[Congressional Record Volume 144, Number 49 (Tuesday, April 28, 1998)]
[Senate]
[Pages S3709-S3723]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
By Ms. COLLINS (for herself, Mr. Chafee, Mr. Leahy, Mr. Jeffords,
Mr. Feingold, Mr. Durbin, Mr. Harkin, Ms. Snowe, Mr. Reed, Mr.
Santorum, Mr. Torricelli, Mr. Levin, Mr, Daschle, and Mr.
Specter):
S. 1993. A bill to amend title XVIII of the Social Security Act to
adjust the formula used to determine costs limits for home health
agencies under medicare program, and for other purposes; to the
Committee on Finance.
THE MEDICARE HOME HEALTH EQUITY ACT OF 1998
Ms. COLLINS. Mr. President, America's home health agencies provide
invaluable services that have enabled a growing number of our most
frail and vulnerable senior citizens to avoid hospitals and nursing
homes and stay just where they want to be--in their own homes. Today,
home health is the fastest growing component of Medicare spending, and
the program grew at an astounding average annual rate of more than 25
percent from 1990 to 1997. As a consequence, the number of Medicare
home health beneficiaries has more than doubled, and Medicare home
health spending has soared from $2.7 billion in 1989 to $17.1 billion
in 1996.
This rapid growth in home health spending understandably prompted
Congress and the Health Care Financing Administration, as part of the
Balanced Budget Act of 1997, to initiate changes that were intended to
make the program more cost-effective and efficient and protect it from
fraud and abuse. However, in trying to get a handle on costs, we in
Congress and the administration have unintentionally created problems
that may restrict some elderly citizens' access to vitally needed home
health care.
Critics have long pointed out that Medicare's cost-based payment
method for home health care has inherent incentives for home care
agencies to provide more services, which has driven up costs.
Therefore, the Balanced Budget Act called for the implementation of a
prospective payment system for home care by October 1, 1999. Until
then, home health agencies will be paid according to what is known as
an Interim Payment System.
Under the new IPS, home health agencies will be paid the lesser of:
their actual costs; a per-visit cost limit; or a new blended agency-
specific per beneficiary annual limit based 75 percent on an agency's
own costs per beneficiary and 25 percent on the average cost per
beneficiary for agencies in the same region. These costs are to be
calculated from cost reports for reporting periods ending in 1994.
I spent some time going over the formula because it is important to
understand what the importance of that very
[[Page S3710]]
complicated formula is for many of our home health agencies.
At a recent hearing of the Senate Special Committee on Aging, on
which I serve, we heard testimony from a number of witnesses who
expressed concern that the new Interim Payment System inadvertently
penalizes cost-efficient home health agencies by basing 75 percent of
the agencies' per patient payment limits on their FY 1994 average cost
per patient. This system effectively rewards agencies that provided the
most visits and spent the most Medicare dollars in 1994, while it
penalizes low-cost, more efficient providers. Let me repeat that point,
Mr. President. The agencies, usually the non-profits, that have
provided services at the lowest cost, are penalized by the new payment
system.
Home health agencies in the Northeast are among those that have been
particularly hard-hit by the formula change. As the Wall Street Journal
recently observed,
If New England had been just a little greedier, its home-
health industry would be a lot better off now . . .
Ironically, . . . [the region] is getting clobbered by the
system because of its tradition of non-profit community
service and efficiency.
Moreover, there is no logic to the variance in payment levels. As the
same article goes on to point out, the average patient cap in Tennessee
is expected to be $2,200 higher than Connecticut's, and the cap for
Mississippi is expected to be $2,000 more than Maine's, without any
evidence that patients in the Southern states are sicker or that nurses
and other home health personnel in this region cost more. Mr.
President, I ask unanimous consent that the entire text of this article
be printed in the Record.
The ACTING PRESIDENT pro tempore. Without objection, it is so
ordered.
Ms. COLLINS. Mr. President, this system also gives a competitive
advantage to high-cost agencies over their lower cost neighbors, since
agencies in a particular region may have dramatically different
reimbursement levels regardless of any differences among their patient
populations. And finally, this system may force low-cost agencies to
stop accepting patients with more serious health care needs.
That is exactly the opposite of what we should want. I simply do not
think that this is what Congress intended. To rectify this problem,
today I am pleased to introduce legislation along with Senators Chafee,
Jeffords, Leahy, Feingold, Snowe, Durbin, Harkin, Reed and Santorum.
The Medicare Home Health Equity Act will level the playing field and
make certain that home health agencies that have been prudent in their
use of Medicare resources are not unfairly penalized. The legislation
will also ensure that home health agencies in the same region are
reimbursed similarly for treating similar patients.
Instead of allowing the experience of high-cost agencies to serve as
the basis for the new cost limits, the bill we are introducing today
sets a new per beneficiary cost limit based on a blend of national and
regional average costs per patient. This new formula will be based 75
percent on the national average cost per patient and 25 percent on the
regional average cost per patient. Moreover, by eliminating the agency-
specific data from the formula, the Medicare Home Health Equity Act
will move us more quickly to the national and regional rates which will
be the cornerstones of the future prospective payment system, and it
will do so in a way that is budget neutral. This is a matter of common
sense and fairness. It is also a matter of ensuring that there is a
fair system for reimbursing these vitally needed home health agencies
that are providing services that are so important to so many of our
senior citizens. I urge all of my colleagues to join as cosponsors of
the Medicare Home Health Equity Act, and I ask unanimous consent that
the text of the bill as well as a section by section summary be printed
in the Record.
The ACTING PRESIDENT pro tempore. Without objection, the items were
ordered printed in the Record, as follows:
S. 1993
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Medicare Home Health Equity
Act of 1998''.
SEC. 2. REVISION OF HOME HEALTH INTERIM PAYMENT FORMULA.
(a) Restoration of Cost Limits.--Section
1861(v)(1)(L)(i)(IV) of the Social Security Act (42 U.S.C.
1395x(v)(1)(L)(i)(IV)) (as added by section 4602 of the
Balanced Budget Act of 1997) is amended--
(1) by striking ``105 percent'' and inserting ``112
percent''; and
(2) by striking ``median'' and inserting ``mean''.
(b) Change in Additions to Cost Limits.--Section
1861(v)(1)(L)(v) of the Social Security Act (42 U.S.C.
1395x(v)(1)(L)(v)) (as added by section 4602 of the Balanced
Budget Act of 1997) is amended to read as follows:
``(v)(I) For services furnished by home health agencies for
cost reporting periods beginning on or after October 1, 1997,
the Secretary shall provide for an interim system of limits.
Payment shall not exceed the costs determined under the
preceding provisions of this subparagraph or, if lower, the
product of--
``(aa) an agency-specific per beneficiary annual limitation
calculated based 75 percent on the reasonable costs
(including nonroutine medical supplies) of the standardized
national average cost per patient in calendar year 1994, or
best estimate thereof, (as published in the Health Care
Financing Review Medicare and Medicaid 1997 Statistical
Supplement) and based 25 percent on the reasonable costs
(including nonroutine medical supplies) of the standardized
regional average cost per patient for the agency's census
division in calendar year 1995 (as so published), such
national and regional costs updated by the home health market
basket index and adjusted pursuant to clause (II); and
``(bb) the agency's unduplicated census count of patients
(entitled to benefits under this title) for the cost
reporting period subject to the limitation.
