[Congressional Record Volume 143, Number 89 (Monday, June 23, 1997)]
[Senate]
[Pages S6075-S6084]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                      BALANCED BUDGET ACT OF 1997

  The Senate continued with the consideration of the bill.
  Mr. HARKIN. Mr. President, who yields me time?
  Mr. President, I ask unanimous consent that my time be taken off the 
minority's time on the bill.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. HARKIN. Mr. President, for many years, I have been working hard 
to identify and combat fraud, waste, and abuse in the Medicare Program. 
Starting in 1990, when I took over as chairman of the appropriations 
subcommittee that funds and has jurisdiction over the administrative 
funding of Medicare, I began holding hearings, and I held several 
hearings through

[[Page S6076]]

those years, released report after report, documenting the unnecessary 
losses to the Medicare Program. These losses are truly staggering. I 
have taken the floor many times over the last several years to document 
this for other Senators. The General Accounting Office estimates that 
up to 10 percent of Medicare payments could be lost to fraud, waste, 
and abuse. That adds up to about $18 billion a year.
  The HHS inspector general just concluded a comprehensive audit of 
Medicare claims paid last year. It is the most comprehensive review of 
claims ever made. They found that up to $23 billion of those payments, 
or about 14 percent, should not have been paid. This is last year, 1 
year. The HHS inspector general said that up to $23 billion should not 
have been paid. So the problem may even be worse than we originally 
thought.
  There are many components to this problem. Mr. President, if you can 
dream up a scam or a ripoff, it has probably already been tried in 
Medicare. We have uncovered losses due to out-and-out fraud--billing 
for services that weren't administered, providers paying and receiving 
kickbacks, double billing. We now even have evidence that organized 
crime has entered the Medicare fraud business. Clearly, there is a lot 
of criminal activity that is going on out there which is costing us 
billions of dollars each year.
  However, we found, with help from the GAO and inspector general, that 
even greater losses are due to waste and abuse. That's right, waste and 
abuse is even bigger than fraud in the Medicare Program, and those 
losses are often directly due to or encouraged by wasteful Medicare 
payment policies and practices.
  At long last, it appears that the bill before us will address some of 
the most glaring problems. It would make changes that I have been 
advocating since the beginning of this decade, changes, I might add, 
that this body has previously defeated. I have offered amendments on 
the floor in the past to provide for competitive bidding for Medicare, 
just like the Veterans Administration has, and I was not successful.
  So now with the competitive bidding, plus a streamlining of 
Medicare's authority to pare back excessive payment rates, these two 
steps can cut waste and save taxpayers billions of dollars. I commend 
Senator Graham of Florida for offering the amendment in committee on 
competitive bidding. He had cosponsored my proposals in the past. 
Senator Graham has done us all a great service for his action, and I 
commend the full committee for adopting it and having it in the bill 
before us.
  The need for these reforms could not be clearer. Let me just give you 
an idea of what I am talking about. Last year, I released a report 
prepared by my staff on waste in Medicare payments for medical 
supplies. Remember the $500 toilet seats from the Pentagon of a decade 
or two decades ago? The good news is, the Pentagon isn't buying them 
anymore. The bad news is, Medicare is.
  Our analysis of Medicare payments for a sample of medical supplies 
and equipment from saline solution to hospital beds reveals that 
Medicare is paying up to six times more for these items than other 
Government or private-sector entities. For just 18 items reviewed, 
Medicare could save over 50 percent, or up to $236 million this year. 
Let me repeat that. We reviewed 18 items--just 18--out of the tens of 
thousands that Medicare pays for. In just those, we could save $236 
million this year if we paid the same rates in Medicare as we paid in 
the Veterans' Administration. Same item.
  If Medicare were just to pay wholesale rates offered to others around 
the country, it could save $218 million this year. In fact, it was so 
bad, we found that if Medicare just went down to the local drugstore 
and paid retail rates, it could save $371 million over the next 7 
years; $371 million over 7 years if they just paid retail rates for the 
18 items that we looked at.
  For example, we found that Medicare pays up to $182.80 to rent an air 
mattress, more than six times the wholesale price of $29.95, three 
times the price of $53.88.
  Medicare is paying $99.35 for a simple commode chair that the VA is 
able to buy for $24.12.
  Medicare is paying $7.90 for a bottle of sterile saline solution; the 
VA buys it for $2.38.
  I have a chart here which just shows some of these items and the 
potential savings. Here is an irrigation syringe which Medicare is 
paying $2.93 for; the VA is paying $1.89.
  Here is a walker. This is one of those plain walkers that elderly 
people use. It has four legs on it. Medicare is paying $75.52 for them; 
the Veterans' Administration is paying $25.40 for the same one, the 
exact same walker made by the same company.
  A commode chair. You know what a commode chair is; if you can't get 
to the bathroom, you have it by your bed. Medicare is paying $99.35 for 
it; the same commode chair, identical, the Veterans' Administration is 
paying $24.12 for it.
  Here is the sterile saline solution I talked about. Medicare is 
paying $7.90 for it; the same item, the Veterans Administration is 
paying $2.38 for it.
  Why? Why would the Veterans' Administration pay $25.40 for a walker 
that Medicare is paying $75 for? Same item, same town. Why? Because the 
Veterans' Administration is engaging in good old-fashioned competitive 
bidding. If you want to sell it, put out a bid for what you are selling 
it for, we will take the lowest bid. That is why Medicare pays bloated 
prices based on historical charges and the VA, which has much less 
purchasing power than Medicare, puts it out for both quality and cost 
control. So the Veterans' Administration is able to save money, because 
they use competitive bidding to assure it is getting the best rate 
possible.
  Right now, under law, Medicare is prohibited--prohibited--from using 
this measure. Medicare is prohibited from engaging in competitive 
bidding. But the bill before us now gives them that much-needed 
authority. It doesn't mandate it. I think we ought to mandate it, but 
the bill at least gives HCFA the authority to engage in competitive 
bidding.
  In the hearings that I have held in the past, Mr. Vladeck, the 
Administrator of HCFA, has testified that if given the authority, they 
would use it. So I think this will be sufficient and will get the 
Health Care Financing Administration to start engaging in competitive 
bidding.
  Another important reform that is in this bill is the streamlining of 
Medicare's authority to reduce grossly excessive payment for items it 
purchases. It is called the inherent reasonableness authority. Under 
current law, the authority is tortuous to complete. As a result, it has 
only been used once.
  Three years ago, we found that Medicare was paying up to $211 for a 
home diabetes monitor. At that time, I sent a staff person of mine out 
to the local K-mart and bought the same item for $49.99 that Medicare 
was paying $211 for.
  After several hearings, we got Medicare to begin the process of using 
their authority, the authority that they call inherent reasonableness 
authority. We got them to use that to reduce this gross overpayment for 
these blood glucose monitors. It took them 2 full years to go through 
all of the hurdles set up in the law. They finally reduced the payment 
to around $50, and that alone is saving taxpayers $25 million over 5 
years. But it took 2 years just to get that done. That delay cost 
taxpayers $10 million.
  The bill before us includes a streamlining of this process that I 
have been suggesting for years. It would allow Medicare to respond 
quickly when it finds that it is paying prices that are out of line 
with what everyone else pays. So I am pleased that this finally is 
before this body, and I hope it is agreed to.
  Mr. President, I have an amendment that I will be asking to send to 
the desk, after I give a brief explanation. They are changes that will 
help to reduce the massive losses due to waste, fraud, and abuse. All 
of these are based on reports and recommendations by the General 
Accounting Office and the inspector general of Health and Human 
Services. I don't believe it will be controversial to anyone, and I 
hope it will be accepted by the managers of the bill.
  First of all, Mr. President, the first part of the amendment has to 
do with improving information to beneficiaries. Under current law, 
beneficiaries are sent a statement, an explanation of charges and 
payments. They are brief

