanently implantable medical devices in the United 
States.
  The product liability concerns that are causing the unavailability of 
raw materials and component parts for medical implants is part of a 
larger product liability crisis in this country. Immediate action is 
necessary to ensure the availability of raw materials and component 
parts for medical devices so that Americans have access to the devices 
they need. Addressing this problem will solve some important aspect of 
our broken medical product liability system.

  This issue came to my attention when I was contacted by one of my 
constituents, Linda Flake Ransom, about her daughter Tara who requires 
a silicon brain shunt. Without a shunt, due to Tara's condition called 
hydrocephalus, excess fluid would build up in her brain, increasing 
pressure, and causing permanent brain damage, blindness, paralysis and 
ultimately death. With the shunt, she is a healthy, happy and 
productive straight-A student with enormous promise and potential.
  Tara has already undergone the brain shunt procedure five times in 
her brief life. However, the next time that she needs to replace her 
shunt, it is not certain that a new one will be available due to the 
unavailability of shunt materials. This situation is a sad example that 
our medical liability system is out of control. It is tragic, but not 
surprising that manufacturers have decided not to provide materials if 
they are subject to tens of millions of dollars of potential liability 
for doing so.
  It is essential that individuals such as Tara continue to have access 
to the medical devices they need to stay alive and healthy. This 
amendment would have helped to ensure the ongoing availability of 
materials necessary to make these devices. It would not, in any way, 
have protected negligent manufacturers or suppliers of medical devices, 
or even manufacturers or suppliers of biomaterials that make negligent 
claims about their products. However, it would have protected 
manufacturers and suppliers whose materials are being used in a manner 
that is beyond their control.
  Mr. President, we must act to ensure the continued availability of 
biomaterials to ensure that the lives of Tara and thousands of other 
Americans are not jeopardized. Because this is a life and death 
situation, I will do everything I can to assure that the Senate 
addresses this issue in the near future.


            health insurance reform and genetic information

  Mr. HATFIELD. Mr. President, as we are all too aware, the past 
several months, it has grown exceedingly difficult for Members of 
Congress to focus their attention on anything other than sad 
circumstances of our Federal budget. As chairman of the Appropriations 
Committee, I share in the frustration. Fortunately, I am pleased to see 
that in the midst of our negotiations, and setbacks, excellent progress 
has been made in the area of health insurance reform. Senators 
Kassebaum and Kennedy are to be commended for their efforts this past 
year. While compromise may not be in fashion, they have utilized this 
tool with extreme skill, crafting a bill that makes great strides 
towards improving the infrastructure of health care in the United 
States.
  Accessibility to health care was the focus of debate in the 103d 
Congress and it has become our focus again. Many of you know that the 
State of Oregon is already on the cutting edge of improving 
accessibility for many groups. The Oregon Health Plan, with its focus 
on providing health care coverage under the Medicaid program, has 
successfully prioritized those health care services most important to 
its citizens. Oregon is therefore able to provide coverage to thousands 
of low-income individuals who would otherwise be uncovered. Oregon is 
also making progress improving its health insurance system. But issues 
to accessibility, affordability and portability are national issues as 
well.
  Several of my colleagues have already discussed the merits of the 
Health Insurance Reform Act. As one who is about to change jobs, I 
strongly support the goal of increasing health insurance portability. 
We must keep this focus in mind. Several amendments are being offered, 
which I would normally tend to vote for. However, in light of our need 
to ensure that this reform is passed and signed, I will not be 
supporting such amendments. Again, several of these amendments being 
considered today are excellent. But if their passage only serves to 
make health insurance reform impossible to pass, my support would be in 
vain and our goal to increase portability would be unmet.
  Increasing the availability and renewability of health coverage for 
millions of Americans is a reform Congress has sought for years. 
Individuals should not be refused the opportunity to renew or change 
health plans based on their preexisting conditions. Senator Kassebaum's 
bill addresses this problem and it is estimated it will serve over 25 
million Americans each year. But I also want to thank Senator Kassebaum 
for clarifying in her bill that individuals with genetic information 
that predisposes them to a disease will also benefit from the Health 
Insurance Reform Act's portability conditions. This clarifying language 
is a first step toward bringing important issues surrounding genetics 
to their forefront. I would also like to thank Senator Harkin for his 
leadership on the Labor Committee in working to see that genetic 
information is protected in the health insurance reform bill.
  New biomedical technologies have resulted in scientific breakthroughs 
unimaginable just a generation ago. Scientists are working to decode 
our DNA and will ultimately map and sequence every gene in the human 
body. Such genetic research is our most advanced tool in the search for 
treatments and cures to diseases such as breast cancer, Alzheimer's or 
Huntington's disease. These are exciting medical frontiers, but if the 
fruit of this labor is to be realized, an unhindered commitment to 
genetic research must be promoted, and this includes protecting an 
individual from the threat of genetic discrimination. There have 
already been cases cited where a physically fit individual, with no 
previous health problems, is denied insurance on the basis of a single 
genetic test result.
  This is a problem for two reasons. First, information about our genes 
tells us much about who we are, but is not accurate enough to tell us 
the state of our health in the future. Our future medical condition is 
a complex puzzle, of which our genetic makeup is just one piece. Health 
plans should not be discriminating on the basis of this single piece. 
Second, cases have been documented of individuals who wanted