``(II) The labor-related portion of the updated national
and regional costs described in subclause (I)(aa) shall be
adjusted by the area wage index applicable under section
1886(d)(3)(E) for the area in which the agency is located (as
determined without regard to any reclassification of the area
under section 1886(d)(8)(B) or a decision of the Medicare
Geographic Classification Review Board or the Secretary under
section 1886(d)(10) for cost reporting periods beginning
after October 1, 1995).''.
(c) Conforming Amendments.--
(1) Section 1861(v)(1)(L)(vi) of the Social Security Act
(42 U.S.C. 1395x(v)(1)(L)(vi)) (as added by section 4602 of
the Balanced Budget Act of 1997) is amended to read as
follows:
``(vi) In any case in which the Secretary determines that
beneficiaries use services furnished by more than 1 home
health agency for purposes of circumventing the per
beneficiary annual limitation in clause (v), the per
beneficiary limitations shall be prorated among the
agencies.''.
(2) Section 1861(v)(1)(L)(vii)(I) of the Social Security
Act (42 U.S.C. 1395x(v)(1)(L)(vii)(I)) (as added by section
4602 of the Balanced Budget Act of 1997) is amended by
striking ``clause (v)(I)'' and inserting ``clause
(v)(I)(aa)''.
(d) Effective Date.--The amendments made by this section
shall apply as if included in the enactment of the Balanced
Budget Act of 1997.
SEC. 3. CBO ESTIMATE OF HOME HEALTH PAYMENT SAVINGS.
(a) Estimate.--Not later than 60 days after the date of
enactment of this Act, and annually thereafter until the
prospective payment system for home health agencies
established by section 1895 of the Social Security Act (42
U.S.C. 1395fff) is in effect, the Director of the
Congressional Budget Office (referred to in this section as
the ``Director'') shall estimate the amount of savings to the
medicare program under title XVIII of such Act (42 U.S.C.
1395 et seq.) resulting from the interim payment system for
home health services established by the amendments to section
1861 of such Act (42 U.S.C. 1395x) made by section 4602 of
the Balanced Budget Act of 1997.
(b) Certification.--If the Director determines that the
amount estimated under subsection (a) exceeds the amount of
savings to the medicare program that the Director estimated
immediately prior to the enactment of the Balanced Budget Act
of 1997 by reason of such interim payment system, then the
Director shall certify such excess to the Secretary of Health
and Human Services (referred to in this subsection as the
``Secretary'').
(c) Adjustment.--
(1) In general.--If the Director certifies an amount to the
Secretary pursuant to subsection (b), the Secretary shall
prescribe rules under which appropriate adjustments are made
to the amount of payments to home health agencies otherwise
made under subparagraph (L) of section 1861(v)(1) of the
Social Security Act (42 U.S.C. 1395x(v)(1)(L)) (as amended by
section 4602 of the Balanced Budget Act of 1997) in the case
of outliers--
(A) where events beyond the home health agency's control or
extraordinary circumstances, including the case mix of such
agency, create reasonable costs for a payment year which
exceed the applicable payment limits; or
(B) in any case not described in subparagraph (A) where the
Secretary deems such an adjustment appropriate.
(2) Amount.--The total amount of adjustments made under
paragraph (2) for a year may not exceed the amount certified
to the Secretary pursuant to subsection (b) for such year. To
the extent that such adjustments in
[[Page S3711]]
a year would otherwise exceed the amount certified to the
Secretary pursuant to subsection (b) for such year, the
Secretary shall reduce the payments to home health agencies
in a pro rata manner so that the adjustments do not exceed
such amount.
____
Medicare Home Health Equity Act--Section-by-Section Summary
CURRENT LAW
The cost-based payment method that has historically been
used for Medicare home health services has inherent
incentives for home care agencies to provide a higher volume
of services. Therefore, the Balanced Budget Act of 1997 (BBA)
called for the implementation of a prospective payment system
(PPS) for home care by October 1, 1999. In the interim (FYs
1998 and 1999), home health agencies will be paid according
to an Interim Payment System (IPS) established by the BBA.
The IPS reimburses home health agencies using the lowest of
three cost limits: 1) an agency's actual costs; 2) a per
visit cost limit applied to each skilled nursing, physical
therapy, or other type of home health visit provided; or 3)
an agency-specific aggregate per patient cost limit that is
based 75 percent on an agency's average cost per patient in
1994 and 25 percent on a regional average cost per patient in
1994.
The Interim Payment System penalizes cost-efficient home
health agencies by basing 75 percent of the agencies' per
patient payment limits on their FY 1994 average cost per
patient. Giving such a heavy weight to the agency-specific
costs per beneficiary effectively rewards agencies that
provided the most visits and spent the most Medicare dollars
in 1994, while it penalizes low-cost, more efficient
providers. As a result, high-cost and inefficient agencies
will continue to receive a disproportionate share of Medicare
home health dollars.
The Medicare Home Health Equity Act
Formula change for setting per beneficiary cost limits
The Medicare Home Health Equity Act will level the playing
field and make certain that those home health agencies that
have been prudent in their use of Medicare resources are not
unfairly penalized. Moreover, it will ensure that home health
agencies in the same region are reimbursed similarly for
treating similar patients. Instead of allowing the experience
of high cost agencies to serve as the basis for the cost
limits, the bill sets a new per beneficiary cost limit based
on a blend of national and regional average costs per
patient. This new formula would be based 75 percent on the
national average cost per patient in calendar year 1994
($3,987) and 25 percent on the regional average cost per
patient in calendar year 1995.
Restoration of the per-visit cost limit to 112 percent of the national
mean
The per visit cost limits essentially place a cap on the
amount of costs that can be reimbursed by Medicare for each
home health care visit provided. The BBA reduced these cost
limits from 112 percent of the mean to 105 percent of the
median. This was done to provide additional savings. However,
most of the BBA savings (at least 80 percent) came from the
per-beneficiary cost limits. According to Price-Waterhouse,
changing the formula from an agency-specific to a national/
regional average cost per patient blend achieves an
additional $5.5 billion in savings. The Medicare Home Health
Equity Act of 1998 uses these savings to restore the per-
visit cost limit to 112 percent of the national mean.
Most analysts agree that the growth in Medicare home health
expenditures is due to the high number of visits provided to
patients, not by the cost per visit. In fact, the cost per
visit has remained relatively stable in recent years, and CBO
confirms that controlling use, not price, is the key to
Medicare home health cost containment. It is appropriate to
use the savings achieved by rewarding rather than penalizing
cost-efficient agencies to re-establish the cost limits that
enabled many of those agencies to provide more efficient care
over the entire episode of care. The average cost per visit
tends to be higher for lower-overall cost, non-profit HHAs
which tend to provide care in fewer visits. By keeping visits
to the number that are medically necessary, costs per visit
may increase slightly, but overall costs per patient
decrease.
Modifies Application of Proration of Per Beneficiary Limits Provision
The BBA contained a provision which requires proration of
the per beneficiary annual limit where the patient is served
by more than one home health agency. The Medicare Home Health
Equity Act modifies this provision to clarify that proration
only applies where it can be demonstrated that a home health
agency is attempting to circumvent the limits by shifting
care between agencies.
Establishes an Outlier Provision
The bill instructs the Secretary of HHS to prescribe rules
under which adjustments can be made in payments to home
health agencies that are ``outliers'' where events beyond
their control or extraordinary circumstances, including their
case mix, create ``reasonable costs'' that exceed what
otherwise would be their payment limits. This is included so
that there is some provision for higher payments for home
health agencies that treat the sickest Medicare home care
patients and does so in a way that is budget neutral.