[[Page S6077]]

summaries of the actual bills and payments. There are several 
shortcomings of these current statements that are sent to 
beneficiaries. The first thing that you will notice, if you look at a 
statement, it says in big bold letters: ``This is not a bill.''
  So you are an elderly person, you get this, it says, ``This is not a 
bill.'' Hey, I get a lot of things in the mail that is not a bill. I'm 
not going to worry about it. So many beneficiaries don't take the time 
to examine them for the mistakes. In addition, the statements do not 
provide the number of the toll-free hot line operated by the Medicare 
contractor to receive reports of errors or fraud or abuse. Finally, 
there is no requirement that beneficiaries can get copies of complete 
itemized bills submitted by providers.
  So what my amendment does is it requires that each explanation of 
benefits sent to beneficiaries, including the statement, because 
billing errors do occur and there is significant waste, fraud, and 
abuse, that the beneficiary should carefully review the statement for 
errors or other questionable billings and report those to Medicare.
  It also requires that the statement include the toll-free hotline 
number to report the suspected problems. These toll-free lines already 
exist. I am not setting anything up that does not exist. They already 
exist, but many seniors do not know about it. All I am saying is, the 
phone number ought to be put on the statement of benefits.
  My amendment provides that a beneficiary may, if they request, be 
provided an itemized bill within 30 days of their request when the 
beneficiary suspects irregularities from having read the summary 
provided to them.
  My amendment also requires that any specific allegations of errors or 
other problems made by beneficiaries based on a review of the itemized 
bill be reviewed and any appropriate recoveries made for the trust 
fund.
  Second, Mr. President, Medicare payments are supposed to be limited 
to those that are reasonable, necessary, and related to patient care. 
That is the law, and those are the regulations. However, while most 
other Federal agencies specifically prohibit indirect cost allowances 
for gifts, entertainment expenses, education costs for spouses and 
dependents, Medicare does not prohibit this.
  In addition, Medicare does not explicitly prohibit indirect cost 
reimbursement for fines and other penalties imposed by Federal, State, 
or local governments on health care providers. As such, providers can 
escape a fine by simply charging them back to Medicare. Well, as 
documented by the General Accounting Office and the Office of Inspector 
General, this lack of clarity in Medicare policy invites confusion and 
abuse.
  For example, a report by the Office of Inspector General found that 
Medicare had been billed for a portion of the cost of a sailing regatta 
for hospital employees, reimbursement for ballet tickets, reimbursement 
for Tiffany crystal pitchers, reimbursement even for a trip to Italy to 
inspect a piece of art for an executive office.
  This amendment explicitly prohibits Medicare reimbursement for 
indirect costs related to entertainment, gifts, donations, personal use 
of motor vehicles, costs for fines and penalties, and tuition for 
spouses or dependents of health care providers. In other words, it 
brings it into line with other Federal law.
  The next part of my amendment goes to the losses due to frequently 
abused items. Currently under the law, the Secretary may--may; does not 
say ``shall''--may make a list of medical supply and equipment items 
that she finds to be frequently subject to unnecessary utilization. In 
other words, you see something popping up all the time, it keeps being 
utilized, well, the Secretary may develop a list of suppliers found to 
have business practices that result in a pattern of utilization.
  So the Secretary's power is she may. The Secretary has failed to use 
this authority, thereby missing potential for significant savings. I do 
not mean to point at this Secretary. The Secretary before this one did 
not use it either. And therein lies the problem.
  My amendment simply changes the word ``may'' to ``shall'' and 
requires the Secretary to develop the list of overutilized medical 
supply items and questionable suppliers.
  Lastly, in OBRA 1993, it provided for certain medical supplies, 
including surgical dressings, to be reimbursed based on a fee schedule. 
As a result, providers must submit to fiscal intermediaries claims that 
itemize the specific supplies and quantities billed. However, this 
provision does not apply to items billed by home health care agencies. 
So since 1993, for certain medical supplies, like surgical dressings, 
reimbursed on a fee schedule, it does not apply to home health 
agencies.

  Now, in addition, current law prohibits the Secretary--prohibits the 
Secretary--from using her inherent reasonableness authority to reduce 
grossly excessive payment rates for surgical dressings. Why that was 
left out we do not know, but it was left out.
  The General Accounting Office has documented that these two 
exceptions to Medicare law result in considerable unnecessary losses. 
They found, for example, that items as diverse as pacemakers were being 
billed as medical supplies, and those claims were paid because Medicare 
does not know what specific items they are being billed for.
  In addition, the GAO found that payments for surgical dressings could 
be reduced by half if more reasonable prices were paid. For example, 
they found that Medicare pays $2.32 for a gauze pad whose wholesale 
price is 19 cents and that another Government agency buys for 4 cents, 
in this case the Veterans' Administration. Again, Medicare is paying 
$2.32 for a gauze pad; the VA is paying 4 cents for the same one.
  My amendment would say the home health agencies would be required to 
submit to fiscal intermediaries claims that itemize the specific 
supplies and the quantities billed for surgical dressings. All other 
providers are currently required to do the same, but not home health 
agencies. Mine would just bring the home health agencies in under this 
umbrella.
  Finally, the loophole that for some reason is there that excludes 
surgical dressings from the Secretary's inherent reasonableness 
authority would be closed. She would have that authority to pay on a 
reasonable basis, to get that down to the same level that the Veterans' 
Administration is paying.
  Mr. President, I am going to be asking unanimous consent to set aside 
the pending amendment and lay down my amendment. We are now discussing 
it with the Finance Committee. I am hopeful it can be cleared without 
the need for a vote in the next day or two.


                           Amendment No. 428

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

  Mr. HARKIN. So, Mr. President, I ask unanimous consent to have the 
pending amendment laid aside so that I may lay down my amendment.
  The PRESIDING OFFICER. Is there objection?
  Mr. DOMENICI. Reserving the right to object.
  The PRESIDING OFFICER. The Senator from New Mexico is recognized.
  Mr. DOMENICI. I say to the Senator, I need you to further agree, if 
you would please, that we can, with the assurance that your amendment 
will be placed in a stacked order to leave us the range of offering the 
two major committee amendments first. They are going to be offered this 
afternoon.
  Mr. HARKIN. Sure.
  Mr. DOMENICI. Then we will stack them, and perhaps yours will be the 
third or fourth. But you will get it in that manner.
  Mr. HARKIN. Absolutely.
  Mr. DOMENICI. Is that sufficient for you to understand the unanimous-
consent request?
  The PRESIDING OFFICER. The Chair understands the request.
  Mr. HARKIN. I understand it.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. HARKIN. We are working with the Finance Committee. What I 
suggested I hope will be accepted in the next day or two.
  Mr. DOMENICI. You are going to work with them on that account, right?
  Mr. HARKIN. Yes.
  Mr. DOMENICI. Have you sent your amendment to the desk?
  Mr. HARKIN. Yes; I sent it to the desk.
  Mr. DOMENICI. There is time still reserved in opposition to it. We 
have not yielded back.
  The PRESIDING OFFICER. The Chair understands.

[[Page S6078]]

  Mr. DOMENICI. We will probably need a couple minutes, so let us leave 
it to the reservation time. And he has time, too.
  Should the clerk report his amendment so it will be ready?
  The PRESIDING OFFICER. The clerk will report the amendment.
  The legislative clerk read as follows:

       The Senator from Iowa [Mr. Harkin] proposes an amendment 
     numbered 428.