[[Page S3608]]

to participate in a genetic test, but when they were told that their 
participation may threaten their insurability, they turned around and 
walked out of the lab.
  This is not in the best interest of research; this is not in the best 
interest of society; and it is certainly not in the best interest of 
the individual. Furthermore, while including genetic discrimination in 
the Health Insurance Reform Act is a good start, but is just the 
beginning of a process aimed at protecting the privacy and insurability 
of individuals, regardless of their genetic information or family 
history.
  As I mentioned earlier, it is estimated that this bill will affect 
about 25 million each year. I have sponsored a separate piece of 
legislation, the Generic Privacy and Nondiscrimination Act, S. 1416, 
with Senator Mack, which addresses the needs of millions of Americans 
who may not fit within the boundaries of the bill we are discussing 
today. S. 1416 also addresses issues of genetic privacy and employer 
discrimination. I am hopeful that the Senate's consideration of genetic 
information in this legislation will open the door wider to a deeper 
understanding of these important issues.
  Mr. KENNEDY. Mr. President, I want to raise two concerns about the 
long-term care provisions in the leadership amendment to the Kassebaum/
Kennedy health insurance reform bill.
  First, under the leadership amendment, long-term care insurance 
receives the same tax treatment as medical insurance. Since long-term 
care insurance is treated as medical insurance, I want to make sure 
long-term care insurance provided to employees by an employer is 
subject to the same nondiscrimination rules as health insurance.
  Second, I have a concern that the long-term care provisions in the 
leadership amendment (which includes the National Association of 
Insurance Commissioners' model long-term care consumer protections) 
precludes States from enacting stronger long-term care consumers 
protections.
  Mr. ROTH. Mr. President, with respect to the first point, long-term 
care insurance is treated the same as medical insurance for tax 
purposes under the leadership amendment. Since long-term care insurance 
is treated as medical insurance it is intended that it will be subject 
to the nondiscrimination rules applicable to medical insurance provided 
to employees by an employer.
  On the Senator's second point, it is not the intent of the leadership 
amendment to preclude States from enacting stronger long-term care 
consumer protections. A clarification of this issue can be addressed in 
the conference report to the bill if necessary.