____
[From the Wall Street Journal]
Region's Home-Care Firms Face Being Punished for Their Efficiency
(By Carol Gentry)
If New England had been just a little greedier, its home-
health industry would be a lot better off now.
In a rush to cut Medicare spending, Congress has set up a
home-health payment system that punishes low-cost agencies
and states, while it rewards big spenders and regions where
audits have found widespread fraud and abuse. Ironically, New
England is getting clobbered by the system because of its
tradition of non-profit community service and efficiency.
And patients are feeling the effects. In the past two
weeks, about 30 complaints have come into the Boston office
of the federal agency that must implement the change, the
Health Care Financing Administration. The agency says the
complaints are coming from patients who need frequent, long-
term nursing visits, but say they are being turned away or
cut off.
``I fear we're now looking at home health agencies dumping
(expensive) patients,'' says Margaret Leoni-Lugo, chief of
the HCFA quality-improvement branch for New England. Such
discrimination violates state and federal regulations.
Ms. Leoni-Lugo says she sympathizes with the difficult
situation confronting New England agencies, but cannot
condone patient dumping. Today she is expected to hold a
telephone conference with health-department officials in the
six New England states, warning them to watch for evidence
that agencies are cutting care too much.
``We want to keep the beneficiaries safe,'' says Ms. Leoni-
Lugo.
the new formula
The new system rolls back payments to 1993-94 levels minus
2%, regardless of whether an agency's budget was low or
grossly inflated during those years. Under the system, home-
health agencies' Medicare payments will be affected not only
by their own budget history, but also by their location. If a
company is in a penny-pinching region, its payments will be
lower than if it comes from an area of big spenders. The
agencies that come out best under this formula are those that
spent money willy-nilly five years ago and were surrounded by
companies that did the same thing. The biggest winners will
be states in the South.
Meanwhile, frugal agencies in regions with moderate costs--
especially New England, the Midwest and the Mountain states--
are reeling. Vermont, New Hampshire and Maine will be among
the hardest-hit states in the nation. Massachusetts,
Connecticut and Rhode Island fare only marginally better.
Advocates for the elderly and the region's home-health
agencies say such a system gives a competitive advantage to
the worst players in the industry. ``This is not in the best
interest of taxpayers,'' says Susan Young, executive director
of the Home Care Association of New Hampshire.
Adds Margaret Gilmour, president and chief executive
officer of Home Health & Hospice Care, a home-care agency in
Nashua, N.H.: ``This is going to be a tidal wave of disaster
for elder care.''
Layoffs are already under way in New Hampshire, Ms. Young
says, where the industry is among the leanest in the nation.
The congressional delegation from Massachusetts hopes to
derail the new system before it can do massive damage. ``This
defies common sense.'' says Rep. James P. McGovern, a
Democrat from Worcester. ``This is a big, fat mistake.''
Taking Care of the Homebound
In late November, Rep. McGovern and 11 other members of the
state's congressional delegation sent a letter of concern to
HCFA. The group hopes to meet with top agency officials in
Washington soon.
Home-health agencies send nurses, aides, and physical and
speech therapists to the homes of patients who are so
physically or mentally disabled that they cannot easily go or
be taken to a medical clinic.
While most private insurers and health-maintenance
organizations cover home health care, the main money pipeline
is Medicare. All homebound elderly and disabled beneficiaries
of the program are eligible for free unlimited visits, as
long as the visits are part of a treatment plan that is
authorized by a physician and is updated every two months.
There are several types of home-health agencies, including
the community-based nonprofits, such as the Visiting Nurses
Associations of America; the newer for-profit companies; and
hospital-affiliated agencies. Medicare's costs have been
higher for patients who go through one of the hospital or
for-profit companies.
Hospital-affiliated agencies tend to have higher per-visit
costs than independent ones because they can legally transfer
some of the hospital's overhead to the home-health books and
have Medicare pay for it. For-profit agencies tend to
generate higher Medicare payments by billing for a greater
number of visits per patient.
Patients recuperating from surgery or a short-term illness
may need only a few visits, but home-health agencies are a
lifeline for patients with long-term conditions--multiple
sclerosis. Alzheimer's disease, heart failure, severe
diabetes--who are trying to stay out of nursing homes.
[[Page S3712]]
The new system sets an annual limit on the amount that
Medicare will spend on any given patient. While that cap is
different for every agency, it averages out to 75 visits a
year in Massachusetts. Patient advocates say this gives
agencies an incentive to take only those clients who are
going to get better or die in a short time.
To make matters worse, agencies must reduce expenses
without knowing just how deep the cuts will be. The details
of the payments formula won't be determined until April 1,
but will be retroactive to Oct. 1.
seeking formula change
In the letter to HCFA, the Massachusetts delegation asked
administrators to alter the new formula to ``lessen the
blow'' to low-cost, efficient home-health agencies. The
letter says it is unfair to tag payments to a 1994 average
per-patient cost of $4,328 in Massachusetts, when Tennessee
was getting $6,508 and Louisiana $6,700.
Rep. McGovern says he hopes to repeal the payment-system
provision when Congress convenes later this month, but he
knows that may not be easy. Many of the leaders of Congress
are from the South, where payment rates are projected to be
double those in much of New England.
Massachusetts has a lot at stake. In 1995, the last year
for which Medicare has complete data, the program spent more
than $1 billion in New England to provide home health to
246,000 beneficiaries. Of that money, Massachusetts absorbed
more than half for 119,000 homebound patients. More than 14%
of the state's Medicare beneficiaries were served by home
care, while the rate was about 10% nationwide.
Under the new payment system, members of the Massachusetts
delegation say, their state stands to lose $95 million and at
least 1.5 million patient visits in the first year.
Why will the system affect Massachusetts so much? The
state's home-health agencies deliver care at a more moderate
cost per visit than most other states, federal data show, but
also perform more visits per patient, on average. Pat
Kelleher. executive director of the Home Health Care
Association of Massachusetts, says one reason is that the
state has deliberately pushed home care to save state tax
money. Federally paid Medicare home-health visits keep
patients out of nursing homes, which draw most of their
revenue from the state Medicaid program.
Rough Time Ahead for Vermont
If the other New England states affected, Vermont, the only
state that legally requires home-health companies to be non-
profit, especially faces troubled times. After consistently
providing home care at the lowest cost per patient in the
nation. Vermont's 13 agencies stand to lose more than $2
million this year and estimate they will have to reduce
service by 10%.
The Vermont Assembly of Home Health Agencies estimates the
average per person payments in the state this year will be
$2,600 a year, less than half what they payout is expected to
be in, say, Alabama.
``The system was supposed to limit the high rollers'' says
the association's director, Peter Cobb but instead ``Congress
rewarded excess.''
The rule changes stem from the passage last August of the
Balanced Budget Act, which cuts $115 billion from Medicare by
2002. The home-care portion of the act slices $16.2 billion
from the budget.
Home care seemed a logical place to look for cuts, since
it's the fastest-growing segment of the health industry.
Between 1990 and 1995, while the number of Medicare
beneficiaries rose 10%, the number of home-health visits grew
255% and spending went up 316%.