  Mr. HARKIN. 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 end of the bill add the following:

     SEC.   . IMPROVING INFORMATION TO MEDICARE BENEFICIARIES.

       (c) Clarification of Requirement To Provide Explanation of 
     Medicare Benefits.--Section 1804 of the Social Security Act 
     (42 U.S.C. 1395b-2) is amended by adding at the end the 
     following new subsection:
       ``(c)(1) The Secretary shall provide a statement which 
     explains the benefits provided under this title with respect 
     to each item or service for which payment may be made under 
     this title which is furnished to an individual, without 
     regard to whether or not a deductible or coinsurance may be 
     imposed against the individual with respect to such item or 
     service.
       ``(2) Each explanation of benefits provided under paragraph 
     (1) shall include--
       ``(A) a statement which indicates that because errors do 
     occur and because medicare fraud, waste and abuse is a 
     significant problem beneficiaries should carefully check the 
     statement for accuracy and report any errors or questionable 
     charges by calling the toll-free phone number described in 
     (C)
       (B) a statement of the beneficiary's right to request an 
     itemized bill (as provided in section 1128A(a)); and
       ``(C) a toll-free telephone number for reporting errors, 
     questionable charges or other acts that would constitute 
     medicare fraud, waste, or abuse, which may be the same number 
     as described in subsection (b).''.
       (b) Request for Itemized Bill for Medicare Items and 
     Services.--
       (1) In general.--Section 1128A of the Social Security Act 
     (42 U.S.C. 1320a-7a) is amended by adding at the end the 
     following new subsection:
       ``(m) Written Request for Itemized Bill.--
       ``(1) In general.--A beneficiary may submit a written 
     request for an itemized bill for medical or other items or 
     services provided to such beneficiary by any person 
     (including an organization, agency, or other entity) that 
     receives payment under title XVIII for providing such items 
     or services to such beneficiary.
       ``(2) 30-day period to receive bill.--
       ``(A) In general.--Not later than 30 days after the date on 
     which a request under paragraph (1) has been received, a 
     person described in such paragraph shall furnish an itemized 
     bill describing each medical or other item or service 
     provided to the beneficiary requesting the itemized bill.
       ``(B) Penalty.--Whoever knowingly fails to furnish an 
     itemized bill in accordance with subparagraph (A) shall be 
     subject to a civil fine of not more than $100 for each such 
     failure.
       ``(3) Review of itemized bill.--
       ``(A) In general.--Not later than 90 days after the receipt 
     of an itemized bill furnished under paragraph (1), a 
     beneficiary may submit a written request for a review of 
     the itemized bill to the appropriate fiscal intermediary 
     or carrier with a contract under section 1816 or 1842.
       ``(B) Specific allegations.--A request for a review of the 
     itemized bill shall identify--
       ``(i) specific medical or other items or services that the 
     beneficiary believes were not provided as claimed, or
       ``(ii) any other billing irregularity (including duplicate 
     billing).
       ``(4) Findings of fiscal intermediary or carrier.--Each 
     fiscal intermediary or carrier with a contract under section 
     1816 or 1842 shall, with respect to each written request 
     submitted to the fiscal intermediary or carrier under 
     paragraph (3), determine whether the itemized bill identifies 
     specific medical or other items or services that were not 
     provided as claimed or any other billing irregularity 
     (including duplicate billing) that has resulted in 
     unnecessary payments under title XVIII.
       ``(5) Recovery of amounts.--The Secretary shall require 
     fiscal intermediaries and carriers to take all appropriate 
     measures to recover amounts unnecessarily paid under title 
     XVIII with respect to a bill described in paragraph (4).''.
       (c) Effective Date.--The amendments made by this section 
     shall apply with respect to medical or other items or 
     services provided on or after January 1, 1998.

     SEC.   . PROHIBITING UNNECESSARY AND WASTEFUL MEDICARE 
                   PAYMENTS FOR CERTAIN ITEMS.

       Notwithstanding any other provision of law, including any 
     regulation or payment policy, the following categories of 
     charges shall not be reimbursable under title XVIII of the 
     Social Security Act:
       (1) Entertainment costs, including the costs of tickets to 
     sporting and other entertainment events.
       (2) Gifts or donations.
       (3) Personal use of motor vehicles.
       (4) Costs for fines and penalties resulting from violations 
     of Federal, State, or local laws.
       (5) Tuition or other education fees for spouses or 
     dependents of providers of services, their employees, or 
     contractors.

     SEC.   . REDUCING EXCESSIVE BILLINGS AND UTILIZATION FOR 
                   CERTAIN ITEMS.

       Section 1834(a)(15) of the Social Security Act (42 U.S.C. 
     1395m(a)(15)) is amended by striking ``Secretary may'' both 
     places it appears and inserting ``Secretary shall''.

     SEC.   . IMPROVED CARRIER AUTHORITY TO REDUCE EXCESSIVE 
                   MEDICARE PAYMENTS.

       Payment for Surgical Dressings.--Section 1834(i) of the 
     Social Security Act (42 U.S.C. 1395m(i)) is amended by adding 
     at the end the following new paragraph:
       ``(3) Grossly excessive payment amounts.--Notwithstanding 
     paragraph (1), the Secretary may apply the provisions of 
     section 1842(b)(8) to payments under this subsection.''.

     SEC.   . ITEMIZATION OF SURGICAL DRESSING BILLS SUBMITTED BY 
                   HOME HEALTH AGENCIES.

       Section 1834(i)(2) (42 U.S.C. 1395m(i)(2) is amended to 
     read as follows:
       ``(2) Exception.--Paragraph (1) shall not apply to surgical 
     dressings that are furnished as an incident to a physician's 
     professional service.''.

  Mr. KENNEDY addressed the Chair.
  The PRESIDING OFFICER. The Senator from Massachusetts is recognized.
  Mr. KENNEDY. Mr. President, I see the floor manager.
  I was wondering if we could follow the same procedure with an 
amendment that I would send to the desk in regard to the copayment on 
home health services. I ask unanimous consent for that.
  Would that be agreeable?
  Mr. DOMENICI. That would be satisfactory, so long as it is 
understood, I say to the Senator, that it may be the fourth, fifth, but 
it will be in order.
  Mr. KENNEDY. Fine.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                           Amendment No. 429

   (Purpose: To strike the provision relating to the imposition of a 
               copayment for part B home health services)

  Mr. KENNEDY. Mr. President, I send to the desk an amendment for 
myself and Senator Wellstone.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Massachusetts [Mr. Kennedy], for himself 
     and Mr. Wellstone, proposes an amendment numbered 429.

  The amendment is as follows:

       Strike section 5362.

  Mr. KENNEDY. Mr. President, I thank the floor manager.
  As I understand the procedure that we are following now, amendments 
are being sent in and there will be an order that will be worked out by 
the managers, both the Republican manager and the Democratic manager, 
so that there will be time so that Members will know when the vote will 
be expected. As I understand from the previous discussions, there is 
the best expectation it will be sometime either in the morning or in 
the early afternoon.
  Mr. DOMENICI. The Senator is correct.
  Mr. KENNEDY. I would not, in cooperating with the managers, 
obviously, take much additional time. I would like to be able to at 
least preserve some time to allow for a brief comment. But I will 
follow our leaders on these issues, and try to ensure we are able to 
move in an expeditious way.
  Mr. DOMENICI. Would Senator Kennedy just yield?
  Mr. KENNEDY. Yes.
  The PRESIDING OFFICER. The Senator from New Mexico.
  Mr. DOMENICI. My impression, with a brief observation, is that the 
amendment is subject to a point of order. There is no intention at this 
point in any discussion to in any way waive points of order against the 
amendment if they lie.
  Is that correct, Mr. President?
  The PRESIDING OFFICER. The points of order are not made by these 
arrangements.
  Mr. DOMENICI. I say to Senator Kennedy, each amendment has an hour on 
each side, and I am not attempting to change that.
  Mr. KENNEDY. Fine. Good. I appreciate that.
  Mr. DOMENICI. I think tomorrow we will narrow it down.
  Mr. KENNEDY. We will cooperate with the floor managers.