            jeffords-simon and domenici-wellstone amendments

  Mr. BREAUX. Mr. President, tonight the Senate voted on two amendments 
to S. 1028. The first offered by Senator Jeffords and Simon, would 
increase the maximum lifetime benefit caps in health insurance plans to 
$10 million. The second, offered by Senators Domenici and Wellstone, 
would require health plans to provide mental health benefits comparable 
to their other medical benefits. I believe both of these amendments are 
good policy--providing meaningful and equitable coverage for those who 
purchase health insurance. Following the no amendment strategy of the 
bill's managers--Senators Kassebaum and Kennedy--I regretfully voted to 
table these amendments. It is the unfortunate outcome the no-amendments 
strategy to have to table good policy such as these. However, the 
purpose is intended to maintain an important yet fragile bipartisan 
coalition to pass necessary insurance reform. I would otherwise support 
these policies.
  Mr. KOHL. Mr. President, earlier today I noted the serious problem 
this Congress faced in 1994 when it tried to take on too many health 
care-related issues under one bill. We learned that painful lesson 
during debate on the President's health care reform proposal.
  For that reason, I mentioned that some amendments that would come up 
today, no matter how meritorious, should be considered on future 
measures and not impede passage of the Health insurance Reform Act.
  Several amendments required votes today that, in another context, I 
would have strongly supported. The issue of life-time caps, and 
treatment of mental health coverage were passionately debated and 
deserve the attention of this Congress.
  My votes on these issues were not intended to approve or disapprove 
of their merits. My overriding concern was that they could complicate 
this narrowly crafted proposal and jeopardize any chance at health 
reform this year. The sooner we pass this bill to address insurance 
problems of pre-existing condition exclusions, portability and 
renewability, the sooner we can address other pressing problems that 
affect the quality of health care in this Nation.
  In the interest of time, I believe we should pass a clean health 
reform bill. I also believe that Congress should carefully consider 
several of the measures that failed today as soon as possible.
  Ms. MOSELEY-BRAUN. Mr. President, subpart (a)(1)(B) of Section 101, 
Subtitle A of Title I of the bill now before us provides that ``an 
employee health benefit plan or health plan issuer offering a group 
health plan may establish eligibility, continuation of eligibility, 
enrollment, or premium contribution requirements under the terms of 
such plan, except that such requirements shall not be based on health 
status, medical condition, claims experience, receipt of health care, 
medical history, evidence of insurability, or disability.'' As I 
understand it, this formulation is intended to ensure that, among other 
things, that participants and beneficiaries are not excluded from 
health care coverage because they participate in activities such as 
motorcycling, skiing, horseback riding, snowmobiling, all-terrain 
vehicle riding, or other similar kinds of activities. I would like to 
ask the distinguished manager of the pending bill whether my 
interpretation of this provision is a correct one.
  Mrs. KASSEBAUM. The Senator from Illinois is correct.
  Mr. McCAIN. Mr. President, Americans deserve the security of knowing 
that they will not lose their health care coverage if they get sick or 
lose their job or if they can change jobs. Currently, our system does 
not provide this security, and as a result many of our workers have to 
choose between changing jobs and retaining adequate health care for 
themselves or their families. Others live in fear of losing their 
health insurance if they lose their job. And many who have paid 
insurance premiums for years cannot get insurance at any price if they 
get sick. Clearly these Americans deserve to know that when they are 
sick or injured, they will get the medical attention that they need 
when they need it, without having to worry about losing their homes, 
savings and financial security.
  Rather than attempting to change the entire health care system at 
once, this is an incremental approach which targets these specific 
problems. It will make it easier for those who change or lose their 
jobs to keep their health insurance, and by limiting exclusions for 
preexisting conditions, it will assure access to health care for many 
who are sick. By making health care portable, the legislation will 
allow millions of Americans to move to better jobs and improve their 
standard of living. And by ending ``job lock,'' the legislation will 
improve the fit between workers and their jobs and increase the overall 
productivity of American workers. Finally, this legislation will make 
it easier for small employers to obtain adequate coverage for their 
employees. As a result, health insurance will be available to more 
Americans.
  In addition to providing portability of health insurance and limiting 
exclusions for preexisting conditions, this legislation contains 
certain other important provisions. It will increase the tax deduction 
for health insurance for the self-employed to 80 percent, granting long 
overdue tax relief to the owners of small businesses and farms. The 
legislation also provides tax deductibility for long term care and 
insurance, making it possible for more Americans to avoid financial 
difficulty as the result of chronic illness.
  Although there is broad bipartisan support for this legislation, I am 
aware of the concerns that it may increase individual health insurance 
premiums. The legislation addresses this issue in two ways. First, the 
legislation imposes no limit on the rate which individual insurers may 
charge those with

[[Page S3609]]

preexisting illnesses, allowing premiums to be set at a level which 
would not raise costs for others. Therefore any increase in premiums 
which does occur will not be the result of this legislation but of how 
each State chooses to regulate its individual insurance market. Second, 
the legislation gives States considerable flexibility in how they 
address the requirements of the bill. This will allow States to devise 
strategies which fit their individual situations.

  In the past several years, many States have taken significant steps 
to reform their health care systems, and they are to be commended for 
these efforts. For example, my home State of Arizona was one of the 
first to use managed care to improve the efficiency of publicly funded 
health care, and has passed legislation which encourages the use of 
Medical Savings Accounts. There are certain reforms, however, which 
only the Federal Government can make. These reforms fall in that 
category, and it is our responsibility to make them.

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