Some of that increase accompanied the rise of managed-care
companies that try to keep patients out of the hospital to
save money and, if they must go, keep the visits as brief as
possible. However, much of the inflation in home care was a
predictable response to a payment system that offered no
incentive to be frugal.
probe finds waste, fraud
Massive fraud, waste and ineptitude in Medicare billings
were reported last summer by the Office of the Inspector
General of the U.S. Department of Health and Human Services
following a two-year investigation called Operation Restore
Trust. The study covered five states that account for 40% of
Medicare payments: California, New York, Florida, Texas and
Illinois.
The report said one-fourth of home-health agencies in those
states received nearly half the Medicare dollars spent on
home-health care. According to the report, the ``problem''
agencies tended to be for-profit, closely held corporations
with owners that were involved in a tangle of interlocking,
self-referring businesses. Texas was cited as the biggest
home-health spender of the states studied. (An HCFA audit
conducted in Massachusetts and Connecticut last year found a
few overpayments, but no cases of fraud.)
It just so happened that the revelations of Operation
Restore Trust occurred at the same time that Congress was
looking for ways to cut Medicare spending.
Congress wanted to change the home-health payment system so
that it would reward efficiency, by switching to a flat rate
by diagnosis. This ``prospective payment system'' would be
similar to the one that Medicare uses to pay hospitals.
But HCFA said it needed more time to develop the complex
formula to set prospective payment in motion. So Congress
created an interim system that will run until Oct. 1, 1999.
It freezes spending at the rates there were in place in 1993-
94--before Operation Restore Trust began.
varying payments
Now payments vary illogically. The average patient cap in
Tennessee is expected to be $2,200 higher than that in
Connecticut, and the cap for Mississippi $2,000 more than
Maine, without any evidence that patients in the Southern
states are sicker or that nurses cost more there.
But those who think the Southern states are pleased at
getting a patient cap double that of New England are
mistaken. Officials at the Texas Association for Home Care
say they need bigger payment rates because they have a high
rate of poor elderly who have never had proper health care,
and the state Medicaid program hasn't taken care of them
because it's stingy.
``Congress has cut into the bone,'' says Sara Speights,
director of government and public relations for the Texas
group.
Inequities exist even within the same region. Ms. Gilmour
of the Nashua, N.H., home-care agency says a competitor in
northern Massachusetts could end up with a payment cap twice
as high as her own as a result of her staff's efforts to keep
costs down. Because patients are free to choose either
agency, she worries they will gravitate to the one that has a
bigger budget.
Joan Hull, chief executive of the nearby competitor, the
Home Health Visiting Nurses Association of Haverhill, Mass.,
says her agency is a product of a merger between agencies
that had different payment rates, so she doesn't know whether
the Medicare cap will be $3,400 or $4,600 per patient.
Unfortunately for her agency, services it has delivered since
the beginning of its fiscal year in October will be on the
new payment rate, but the agency won't know what the rate is
until April.
``It's crazy, isn't it?'' Ms. Hull says with a laugh.
yankee thrift
Home health agencies in the New England states have
delivered care for less money than the national average, both
in Medicare payments per visit and per patient. (Data shown
here are from 1995.)
----------------------------------------------------------------------------------------------------------------
Pct. Pct.
No. of Avg. above or Avg. above or
patients payment below payment below
(in per national per national
thousands) visit avg. patient avg.
----------------------------------------------------------------------------------------------------------------
Connecticut................................................... 57 $60 -30 $4,770 6.6
Massachusetts................................................. 119 50 -19.0 4,730 -5.7
Rhode Island.................................................. 19 64 3.0 4,037 -9.7
Maine......................................................... 22 53 -15.0 3,717 -16.9
New Hampshire................................................. 17 50 -19.0 3.057 -31.7
Vermont....................................................... 12 45 -28.0 3,030 -32.3
New England................................................... 246 53 -15.0 4,400 -1.6
U.S........................................................... 3,430 62 ........ 4,473 ........
----------------------------------------------------------------------------------------------------------------
Sources: Health Care Financing Administration and The Wall Street Journal
big spenders
While Medicare costs for home health services have gone up
nationwide, Sunbelt states led the spending spree. The new
payment system rewards states where payments were far above
average, as shown below (Data are for 1995.)
------------------------------------------------------------------------
No. of Avg. Pct.
visits payment above
per per national
patient patient avg.
------------------------------------------------------------------------
Louisiana.............................. 144 $7,867 75.9
Oklahoma............................... 127 7,358 64.5
Texas.................................. 117 7,217 61.3
Tennessee.............................. 121 6,886 53.9
Utah................................... 106 6,283 40.5
Mississippi............................ 128 6,205 38.7
THE SOUTH.............................. 95 5,488 22.7
U.S.................................... 72 4,473 .........
------------------------------------------------------------------------
Sources: Health Care Financing Administration and The Wall Street
Journal
Mr. FEINGOLD. Mr. President, I rise today to join my colleagues,
Senators Collins, Chafee, Jeffords, Leahy, Reid and others in
introducing the Home Health Medical Equity Act of 1998. I especially
want to compliment the Senator from Maine, who has taken the lead on
this issue. It is a matter of enormous concern in her State and also in
mine. I think it is worth taking a moment just to acknowledge how
useful the Senate Aging Committee is, to be able to highlight an issue
like this. I wonder whether this issue would have gotten the attention
it deserves had it not been for that forum, where we were able to have
an excellent hearing and hear from Senators all over the country whose
States are very negatively affected by the rules that were put into
place. I congratulate the Senator from Maine for taking the initiative
out of that hearing to introduce legislation.
This legislation is a crucial step in ensuring that the Medicare Home
Health Care program's Interim Payment System does not penalize regions
of the country that have been providing home health services
efficiently.
Mr. President, I have been working to promote the availability of
home care and other long-term care options for my entire public life
because I believe strongly in the importance of enabling people to stay
in their own homes. For seniors who are homebound and have skilled
nursing needs, having access to home health services through
[[Page S3713]]
the Medicare program is the difference between staying in their own
home and being moved into a nursing facility. Home care offers feelings
of security, dignity and hope. Where there is a choice, we should do
our best to allow patients to choose home health care.
Mr. President, I recognize that there are situations when one's
ability to conduct the activities of daily living are so limited, and
the medical needs are so great, that the patient would be better
served, in some cases, in a skilled nursing facility. I also want to
recognize that my State of Wisconsin has a very, very good network of
caring and high-quality nursing homes. Without a doubt, there is a need
for these services. But, Mr. President, as I travel throughout
Wisconsin's 72 counties every year, what seniors tell me again and
again is that, to the extent possible, and as long as it is medically
appropriate for them to do so, they would like to remain in their own
homes. I think seniors need and deserve that choice.
Mr. President, seniors clearly prefer to remain in their own homes
rather than be moved to a nursing home. Their medical needs can often
be met through home health services. Despite these facts, the
implementation of the Medicare Home Health Interim Payment System as
passed in last year's budget could create serious access problems for
seniors in States like Wisconsin and Maine when they seek the home
health benefit. The cuts to the Medicare Home Health program imposed by
the Interim Payment System are so severe that home health agencies will
have no choice but to reduce dramatically the amount of services
provided. Some home care agencies may get out of the home care business
altogether. But, Mr. President, the real impact of the Interim Payment
System will not be simply to reduce payments to home care providers and
force some out of business, what it will really do and what really
concerns me is it will drastically reduce the options that homebound
seniors now have today with respect to whether they will remain in
their home in the community or whether they will be forced into a
nursing home situation that is not necessarily the best place for them.