[[Page S6079]]

  Mr. DOMENICI. Thank you.
  Mr. KENNEDY. We believe this is in order. But we will have an 
opportunity to address that issue at the appropriate time.
  Mr. President, I rise this afternoon to offer an amendment to strike 
the new copayment for Medicare's home health patients. Without warning, 
the Finance Committee has imposed a tax on America's seniors of nearly 
$5 billion in new copayments for part B home health services.
  This cruel and unexpected provision, which was not debated or voted 
on in the committee and is not necessary to meet the committee's 
reconciliation targets, will fall primarily on the oldest, poorest, and 
sickest Medicare beneficiaries.
  Let me repeat that. The nearly $5 billion that is raised by this 
provision is not necessary to meet the requirements of the budget 
agreement. Nonetheless, it was put into the agreement. Why? The best 
estimate is that those will be used for tax reductions, perhaps for the 
wealthier individuals.
  I am sure that some in the Senate will justify to the American people 
this change and the other dangerous proposals in this bill by claiming 
they are needed to preserve Medicare for future generations. This could 
not be further from the truth.
  As I understand, the agreement worked out in the bipartisan budget 
negotiations was to stabilize the Medicare trust fund for at least 10 
years and to establish a commission that will make recommendations to 
preserve Medicare for the future.
  The proposal we are debating now does neither of these things. It 
establishes a $5 copay that will affect the oldest, the sickest, and 
the poorest senior citizens. This provision preys primarily on the 
elderly women who are dependent upon Medicare and the home health care 
system.
  The assault on Medicaid that began last Congress is continuing with 
full force. Congress should reject this just as we rejected it last 
year. There is no rationalization, none whatsoever, for Congress to 
rush forward with ill-considered changes in Medicare under the thinly 
veiled pretext of balancing the Federal budget. None of these basic 
changes in Medicare were part of the budget agreement.
  It is the height of hypocrisy for those who voted against including 
the Hatch-Kennedy children's health plan in the agreement last month to 
make this assault on Medicare part of the agreement this month.
  When we brought that measure up here, we were told that this is going 
to break the budget agreement, even though it is completely paid for. 
Now, we have before us a plan to collect $5 billion in copays from 
elderly widows and the poorest in our society. Under this proposal, we 
would collect $5 billion that is not even necessary to meet the terms 
of the budget agreement.
  In 1996, Mr. President, Medicare beneficiaries spent an average of 
$2,605 on health care. However, the sicker seniors spent $5,600 out of 
their own pockets for cost-sharing related only to Medicare coverage 
services. Now the Senate Finance Committee is asking them to spend up 
to $760 more.
  I understand that some of my colleagues are interested in increasing 
cost sharing because they feel it would lead to a reduction in 
utilization and, therefore, a reduction in Medicare spending. It is 
important to note, however, that cost-sharing is a blunt tool to 
express change. It may reduce utilization but the goal is to reduce 
unnecessary utilization. It is almost certain this policy will fail to 
meet this objective.
  Let me remind my colleagues that home health services were exempted 
from part B coinsurance in 1972 to encourage use of less costly 
noninstitutionalized services. Reimposing a copayment will undermine 
that effort. We removed cost-sharing requirements on home health care 
in 1972 specifically to reduce utilization, to the extent that we could 
in an appropriate health context, of services in acute hospitals and in 
high-cost medical delivery systems. We wanted to encourage the 
provision of home health care, which provides very important services 
and does so less expensively than in acute care settings.
  It was the belief at that time, and it is my belief now, that 
burdensome cost-sharing can seriously threaten the health of the frail 
elderly, particularly those who are hard pressed to make ends meet. 
Imposing a $5 new copayment will reduce access for those who need the 
services the most. If we are interested in reducing home health care 
utilization we ought to first look at ways to alter the behavior of 
providers, as we have done in the bill's proposed payment reform, 
before forcing the sickest beneficiaries to pay more.
  Mr. President, just a few moments ago we had some excellent 
commentary from Marian Brown, an 82-year-old widow who lives 
independently in Marlow Heights, MD. She has numerous health ailments 
and is confined to a wheelchair. She is treated three times a week by a 
home health aide who tends to her physical troubles, spending 2 to 3 
hours in her home on each visit. Her annual income is $6,786. She 
simply cannot afford to spend an additional $15 a week, $60 a month, or 
$720 a year on copayments for these necessary visits. She spoke 
articulately and compellingly about what this particular proposal would 
mean to her. She has difficulty with her hip, but doctors do not want 
to operate because of a serious heart condition. Yet her hip prevents 
her from being able to move in and out of the bathtub. It prevents her 
from being able to wash her own feet.
  She is a very proud individual who takes great delight in living 
where she does with her friends and associates, and has a great sense 
of joy about her and in her optimism about the future. She is not 
asking for very much. She is just saying, ``I can just about make ends 
meet now, but, if you pass this copayment, I will have to give up 
stretching exercises to keep me from further disability, or the ability 
to be able to get out of bed and get dressed and cleaned up in a manner 
that allows me to retain my sense of respect and dignity and self-value 
and joy, or cut back on prescription drugs or food or heating of my 
apartment during the winter.'' She makes that case, Mr. President.
  We have to ask ourselves what was the sense of urgency in this 
legislation. Those funds were not even needed in terms of balancing the 
budget. We ought to look at all the provisions--not only of this bill, 
which is the cutting of the spending programs--but also in the tax 
bill, to see who will benefit, where the pain is coming, where the 
fairness is.
  I daresay I think those in the majority will be hard pressed at the 
end of the day to think that this kind of financial burden and 
anxiety--even though these are only $5 payments that the individual 
will have to pay--that ought to be used to balance the budget. The 
amendment that I offer, joined by Senator Wellstone, will give the 
opportunity for the Senate to go on record opposing this proposal.
  Finally, Mr. President, this new copayment will be an unfunded 
mandate on the States. I ask for the attention of our colleagues who 
are so concerned about unfunded mandates on the States. Medicare 
beneficiaries who qualify for assistance from State Medicaid programs 
have higher use of home health care services. In fact, the very 
poorest, who are eligible for Medicare and Medicaid, are twice as 
likely as other Medicare beneficiaries to use the home health benefits. 
As a result, State Medicaid programs will have to absorb the new 
copayments for these beneficiaries.