As of right now, Mr. President, the Interim Payment System for
Medicare home health care is a system that pays agencies the lowest of
the following three measures: (1) actual costs; (2) a per visit limit
of 105% of the national median; or (3) a per beneficiary annual limit,
derived from a blend of 75% an agency's costs and 25% regional costs.
Now, these measures are pretty technical and I will not go into any
more of the specifics about them. But suffice it to say that the net
effect of the Interim Payment System will be to penalize severely
agencies who have been operating efficiently all these years. Since the
Interim Payment System will pay the agency the lowest of the
three measures that I mentioned, agencies in areas where costs have
been kept lower will be disproportionately and unfairly affected.
Mr. President, according to the Health Care Financing Administration,
just in Wisconsin alone, there are currently 181 home health care
agencies that participate in Medicare. Of these, two-thirds of them are
operated as nonprofit entities. These nonprofit home health care
providers are often county health departments and visiting nurse
organizations; these are not entities out to make a fast buck on the
backs of homebound seniors. According to administrators of Valley
Visiting Nurse Association in Neenah, WI, the average, per patient
Medicare home care cost in Wisconsin is $2,586, compared to $5,000 in
other parts of the country. Let me repeat that, the statistics, because
it is really quite striking. The average, per patient Medicare home
care cost in Wisconsin is only $2,586, compared to often over $5,000 or
more in other places in the country. These nonprofit providers in
Wisconsin are already as lean as they can be. I am fairly convinced
they don't have any ``fat'' to cut from their programs. The Visiting
Nurse Association Home Health of Wausau showed me some figures
demonstrating that, over the past 5 years, their services have averaged
30 percent below limits imposed by the Health Care Financing
Administration, with 36 percent fewer visits per beneficiary than the
national average.
Mr. President, the effect of the deep reductions imposed by the
Interim Payment System will be, quite simply, a devastating blow to
these types of agencies, and, in turn, will seriously impact the
availability of home health care services to many people in Wisconsin.
This devastating blow is dealt not because Wisconsin has been providing
too many services too expensively. It is just to the contrary. States
like Wisconsin and others are being penalized more precisely because
they have always operated efficiently. Moreover, on a national level,
with a reduced per-patient limit, home health agencies have a
disincentive to take more seriously ill patients onto their rolls.
Mr. President, the legislation my colleagues and I introduce today
will change the Interim Payment System to bring about greater payment
equity for Medicare home health providers in different parts of the
country. The bill, as the Senator from Maine outlined, would create a
new formula for the per-patient limit that reflects a higher percentage
of national data rather than relying solely on regional and local data.
The change in payment calculation would enable high-efficiency, low-
cost home health agencies to continue providing services efficiently
and cost-effectively. But, Mr. President, the most important impact of
the Medicare Home Health Equity Act will be to make sure that seniors
who are homebound and have skilled nursing needs will retain for as
long as possible the right to decide to stay in their own homes.
Mr. President, I thank the Chair and yield the floor.
Ms. COLLINS. Mr. President, I thank the Senator from Wisconsin for
his cosponsorship of this important legislation and for his leadership
in this issue.
Mr. CHAFEE. Mr. President, I am pleased to sponsor the Medicare Home
Health Equity Act of 1998 with my distinguished colleague from Maine. I
want to applaud Senator Collins' efforts to correct a provision in the
Balanced Budget Act (BBA) of 1997 which has had the effect of
penalizing those home health agencies that have taken the lead in
becoming more cost-efficient over the last several years.
The Medicare Home Health Equity Act of 1998 will help avert the
potentially devastating effect of the Interim Payment System (IPS),
established by the Balanced Budget Act, on many home health agencies in
Rhode Island, and throughout the country.
The IPS for Medicare home health services that was established by the
BBA bases its reimbursement in large part on agency-specific costs
during fiscal year 1994. Consequently, home health agencies that had
already been implementing cost-efficient practices at that time, like
many agencies in Rhode Island were doing, are now finding their
reimbursements greatly reduced.
Home health agencies in my home state have told me that this
decreased reimbursement, in addition to being unfair, might lead to
reductions in critical health services that currently enable elderly
patients to maintain their dignity and quality of life. These agencies
also have pointed out that this interim payment system may well result
in a loss of jobs in the home health industry.
I am greatly troubled by the thought that the IPS now in effect may
well put into financial jeopardy those Rhode Island home health
agencies that have been working diligently to heed our appeal to
deliver cost-efficient services. The impact of this payment system on
one of Rhode Island's most vulnerable populations, the infirm elderly,
is unpredictable and potentially devastating.
The Medicare Home Health Equity Act of 1998 bases Medicare
reimbursement for home health services primarily on national costs
during the baseline year rather than agency-specific costs.
Consequently, the most efficient home health agencies will not be
placed at financial disadvantage. This is a matter of economic
necessity--we will never be able to maintain the financial security of
the Medicare program unless we encourage everyone involved in the
system to help make it work.
This bill is budget-neutral and will not increase overall Medicare
expenditures. The legislation is a big step forward in our goal of a
cost-efficient and reliable health care system for our older citizens.
Mr. President, I encourage my colleagues to join me in supporting the
[[Page S3714]]
Medicare Home Health Equity Act of 1998.
Mr. JEFFORDS. Mr. President, Vermont's home health agencies are a
model of efficiency for the nation. For the past seven consecutive
years, the average Medicare expenditure for home health care in Vermont
has been the lowest in the nation. This efficiency was achieved by
exclusive reliance on 13 nonprofit agencies which provide care without
sacrificing quality, and which adhere strictly to Medicare requirements
and guidelines. Today, I am cosponsoring The Medicare Home Health
Equity Act of 1998, with my good friend Senator Collins, in order to
preserve this high-quality, low-cost home health system from possible
insolvency.
At this moment, Vermont is facing an unprecedented crisis in its home
health care system. This is not a crisis of their own making, and the
home health agencies had little, if any, advance warning that disaster
was imminent. The crisis that befalls Vermont's home health care
agencies, and many others throughout the country, arose from the
decision made by Congress, as a part of the Balanced Budget Act of 1997
(BBA), to adopt a Medicare prospective payment system for home health
care.
There is compelling rationale and general agreement for moving
Medicare to a prospective payment system (PPS) in the home health care
sector. Under a national, prospective payment system, low-cost agencies
will fare well, as they have already learned how to manage their
resources wisely. However, the interim system created by the BBA for
the transition to a PPS is fundamentally flawed and rewards high-cost
agencies. Under the Interim Payment System, reimbursement limits for
home health care are heavily weighted toward an agency's historical
costs. This means that until a prospective payment system can be
designed and implemented, the lowest cost agencies will face the most
significant caps on their Medicare payments.
Where a prospective payment system aims to level the playing field
for agencies that care for similarly situated patients, the interim
system preserves and reinforces significant disparities across
agencies. Although high-cost agencies will face reductions in payments
under the interim system, these will be the agencies in the best
position to make those cuts. Low-cost agencies with budgets that are
already lean have no place to turn. It would be a national tragedy if
those low-cost agencies cannot survive the transition to a prospective
system.