  CBO estimates, Mr. President, that the additional State and local 
costs of home health copayment would amount to $700 million over the 
next 5 years. I hope we are going to have the time and opportunity to 
hear the rationale and justification for this misguided proposal. 
States are usually quite clear in their opposition to unfunded 
mandates.
  Mr. President, Medicare is still one of the most successful social 
programs ever enacted. It has brought health care and health security 
to tens of millions of senior citizens. We can deal with the financial 
problems of Medicare but we must do it the right way, not the wrong 
way.
  Our goal is to save Medicare, not destroy it. Our priority should be 
to keep the promise of medical and financial security for senior 
citizens that Medicare provides. We are the guardians of that promise 
and we should oppose any schemes that violate it.
  There is no question that Medicare will face serious challenges in 
the next century as a result of the retirement of

[[Page S6080]]

the baby-boom generation. Today there are nearly four adults of working 
age for every senior citizen. By the year 2030, that ratio will be down 
to two workers for every senior citizen. There is a right way and a 
wrong way to respond to that challenge, and the wrong way is to destroy 
the program under the guise of saving it.
  I urge my colleagues to vote to strike these unfair and unnecessary 
provisions from the reconciliation bill.
  Mr. LAUTENBERG. Mr. President, I want to commend my colleague from 
Massachusetts for being on the alert here. I worked very hard with my 
distinguished chairman from the Budget Committee to try and assemble a 
consensus agreement that we could all support, and suddenly now we are 
offered a change and that change says, ``Well, senior citizens who have 
home health care pay $5.'' It sounds trivial almost, but Mr. President, 
when we have someone who needs sometimes two, sometimes three visits a 
day to keep them going, $100 a week, when the average for many of these 
people, whose income is $15,000 a year or less--you get up to $3,000, 
$4,000, or $5,000 a year, that is torment. That takes away their very 
life sustenance because they cannot afford the rent, they cannot afford 
the heat, they cannot afford the nutrition.
  On top of that, to impose this new burden, I say, Mr. President, the 
Senator from Massachusetts is always on the lookout for a balance in 
our society to try and provide equal service to those who need help--
the promise for the future, an education for their children--Senator 
Kennedy is always there. In this case I must tell you, I heartily agree 
with him.
  The target group are people, usually women, 75 on balance in years, 
with incomes of under $15,000. They are old, very often frail, sick 
people who do not take home health care if they can get out of their 
homes, if they have any mobility, if they have any opportunity to go 
visit the doctor. These are often critical, life-sustaining services 
that they need.
  Some argue, Mr. President, that most people subject to this copayment 
will not really pay because they have Medigap policies that cover 
copayments and deductibles. That is misleading because a new copayment 
would lead to increased Medigap premiums. So seniors would either have 
to pay the new copayment or their insurance bills would go up. Either 
way, the bottom line would be higher out-of-pocket costs. Already, 
seniors typically pay more than 20 percent of their income on these 
costs.
  As the Senator from Massachusetts said, unfunded mandates, States 
will have to come up with $700 million, I think is the figure the 
Senator used. This is not a particularly good way to get this bill back 
on track, especially when we know immediately hereafter in the next 
part of the reconciliation we will be looking at tax relief for lots of 
folks who do not need it, who can get by very comfortably without it, 
and here we are talking about $5 out of the pockets of the poverty 
stricken, typically those who need help, and whose only contact often 
with the outside world is with these groups, and they want to charge 
them $5 to have somebody come by.

  I commend the Senator from Massachusetts and I support him. I yield 
the floor.
  Mr. KENNEDY. If I could, and I see Senator Wellstone ready to speak 
on this, but just before the Senator sits down, does the Senator 
understand what the Finance Committee was doing since this is a benefit 
that comes from part B. They are using the deductible limit in A which 
is $760, which is a lot more, obviously, than part B which is just 
$100.
  Here they are taking something which is basically a benefit, they are 
tying it to the higher deductible to make the seniors pay more. I find 
that somewhat troublesome, as well. It is just a way of maneuvering the 
system.
  I am just wondering if the Senator also is struck by the fact that 
States are going to be involved in collecting this? Even in the poorest 
of the circumstances, they are going to have a requirement to do so. We 
will not be helping any of the States to do it. We hear a great deal 
about mandates around here, I would have thought this would be a matter 
of concern to some of those that were troubled by unfunded mandates.
  Mr. LAUTENBERG. The Senator is correct. The one thing that I found 
most disturbing about the proposals that have come in the 
reconciliation is the fact that suddenly we are in to a whole new area 
having very little to do with the mission that we have set out for us, 
to get a balanced budget, to try at the same time to invest in 
education, to try at the same time to make sure impoverished senior 
citizens do not have to pay more as a result of the transfer of home 
health services to part B--all of those things.
  Suddenly, now we are seeing that something might be called bait and 
switch, where senior citizens are being told now, well, you may have to 
pay a higher premium for your part B, your deductible may be going up, 
that the most modest-income person would have to pay $5, perhaps to get 
an insulin shot or something like that. Five bucks, when you ain't got 
it, to put it crudely, is an awful lot of money. These people do not 
have it. They do not have contact with the outside world. They are 
frail, they are elderly. For God's sake, where is our conscience on 
these things?
  Mr. KENNEDY. I think the statement that the Senator makes is 
enormously important, since he is the ranking member of the Budget 
Committee. As I understand what he is saying, this was not part of the 
budget agreement. We do not need that $5 billion to meet the terms of 
the budget agreement.
  Mr. LAUTENBERG. The Senator is correct.
  Mr. KENNEDY. Also this was not voted on specifically in the Finance 
Committee, and it is not necessary to balance the budget. It was added 
on in the Finance Committee, as I understand, without even an up-or-
down vote, and here we are faced with the fact that millions of our 
seniors will be faced with this issue unless we move to strike it on 
the floor.
  Now, since I have the Senator's attention, am I correct in my 
understanding that $1.5 billion in premium assistance for low-income 
beneficiaries was included in the agreement?
  Mr. LAUTENBERG. Yes, that is true. That was designed originally to 
pay, through Medicaid, for those who were up to 150 percent of poverty, 
any increase in premium that might occur.
  Mr. KENNEDY. So the agreement included $1.5 billion to offset that 
increased premium, but it was not done under the Finance Committee's 
bill, am I correct?
  Mr. LAUTENBERG. The Senator is correct.
  Mr. KENNEDY. So this bill has short-changed low-income senior 
citizens $1.5 billion, and then asked them to pay $5 billion on top of 
that. And then created an MSA demonstration, which is going to cost 
about $400 million. We already have an MSA demonstration project.
  Mr. LAUTENBERG. Not for the Medicare Program.
  Mr. KENNEDY. My point exactly. The Kassebaum-Kennedy bill created a 
demonstration for those in the private market. We ought to first 
evaluate that proposal, on which we are already spending nearly $1.5 
billion, before doling out scarce Medicare funds in a wild experiment 
sure to benefit only insurance companies and the healthy and wealthy.
  And then we are going to return to the days of balanced billing. 
Certain private plan options will allow doctors to overcharge, or 
balance bill. We have, over a long period of time, prohibited Medicare 
providers from balanced billing and encouraged them to take Medicare 
payment as payment in full. Releasing these important consumer 
protections will undoubtably force seniors to pay more. It doesn't take 
any stretch of the imagination--and I ask my friend and colleague if he 
would agree with me--to envision doctors moving out of Medicare to form 
one of these private plans and invite their Medicare patients to ``come 
into our program.'' Seniors will follow their doctors and find 
themselves being overcharged in those circumstances. That is what 
happened in the past. Is the Senator concerned about that?
  Mr. LAUTENBERG. Yes. They are going to have to pay additional funds 
for services that, otherwise, they might not. And it's true that, in 
the past, we have not permitted the so-called balanced billing, which 
simply says the service was advertised or

[[Page S6081]]

talked about at this level and now it is at a higher level, so you are 
going to get a bill for it.
  Mr. KENNEDY. Was that in the budget agreement? Balanced billing was 
debated last year, in the last Congress here, and we were given 
assurances that it wasn't going to be part of the budget agreement when 
we were talking then. I don't remember much discussion about that prior 
to the time that we voted on this issue here. I think that what is 
important here--we have not even talked about the issue of the part B 
deductible and what that will mean to seniors and the additional out-
of-pocket expenses they will have in that area--is that these 
provisions are going to have a dramatic adverse impact on seniors, and 
it was not mandated in the budget agreement. This is all in 
anticipation of a commission that the bill sets up to try and review 
the Medicare system for the future.
  Mr. LAUTENBERG. If I may ask the Senator a question, this isn't, I 
take it, your idea of a particularly good way to make reforms in 
something as complicated as Medicare, and I could not agree with you 
more. This is fast-track legislation, which means--for those who are 
not familiar with the terminology--that this is supposed to zip through 
this place. This was not part of the consensus agreement we labored 
over for months in order to strike a budget agreement that could pass 
muster and would be a consensus bill. This now is recommended by the 
Finance Committee in terms of their reconciliation on expenditures.
  I have been a loyal trooper in defending the consensus agreement. But 
this, in my view, is certainly outside the pale. I am not any happier 
than the Senator is.
  Mr. KENNEDY. I appreciate that. We will have a chance to address 
these in accordance with the way the amendment process goes during the 
next couple of days. I am very grateful for the Senator's comments 
because I think it is important, as we address these issues, not to 
confuse what is necessary to preserve the financial integrity of the 
Medicare system--as this bill does for at least 10 years--with these 
other proposals that could destroy it. I daresay that those additional 
costs to seniors will reflect themselves by the end of the week, along 
with the additional tax relief for very wealthy individuals and 
corporations.

  I daresay I was so interested when my friend, the majority leader, 
was talking about how the amendment that Senator Hatch and I offered to 
extend health insurance to children would be a budget buster because it 
is financed by an increase on the cigarette tax. And then the Finance 
Committee, with his support, turned right around and offered a 20-cent 
per pack cigarette tax increase. It's only a small part of it, but it 
is amazing the way all of this is being proposed.
  I thank my colleague and friend from New Jersey for his response. He 
has been a leader in terms of responsible economic policy and has a 
challenging position in representing our side through these 
negotiations. We have great respect for someone who understands this 
process so well. I am grateful for his response. I thank my friend and 
colleague, Senator Wellstone, also, for his strong support for this 
particular amendment.
  How much time does the Senator need?
  Mr. LAUTENBERG. Mr. President, I thank the Senator. I am prepared to 
yield as much time as the Senator from Minnesota needs.
  Mr. KENNEDY. I think I have time on my own, is that correct, Mr. 
President, on the amendment?
  The PRESIDING OFFICER. The Senator from Massachusetts controls 33 
more minutes on his amendment.
  Mr. KENNEDY. I see both the manager on his feet and also I have my 
friend and colleague who wanted to speak. The floor manager is perhaps 
the busiest person. I want to be accommodating to him. Otherwise, I 
will yield 7 minutes to the Senator from Minnesota.
  The PRESIDING OFFICER. The Senator from Minnesota is recognized.
  Mr. WELLSTONE. Thank you, Mr. President. I just want to put this in a 
little bit of context. There was a piece today in the New York Times 
headlined, ``Study Shows Tax Proposal Would Benefit the Wealthy.'' This 
is when we get to the tax part of the reconciliation bill.
  I quote:

       The changes in Federal tax and benefit policies now working 
     their way through Congress would eventually be worth 
     thousands of dollars a year to the 5 million wealthiest 
     families in America, while the 40 million families with the 
     lowest incomes would actually lose money, a new study shows.

  This is the Center on Budget and Policy Priorities. Their work, 
generally respected in academic circles, indicates that after-tax 
incomes of the richest 1 percent of Americans--those with incomes above 
$300,000 a year for a family of three--would ultimately be increased by 
an average of $27,000 a year.
  ``Families of three with incomes below about $17,000 a year would end 
up with about $60 a year less than they have now.''
  Mr. President, let me just say that, in this context, I know 
colleagues worked very hard in the Finance Committee, and I also know 
people were up very late, and we did not have a chance to study every 
particular proposal. The copay for home health services makes no sense 
at all. This proposal is profoundly mistaken.
  I am very proud to support Senator Kennedy's amendment. Sixty-six 
percent of the recipients of home health services are over the age of 
75; 43 percent of them have incomes under $10,000 a year; 66 percent 
are women and 33 percent live alone. As Senator Lautenberg pointed out, 
a $5 copay may not sound like much to people who have pretty high 
incomes, and it may not sound like much to those of us in the Senate, 
because we earn a fair amount of income; but to people living on maybe 
$500 a month, and that's it, this $5 copay for a home health visit is 
really worry about it. I am hoping that we will have very strong 
support here on the floor of the Senate.

  Mr. President, I think that part of the direction of where we are 
heading in health care--and I wish there had been more discussion. Part 
of the problem is that these reconciliation bills that are fast-tracked 
don't give us much of an opportunity to really talk about policy and 
its impact on people's lives. Too much of the discussion is adding and 
subtracting numbers. Too much of the discussion is statistics. I don't 
think we are looking at some of these proposals--I am not saying all of 
them--very carefully. To that extent, some of the things in this bill 
are a rush to recklessness, which I think this is.
  Mr. President, if anything, we want to make sure that as many elderly 
people as possible--or, for that matter, people with disabilities--can 
live at home with dignity. That is what we are trying to do. And what 
we are doing here is, we are saying to senior citizens--especially low-
income, and the income profile of elderly people is not that high--we 
are saying, you know, we are going to start charging a $5 copay. And 
for a lot of these people, this isn't going to work. What is going to 
happen is, they are not going to get the help they need; it is that 
simple.
  I don't think this amendment is about party strategy or taking shots 
at somebody. I don't think it is about any of that. This amendment 
speaks to a policy discussion that I don't think we have had. I 
actually think that is part of the problem. I just think it is hard to 
do that on these bills. But this particular proposal--on this provision 
that was put in by the Finance Committee, I don't think there was an 
up-or-down vote. I think it was part of an overall chairman's mark. I 
think it is profoundly mistaken. I just think it was a mistake. I don't 
think this is the way we need to be generating revenue. This is not the 
place where we want to make the cuts.
  I could carry on, and I will later on by marshaling a lot of evidence 
about the tax part, which I still think is way too tilted to those at 
the top. But for right now, let me simply say, since we are talking 
about Medicare, let me enter into a policy discussion and just say to 
all Senators--Democrats and Republicans alike--I hope there will be 
strong support for this amendment that Senator Kennedy has introduced 
and that I am a cosponsor of. In this particular case, it is not a 
matter of numbers. You are really talking about a provision or proposal 
that could have a very, very negative impact on some of the most 
vulnerable citizens in this country. I don't think there is one Senator 
in here who wants to do that.