I commend the efforts of my good friend Senator Collins for bringing
this bill forward. it was a difficult task to craft a remedy that
allows committed and responsible home health agencies to survive and
also maintain budget neutrality. The Medicare Home Health Equity Act of
1998 would alter the interim payment formula by basing payment caps on
a blend of national and regional averages. In this way, we can move
toward a more uniform level of reimbursement and allow home health care
agencies in the same locale to operate under the same constraints.
Furthermore, this legislation can be implemented quickly. This is
important, because the regulations defining the interim payment system
were not published until January of this year--nearly four months after
the payment system was in force.
The situation is serious. We must provide relief to home health
agencies and peace of mind to the clients who are under their care.
Last August, I voted in support of the Balanced Budget Act of 1997. I
was proud of the changes we made to preserve Medicare benefits for the
present and for future generations. Today, I urge my colleagues to
enact The Medicare Home Health Equity Act of 1998 and correct the
unintended consequences of the BBA's interim payment system
reimbursement limits on low-cost home health agencies.
Mr. HARKIN. Mr. President, I am pleased to join today with my
distinguished colleague, Senator Susan Collins, in the introduction of
the ``Medicare Home Health Equity Act of 1998.'' This bill tries to fix
what we believe to be an unintended injustice in the Balanced Budget
Act of 1997.
As many of you know, home health agencies have historically been
reimbursed on the basis of costs. The Health Care Financing
Administration paid each agency to cover the cost of providing care.
This arrangement has been widely criticized because of offers no
incentive for agencies to control their costs.
In order to correct this, we in Congress agreed that Medicare should
move to a prospective payment system to control costs and ensure
quality and access to care. The Balanced Budget Act establishes this
system for home health, effective as of October 1, 1999. In the mean
time, an interim payment system has been put in place. These changes
were needed in order to rein in the incredible growth--some due to
inappropriate payments--in the industry in the last seven years. In
1990, Medicare spent $3.7 billion on home health care. In 1996, $16.7
billion was spent. In addition, the average number of visits per
beneficiary soared from 26 in 1990 to 76 in 1996.
I believe the change to the prospective payment system had to be
done. However, the interim payment system will reward high-cost,
inefficient home health provides at the expense of those home health
agencies that have historically kept their costs low. I don't believe
this was the intent of Congress, and that is why I am cosponsoring
Senator Collins' bill to correct this injustice.
As co-chair of the Senate Rural Health Caucus, I've been working for
a long time to change the big city, urban bias in Medicare's
reimbursement payments. It penalizes more conservative cost-effective
approaches to health care, and that hurts rural areas like Iowa. We
went a long way towards fixing that bias in Balanced Budget Act by
equalizing Medicare's reimbursement payments for managed care services.
But unbeknownst to me and, I believe, most of my colleagues, while we
provided rural equity in one area, we took it away in another. It is
just common sense that we should reward those who provide quality care
in a cost-effective, efficient manner. We did this when we changed the
Medicare managed care rates. It doesn't seem right that in the same
Act, we created an interim payment system for home health services that
rewards the high cost, wasteful agencies and leaves those that have
successfully kept their costs low struggling to survive.
The system's reliance on a provider's historical costs in determining
their reimbursement amounts has produced an uneven playing field. Many
of the newer agencies, who got started during a period of high growth,
now have a competitive advantage. They will now be reimbursed at a
higher rate than their lower cost competitors.
Senator Collins' bill does the right thing--it rewards those agencies
who have done the most to save Medicare money. These include many
visiting nurse associations, non-profit free standing agencies and most
non-profit hospital based programs.
The Home Health Equity Act will revise the current system of
reimbursement based on 75 percent of agency cost blended with 25
percent of national costs. The legislation would create a 75 percent
national rate blended with 25 percent regional rate to level payments
to providers in a given geographic area. In addition, this bill
continues the cost savings that the interim payment system was intended
to achieve. Price Waterhouse has analyzed the bill and found it to be
budget neutral.
If we don't fix the interim payment system, I am afraid we risk a
reduction in access to and quality of health care for Iowa seniors.
Iowa home health care agencies have historically provided efficient,
quality service and they ought to be rewarded, not punished for this.
Most importantly, rural patients and their families deserve continued
access to the best possible care.
Mr. DASCHLE. Mr. President, today I join my colleagues in introducing
the Medicare Home Health Equity Act of 1998.
The Balanced Budget Act (BBA) included numerous changes to Medicare
that were necessary to extend the solvency of the trust fund and
increase the program's integrity. It was extremely important
legislation that I strongly supported, but there was no way to know the
impact of every provision it included.
One provision of the BBA in particular, the interim payment system
for
[[Page S3715]]
home health care, locks in place inequities between regions of the
country, efficient and inefficient providers, and new and older
agencies. I am concerned about the impact of that provision on my state
of South Dakota.
In South Dakota, the interim payment system has raised significant
concern. The interim payment system bases each agency's per patient
cost limit largely on its per beneficiary cost in 1994. My concern is
that South Dakota's cost per beneficiary and number of visits per
patient were well below the national average in 1994. Many of the home
health agencies in the state have expanded the geographic area they
serve since 1994 and have added services that formerly were not
available in the more rural parts of the state. Some of these agencies
are the sole providers in our most rural counties.
I have heard from Hand County Home Health Agency which primarily
serves women, age 85 and older, with little family nearby and with
difficult health conditions. Since 1994, the Hand County Home Health
Agency has kept its costs down, but has added new services such as
physical therapy and has expanded the geographic area to serve areas
that no other provider covers. The agency has told me that they have to
consider discontinuing the new services they cover or decreasing the
geographic area they serve. Neither of these options seems acceptable
to me.
The interim payment system also creates problems between new and
older agencies. In the same geographic area, where there is a new
provider and an old agency, the new provider's limit will be based on
the national median reimbursement. This results in significant
discrepancies in reimbursement and ultimately the services that
agencies can afford to deliver within the same area and market.
Ultimately the impact of this payment system falls on beneficiaries,
and this must be foremost in our minds. Senator Collins' bill would go
a long way to addressing the access, quality, and equity issues that
have been raised by the interim payment system in South Dakota. I am
pleased to join her in beginning the dialogue on this issue that I hope
will lead to construction changes for home health care patients in
South Dakota and across the nation.
______
By Mr. COATS (for himself, Mr. Abraham, Mr. Brownback, Mr.
Coverdell, and Mr. Santorum):
S. 1994. A bill to assist States in providing individuals a credit
against State income taxes or a comparable benefit for contributions to
charitable organizations working to prevent or reduce poverty and to
protect and encourage donations to charitable organizations; to the
Committee on Finance.
______
By Mr. ABRAHAM (for himself, Mr. Brownback, Mr. Coats, Mr.
Coverdell, Mr. Hutchinson, Mr. Santorum, and Mr. Lieberman):
S. 1995. A bill to amend the Internal Revenue Code of 1986 to allow
the designation of renewal communities, and for other purposes; to the
Committee on Finance.
______
By Mr. SANTORUM (for himself, Mr. Abraham, Mr. Brownback, Mr.
Coats, Mr. Coverdell, and Mr. Hutchinson):
S. 1996. A bill to provide flexibility to certain local educational
agencies that develop voluntary public and private parental choice
programs under title VI of the Elementary and Secondary Education Act
of 1965; to the Committee on Labor and Human Resources.
renewal alliance legislation
Mr. COATS. Mr. President, I am here today to announce, along with
several Members--in fact, a coalition of 30 Republican Members from
both the House and the Senate called the Renewal Alliance, which has
been in business now for a considerable amount of time--more than a
year--will be jointly introducing new initiatives to help restore hard-
pressed urban neighborhoods of our country to reach out to families and
communities and neighbors that are dealing with some of the most
difficult and intractable social problems that affect our society.
This package, called REAL Life--renewal, empowerment, achievement,
and learning for life--contains what we believe are essential elements
to help bring improvements and restore hope to impoverished communities
and to bring self-sufficiency to low-income individuals and families.
REAL Life seeks to address the critical deficits facing neighborhoods
and communities, families, those communities and neighborhoods who lie
behind the gleaming skyscrapers, the neighborhoods where some of the
most difficult problems in our society--homelessness, drug abuse, teen
pregnancy, poverty, and violence--are found in some of the most complex
and intractable forms in the neighborhoods, however, where groups of
individuals and private community organizations and leaders are already
at work defeating the poverty and dysfunction that have defied our
well-intentioned and lavishly funded Federal efforts.
Before I begin to make specific comments about the legislation that
we will be introducing, let me take a moment to read from a letter
given to me by Light of Life Ministries, a rescue mission operating in
Pittsburgh, PA. I think this letter communicates in a very compelling
and clear way both the problems that we face today in our low-income
areas and particularly in our cities--although these are no respecters
of income or persons, but it seems that the problems are particularly
acute in some of our urban areas--but also addresses some of the
solutions that even today are within our grasp.
This letter is from a fellow named Benjamin Primis, a young man who,
after a promising start in life, fell on hard times. He was a graphic
artist working in the television industry, and he began using drugs and
became addicted to crack cocaine. Soon he was homeless and desperate.
Benjamin writes:
I found myself homeless in Pittsburgh. It seemed as though
the world had turned its back on me. . . . When there was
nowhere else to run, the Light of Life Ministry in Pittsburgh
opened their doors of unconditional love. . . . Instantly I
was comforted with three hot meals a day, clean linens, drug
and alcohol therapy. . . . They fed me when I was hungry.
They clothed me when I had nothing else to wear. [Most
importantly,] they cared for me when I didn't care for
myself.
Benjamin Primis's story is one of thousands, maybe tens of thousands,
of stories of hope and restoration and healing that bring us together
here on this floor, the Senate floor, this morning. Ben Primis was
failed by both the dogmas and initiatives of Republicans and Democrats,
conservatives and liberals. A booming economy did not prevent his fall
into poverty. And the Government safety net proved to be an illusion.
Instead, Ben was rescued by one of the thousands of neighborhood-based,
privately run, often faith-based religious charities that operate in
poor neighborhoods across our country.
Let me give another example, Mr. President. For years, officials in
the District of Columbia and Members of Congress have wrestled with the
problem of violence in this city that has plagued this city. A lot of
programs have been tried, and the police department has been
strengthened and reorganized and redeployed on several occasions to
almost no effect. It seemed that none of the often very expensive
initiatives had any fruition.
Last year, a group of African American men called the Alliance of
Concerned Men began brokering peace treaties among the gangs that
inhabit, and frequently dominate, some of the city's public housing
complexes. Benning Terrace in southeast Washington, known to the D.C.
police department as perhaps the most dangerous area of the city, has
not had a single murder since the Alliance's peace treaty went into
effect early last year. This movement is now spreading across the city.
These are community healers who are saving lives where all other
Government efforts have failed. I have met with these individuals. I
have listened to their stories and some of the most remarkable stories
of transformation of individual lives and reconciliation that anyone
could ever encounter.
The Light of Life Mission in Pittsburgh, the Alliance of Concerned
Men in Washington, DC, Gospel Rescue Mission of Washington, these are
the kinds of organizations that the Renewal Alliance REAL Life
initiative wants to place at the center of our Nation's welfare and
social policies.
REAL Life is not a handout, it is an opportunity agenda for America's
poor,
[[Page S3716]]
and it is concentrated on those who live on America's meanest streets.
It does acknowledge a role for Government programs, but it makes that
role one of a junior partner--not a CEO, not a director, but a junior
partner, a junior partner with those organizations that, without
Government help, without Government rules and regulations, are reaching
out and actually bringing hope and bringing restoration to some of the
most desperate situations that our country encounters. This whole array
of community-based organizations, faith-based organizations, social
institutions, help restore individual lives and rebuilds neighborhoods.
Finally, REAL Life is a vision that starts with a belief that real
and lasting social reform begins among the families, the churches, the
schools, the businesses, that are the heart and the soul of local
communities.
We have three central components in REAL Life. We have a community
renewal component, which I will talk a little bit more in a moment,
which incorporates a State-based voluntary charity tax credit, charity
donations protection, liability reform. We have an economic empowerment
component, which incorporates a number of empowerment initiatives that
have been discussed and talked about over the years. These will be
discussed by other members of the Renewal Alliance. We have educational
opportunity for low-income families. This real-life initiative by the
Renewal Alliance has narrowed its scope to three essential components
as a means of demonstrating the effectiveness of these initiatives.
Before I yield to other members of the Renewal Alliance--and I note
that Senator Abraham, a key member of our Alliance, is here and ready
to speak--let me briefly discuss the community renewal portion of the
package we are introducing today.
The REAL Life Community Renewal Act begins with the belief that
social capital, the invisible elements of trust, cooperation, and
mutual support that undergird communities life, have been severely
damaged by 30 years of misguided Government programs. The traditional
networks of community action and caring anchored in churches, schools,
and volunteer programs have been displaced by Government programs. Too
much money and too little wisdom have combined to wreak havoc in urban
neighborhoods. We seek to repair that damage done by the Great Society
by shifting authority and resources out of Government and into the
private, religious, and voluntary groups that know the deepest needs of
local neighborhoods. We achieve this through State-based charity tax
credit.
We tap a wide range of existing Federal welfare block grants as a
funding source for these charity tax credits. The credit is entirely
voluntary. It builds up on efforts in the States to find innovative
approaches for the delivery of welfare services. Already, Arizona and
Pennsylvania and Indiana have either incorporated or are in the process
of incorporating charity tax credits as a way to provide incentives for
contributions to these organizations.
As I said, we also contain provisions which will strengthen charities
through enhanced liability protections and also to prevent IRS actions
against these organizations to allow them to better do their mission.
Others here this morning will speak in greater detail about the
economic empowerment and educational opportunities sessions of our
proposal.
The bottom line is this: After 30 years of experiments with top-down
Federal poverty strategies and an enormous expenditure of money, the
returns are in. The Great Society approach, the Government-knows-all
approach, the Government-can solve-all-your-problems approach, has
failed. It has been a failure that has been widespread across this
country. Many of the initiatives were well motivated, but the results
are in. It is time now for us to look at a new approach, a new approach
that makes local leadership, community-based institutions, and
neighborhood center reform efforts the heart of our welfare strategy.
I trust that my colleagues will join us in this effort to bring real
life to those in greatest need in our society. I could spend the day
discussing and talking about initiatives that have taken place in
communities across this country where individuals, inspired by nothing
more than a dream or a vision, often severely and desperately
underfunded, have opened their arms and opened their hearts and opened
their doors to provide real support and real help for real people in
need. They have done so in a remarkable way.