[[Page S6082]]

  Now, if there are some alternatives and other proposals, fine. But 
this was a mistake. We ought not to be doing this $5 copay on home 
health visits for very elderly people, most of them very vulnerable, 
most of them very low-income.
  So I rise to speak on behalf of this amendment. I am proud to be an 
original cosponsor, and I hope we will get a tremendous amount of 
support for it tomorrow.
  Mr. President, I yield the floor.
  Mr. DOMENICI. Mr. President, I should note that the members of the 
Finance Committee who support the proposal that is here before us will 
be here tomorrow to debate the issue.
  Senator Roth is here now. I assume he will present his amendment and 
not argue against the Kennedy amendment, but I assume in due course 
there will be adequate opportunity to present the views.
  Mr. ROTH. Mr. President, will the Senator yield?
  Mr. DOMENICI. Of course.
  Mr. ROTH. I would like to make a comment or two on the question----
  Mr. DOMENICI. On the question of the Kennedy amendment?
  Mr. ROTH. Yes.
  Mr. DOMENICI. Of course I will yield whatever time the Senator 
desires.
  Mr. ROTH. The problem that has been faced in Medicare is the 
explosion of costs in home health care. It has been going up something 
like 30 percent a year. Obviously, that kind of increase cannot be 
permitted if we are going to salvage and strengthen the Medicare 
Program.
  Just let me point out that Medicare spending on home health services 
increased most dramatically in the last decade. In 1989-90, it went up 
53 percent; 1990-91, it went up 44 percent; 1991-92, it went up 40 
percent again; 1992-93, 30 percent; 1993-94, 30 percent; 1994-95, 19 
percent. So, basically, it has been going up roughly 30 percent.
  There has been an increase in beneficiaries using home health care. 
There has been an increase in the number of visits per beneficiary. 
There has been an increase in the number of agencies providing care. So 
the payment system has not controlled the utilization of home care. 
There is the reason that we have put this $5 copayment.
  Let me point out that it is particularly important to understand that 
those who are 100 percent of poverty or less will have this $5 fee paid 
by Medicaid. So those who are under poverty are protected.
  And that is the idea of the program. We want those who are over 100 
percent of poverty to be careful in their utilization. The program is 
there. It is a good program. In many cases, it can save money because 
it is better to have home health care than to put a person into a 
hospital.
  But the problem is that the costs have exploded. Somehow we have to 
make sure that the beneficiaries are more careful in their utilization 
of this program. And that is the reason for this change.
  Again, I want to stress the fact that those who are 100 percent of 
poverty or less will have this copayment of $5 paid by Medicaid. And 
they will not be out of pocket. So they are protected.
  Mr. DOMENICI. I thank the Senator.
  Mr. DOMENICI addressed the Chair.
  The PRESIDING OFFICER. The Senator from New Mexico.
  Mr. DOMENICI. I reserve 5 minutes of my time, and then I want to 
yield to Senator Roth if he is ready to offer the amendment.
  Let me just make a couple of points. Obviously, the seniors in the 
country, and even the AARP--not specifically with reference to this $5 
deductible, but with reference to home health care--there was a general 
understanding that when we moved a part of home health care from the 
trust fund to the part B, which is paid for by the general taxpayers, 
working men and women with kids who do not have any insurance and 
nobody gives them any, when we moved it to the general fund and the 
ratio of payment was 25 percent for seniors and 75 percent for the rest 
of the taxpayers, that in exchange for moving the home health care to 
that part B, there would be some additional fee.
  I am not arguing that every fee that was imposed--it seems like there 
were two--that those were agreed upon, nor am I speaking for anyone 
whose name I just used. But, obviously, the agreement contemplated that 
if we moved part of some or all of that home health care that was under 
100 days, it more likely belonged with a doctor instead of with the 
hospital, that there would be some additional premium paid into the 
part B, the 25 to 75 ratio that I have just described.

  Second, the Senator from Massachusetts, Senator Kennedy, raised $1.5 
billion on the agreement, and says that when the new fee is imposed we 
will use $1.5 billion to accommodate the lower income seniors so they 
won't be burdened by the new fee. I understand the distinguished 
chairman of the Finance Committee, when he offers a broad amendment in 
some other areas, is going to take that $1.5 billion into cognizance 
and do something about rectifying what is clearly a misunderstanding 
and a shortcoming in the Finance Committee bill vis-a-vis the 
agreement.
  With reference to the agreement that we worked out, it is clear that 
there is no restriction on the Finance Committee or any other committee 
to do more than contemplated in the agreement. So we cannot look to the 
agreement every time a committee does something. What we do is we look 
at it to make sure they did at least as much as we asked. And, in the 
case of the issue before us, I understand it was almost unanimous in 
the committee.
  You all can argue that as a committee later this evening or tomorrow. 
This was not all Republicans. It was Republicans, and all the Democrats 
supported the fact that something had to be done about these spiraling 
costs of home health care. Am I somewhat correct?
  Mr. ROTH. I would just point out that the Senator is absolutely 
correct. The proposal was adopted unanimously by the committee, both 
Democrat and Republican. As I said, it was done in such a way as to try 
to make the beneficiaries be more careful in its utilization.
  I would point out that the question was raised, why did we use the 
$760 limitation? The reason for that is that under part A, many people, 
after being in a hospital for 3 days, will utilize home health care. 
They do not pay the $5 fee, but instead they pay $760. So that was the 
ceiling that was set under part A, and we carried that over to part B. 
There the beneficiary pays $5 per visit but not in excess of $760.
  Mr. DOMENICI. I wonder if I might inquire for my own management 
reasons. I understand that the Senator is working on two amendments 
from the committee that he would like to get in today before we close. 
Is that correct?
  Mr. ROTH. That is correct. We are waiting for certain figures from 
the Congressional Budget Office. As soon as we have those, we expect to 
be in a position to offer those amendments.
  Mr. DOMENICI. Might that be relatively soon?
  Mr. ROTH. That is my understanding, I say to the distinguished 
chairman.
  Mr. DOMENICI. Senator Kennedy, I see, is still on the floor. I wonder 
if I might ask a question regarding some management aspects.
  What we have been doing is, we haven't been finishing the debates on 
any of these amendments, and we are holding them until tomorrow and 
will be stacking the amendments in managementwise sequence. I myself am 
very desirous of leaving the Senate shortly and leaving it to Senator 
Roth to offer two additional amendments, and perhaps the Senator from 
Minnesota wanted to offer one more. And that would be all we would do 
this evening.
  How much more time would the Senator like to use this evening?
  Mr. KENNEDY. I would just make a brief comment, maybe 5 or 7 minutes, 
perhaps.
  Mr. DOMENICI. I yield the floor.
  Mr. KENNEDY addressed the Chair.
  The PRESIDING OFFICER. The Senator from Massachusetts
  Mr. KENNEDY. Mr. President, the Senators respond that there has been 
an increase in the utilization of home health care. Well, it isn't the 
patient who says, ``Look, I want to go home instead of going to the 
hospital.'' The person that does that is the doctor.
  If you have problems with overutilization, do something about the 
provider but not the patient. The patient follows what the doctor 
recommends. If the provider says either you have to go

[[Page S6083]]

to the hospital or we can take care of this back home, it isn't the 
patient that is overutilizing. They are responding to options 
prescribed by the medical profession. So we shouldn't penalize our 
senior citizens and our frail senior citizens for behavior they can't 
necessarily modify.

  There are those who say, ``Look, Medicaid will take care of the costs 
of the poorest seniors.'' That may be true, first of all, if the 
beneficiaries know about the financial assistance. But we see many 
people fall through the cracks because they are not aware of this 
assistance. Some estimates indicate that only 10 percent of eligible 
senior citizens take advantage of this offer. And, basically, you are 
talking about individuals whose income rests near $7,700. So, even if 
those in poverty may be taken care of by Medicaid, what do we do about 
the near poor?
  What about the senior citizen whose income is $8,000? What about the 
senior citizen whose income is $9,000, $10,000, $11,000, $12,000? We 
are asking them to pay up to $760 more this year, and the cap will rise 
each year according to the rise in the inpatient hospital deductible. 
For what reason? It was never explained to us. It was never voted on.
  With all respect to the deliberations of the Finance Committee, this 
wasn't even debated.
  Here we are on the floor of the U.S. Senate at 5 o'clock, with an 
hour's debate on something that is going to affect millions of elderly, 
frail senior citizens, many of whom are widows between 75 and 80 years 
old. Look at the profile of who is going to be affected by this.
  It wasn't even discussed. We weren't voting and saying, ``Look, vote 
for this because we are going to collect $5 on the frail elderly.'' To 
help pay for what? For a tax break.
  We wouldn't be having this debate if it were not for the tax break 
for wealthy individuals. The reason we are having this is because of 
the next bill that we are going to consider provides tax breaks for 
wealthy individuals. The Finance Committee has said ``We need to 
squeeze the elderly.'' Otherwise, we wouldn't have this debate.
  No one was saying at the beginning of the session, we really have to 
go out and stop our elderly from overutilizing health care services. No 
one said, by God, one of the real problems we are facing in this 
country is to get those frail seniors to pay more so they won't use it. 
No, no, no. That wasn't even talked about by the proponents of the 
balanced budget.
  Who are the people now that use the home health services? Sixty-six 
percent are over 75 years of age. Almost half of them have incomes 
below $10,000. Sixty-six percent are women, and 33 percent live alone.
  So there you have it. You are talking about women 75 to 80 years old. 
You are talking about those with incomes of $7,000, $8,000, $9,000, or 
$10,000, that need these home health services to stay out of the 
hospital. That saves our health care system a great deal.
  This comes at the same time that the Finance Committee ignored 
instructions to honor a clear commitment to provide $1.5 billion in 
premium assistance for low-income elderly.
  Time is not going to erase this injustice. You can say that the clock 
will be tolled at noontime on Wednesday, but it is not going to erase 
the fact that in that bill tonight frail seniors are required to pay $5 
billion more, that the $1.5 billion to defray premiums for low-income 
seniors is nowhere to be found, and that the bill costs Medicare $400 
million in trial MSA's.
  This is where we are. This is where we come in order to have a 
balanced budget? In order to have tax breaks of billions of dollars--
billions of dollars--just 3 days from now.
  That is the dichotomy here. This is the light Republican effort. Last 
year, we had the major Medicare cuts for major tax breaks and now we 
have smaller cuts to see how much they can get away with. You only have 
20 hours on the floor of the Senate for this bill. The majority has 
decided to see what it can get away with in this first bill, and then 
move to provide the goodies later in the week.
  This is a bad deal. This is a bad deal for senior citizens. It is a 
bad deal for parents. It is a bad deal for aunts and uncles. It is a 
bad deal for children. And at the end of the week, we are going to see 
the distribution of these tax breaks going, again, to the upper 
incomes.
  It is absolutely, fundamentally wrong, and we are not going to let 
this go along without getting rollcall votes and having Members make a 
judgment and decision on those items so that they will hear it when 
they go back to their constituents and the elderly people and answer to 
them why they wanted to move ahead in that direction. It is wrong.
  We will continue this debate tomorrow. Mr. President, I withhold the 
remainder of my time.
  The PRESIDING OFFICER. Who yields time?
  Mr. ROTH addressed the Chair.
  The PRESIDING OFFICER. The Senator from Delaware.
  Mr. ROTH. I yield myself such time as I may take. I say to the 
distinguished Senator from West Virginia I will be brief so that he can 
be recognized.
  Again, I want to emphasize what the factual situation is. The fact is 
that home health care has been exploding at roughly 30 percent a year 
or more, and this kind of increase in cost cannot be permitted if we 
are going to strengthen and preserve Medicare for the long term. So the 
proposal has been made to put a $5 copayment fee on each health care up 
to a limitation of $760, which is what is paid as a deductible under 
part A.
  This matter was discussed and unanimously agreed to in the Finance 
Committee by Republicans and Democrats alike. The reason it was agreed 
to is because it is important that these visits be available but they 
be used prudently and not without consideration to the cost. That is 
the reason we added it.
  Again, I want to emphasize that those 100 percent under poverty will 
not pay this $5 fee. It will be paid by Medicaid for them, so they are 
protected. But again, in reforming and restructuring Medicare, we are 
trying to do it in such a way that it strengthens and preserves the 
program for the long term. That in turn means it is essential that the 
utilization be done carefully, and that is what we seek to do and that 
is what the Finance Committee unanimously adopted.
  Mr. KENNEDY. Will the Senator yield for a question?
  Mr. ROTH. Yes.
  Mr. KENNEDY. Will the Senator yield? Are you using the $5 billion for 
other Medicare benefits for our elderly? Are you saying we will use the 
$5 billion raised through the new copayment to try to help the elderly, 
for example, on prescription drugs, foot care, dental care, or eye 
care? Are we taking the $5 billion, which you say is a result of 
overutilization, and investing it in the elderly for their health care 
needs, or are we taking the $5 billion and putting it aside to be used 
for tax breaks?
  Mr. ROTH. I point out to the distinguished Senator from Massachusetts 
we have added a number of preventive services for the sick. For 
example, we now permit mammography testing to be made, colorectal 
testing or screening; we also permit diabetes home care matching. So we 
have added a number of things. But again, overall, we are trying to put 
this program in such shape that it will survive in the long term. 
Unfortunately, in the area of home health care, the costs have 
exploded. Let me mention again that home health care in 1989-90 went up 
53 percent; 1990-91, it went up 44 percent; 1991-92, 40 percent; 1992-
93, 30 percent; 30 percent again in 1993 and 1994; 19 percent in 1994 
and 1995.

  Let me point out further that other groups, such as the Commonwealth 
Fund, support the idea of a $5 copay. In a report issued by the 
Commonwealth it says that ``this is a sensible approach which would 
make beneficiaries sensitive to use but not form a barrier to care.''
  I yield back the floor.
  Mr. KENNEDY. Mr. President, I know we are going to have a statement 
by the Senator from West Virginia, but the point is that the preventive 
services, which I commend, were included in the President's proposal 
and are paid for under the budget that had been submitted by the 
President.
  So this investment, while I support it, does not quite jell, because 
the preventive programs that have been mentioned now were already 
included prior to the creation of this new copayment.
  Second, I did not think we were looking at the overall long-term 
changes in

[[Page S6084]]

Medicare. We wanted to get the 10 years of solvency that had been 
supported by the President and other Members of the Congress and then 
deal with the long-term issues. I think if the Senator wanted to, we 
could spend some time looking at the increase of home health care and 
the decrease in hospitalization.
  But the bottom line is patients go, by and large, in the health care 
system where the doctor tells them. If the doctor tells them, you need 
to get to that hospital tonight, by and large, patients go there. If 
the doctor says, you need to have those services, by and large, the 
patients get them. When we are talking about individuals who have 
incomes of roughly $7,700 being told they can get an offset in the 
State. We know the number of children, for example, that fall under the 
Medicaid proposals that are not covered by Medicaid. And the seniors 
are facing the same thing.
  So I just think that, let alone, as the chairman has pointed out, the 
very poor can get some of this offset or will get it offset in terms of 
the Medicaid that is requiring the States to collect it. We have heard 
a great deal about putting additional burdens on the States, but it 
seems we are willing to do so as long as we get the additional funds 
for the tax cuts.
  I thank the chairman of the Finance Committee for his response, and I 
appreciate his courtesy in responding to these questions. I will be 
glad to yield the floor.
  The PRESIDING OFFICER. Who yields time?
  Mr. BYRD. Mr. President, I ask unanimous consent that I may speak out 
of order for not to exceed 10 minutes without the time being charged to 
either side.
  The PRESIDING OFFICER. Without objection, it is so ordered. The 
Senator from West Virginia is recognized.
  Mr. BYRD. Mr. President, I thank the Chair.

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