The Center for the Homeless in South Bend, IN, has combined the
efforts of 300 churches spanning the spectrum of denominations and
religions. They have utilized the services of the University of Notre
Dame, the hospital community of St. Joseph County, and help from
volunteers from all walks of life, and put together a model homeless
shelter which has a six-part, 2-year strategy of taking homeless
individuals and turning them into homeowners, restoring their lives,
and, in the process, restoring neighborhoods and restoring communities.
It is one of the most remarkably efficient and effective efforts that I
have witnessed.
But the story is repeated all across the State of Indiana in
initiative after initiative. The Matthew 25 clinic in Fort Wayne, IN, a
combination of doctors, dentists, and nurses, on a volunteer basis, is
reaching out and established a clinic, providing medical care and help
to low-income individuals who are not insured and don't have
opportunities for medical treatment in the normal course of things.
They have made a remarkable difference in our community. It is not a
Federal program; it has nothing to do with a Federal program; there are
no Federal funds. It is voluntary efforts by the community of medical
personnel in our city. Whether it is a maternity home, a home for
girls, a spouse abuse shelter, any of a number of programs, they are
duplicated and replicated in virtually every city in America. Yet, they
are struggling, struggling because, as I said, after 30 years of
Federal initiatives, their efforts have been almost overwhelmed by the
well-intended, well-meaning, extraordinarily expensive, and incredibly
low-result efforts of the Federal Government. It is this problem that
we are trying to address.
This doesn't have to be a partisan issue. This is something
Republicans and Democrats can come together on. I believe liberals, who
have been well-motivated and well-intended, have seen the dismal
results of their efforts and are looking for an alternative. And those
conservatives who say, ``Let this sort itself out; after all, it is an
issue of personal responsibility and there is nothing Government should
be involved in,'' I think are ignoring the fact that some of these
institutions that are so essential to helping in this process need
support and need to be rebuilt.
This is not a new, massive Federal program, this is simply some
startup initiatives to point the way and, hopefully, to encourage the
support and development of these non-Government institutions.
My colleague from Michigan is on the floor, Senator Abraham, who has
been instrumental in helping to develop the REAL Life initiative. I am
pleased to yield time to him to explain another component of this
particular package.
The PRESIDING OFFICER. The distinguished Senator from Michigan is
recognized.
Mr. ABRAHAM. Mr. President, I would like to begin by thanking Senator
Coats for the leadership he has provided. Even before there was such a
thing as the Renewal Alliance, Senator Coats was, in a variety of
contexts, bringing forth the arguments in the case that he has begun to
present here today. I think the existence of his efforts and the
various projects he has worked on was really the basis upon which a lot
of us thought it made sense to begin working on a joint venture, the
Renewal Alliance agenda that we are presenting today.
I would like to discuss a piece of legislation that has to do with an
important part of the Renewal Alliance agenda. This is a bill which
provides economic empowerment in economically distressed areas. It is
part of an effort by a number of us who wish to bring about the
revitalization of economically and socially distressed areas in our
country, especially in our cities.
Traditional responses to persistent poverty have not been
particularly effective. Frankly, even in the best of economic times, we
find that certain parts of our communities still don't see significant
change and feel that they are left behind--and indeed they are,
[[Page S3717]]
economically. On the other hand, at the other end of the spectrum there
has been the Government solution approach that we have seen over the
last several decades, more than $5 trillion in Government programs.
Yet, we have seen very little change in the level of poverty in the
country. The fact is that the debate that has occurred over the past 30
years between, on the one hand, the argument that all we need is a
strong economy and, on the other hand, all we need are more Government
programs, leaves us still short of the mark.
So what the Renewal Alliance has attempted to do is look beyond those
traditional responses, believing that across America people have an
abundance of desire to help the less fortunate to rebuild our cities
and stop moral decay; also believing that too often the Federal
Government impedes or fails to promote the community renewal that we
need.
We must encourage families, churches, small businesses, and community
organizations to take on the hard work of social renewal. How? By
reducing Government barriers that are making it difficult for
economically distressed areas to improve the quality and conditions of
life there and, at the same time, providing incentives so that the
culture and the private sector can assist the Government in achieving
this objective. Yes, we do need a social safety net for the truly
deserving, but that will never give people the opportunity to get out
the economically distressed conditions they find themselves in. We must
go further.
So what I would like to talk about specifically now is the economic
empowerment component of the Renewal Alliance agenda. What we need are
new approaches to our urban problems and problems of any community in
the country that suffers from economic disadvantage because, as I say,
despite the War on Poverty, our cities still face an array of problems.
Illegitimacy in our inner cities is at a record high level, in some
areas exceeding 80 percent.
Harvard's Lee Rainwater estimates that by 2000, 40 percent of all
American births will occur out of wedlock. And our cities are losing
population, as well.
Since the mid-1960s, our largest 25 cities have lost approximately 4
million residents. Too often, the people left behind are the poor.
Half the people in our distressed inner cities lived below the
poverty line in 1993.
To address this tragic situation, we propose the ``REAL Life Economic
Empowerment Act.'' This legislation would target America's 100 poorest
communities and offer pro-growth incentives to create jobs and spur
entrepreneurship where it is needed most.
In order to become a renewal community, a community must meet several
criteria. First, it must need the assistance. That means people in the
area must be experiencing abnormally high rates of poverty and
unemployment.
Second, State and local governments must enter into a written
contract with neighborhood organizations to reduce taxes and fees,
increase the efficiency of local services, formulate and implement
crime reduction strategies, and make it easier for charities to
operate.
Third, the community must agree not to enforce a number of
restrictions on entry into business or occupations, including
unnecessary licensing and zoning requirements.
In exchange, the community would receive a number of benefits from
the Federal level. Our legislation would zero out capital gains taxes
within these empowerment areas, it would increase business expensing,
it would give a 20 percent wage credit to businesses hiring qualified
workers who were still employed after 6 months, and it would provide
tax incentives for entrepreneurs who clean up environmentally
contaminated ``brownfield'' sites.
Unlike the administration's current ``empowerment zones,'' our
incentives recognize that it is the private sector, not the Federal
Government, that must be part of any effort to revitalize our
communities.
Mr. President, there will be no boards established to dole out
Government patronage, and our legislation will not include the onerous
conditions and bureaucratic requirements of current programs. What is
more, States and localities will be joining the Federal Government in
reducing the burden of Government so that local small businesses can
start and grow in distressed areas.
We know that it is these small businesses, from barber shops to local
grocery stores, that often serve as the glue holding communities
together. Not only do these small businesses provide jobs, they also
provide places where people can meet one another to exchange news and
keep in touch with local events and other job opportunities. It is
crucial that we seed our distressed areas with businesses like these so
that residents can pull their communities together and work toward a
better life.
Mr. President, in short, what we hope to do with our legislation is
to provide the incentives so that small entrepreneurial enterprises can
develop in areas where there is currently significant economic
distress. Therefore, the jobs being created will be created where the
people are who don't have jobs. Right now, the biggest impediment to
creating jobs is to create conditions in which entrepreneurship can
exist. That means cleaning up contaminated brownfield sites, it means
providing access to capital so small businesses can begin and flourish,
it means making sure that Government regulations and rules aren't so
burdensome and onerous that even the best-intentioned small business
person can't even open their enterprise. The only way that is going to
happen is if we have State, local, and Federal teams working together
in the fashion that our legislation suggests.
The suggestion that this can work is, I think, abundantly clear if
one looks to just existing examples of this going on in the country
today. In our State of Michigan, under Governor John Engler, we have
launched several extraordinarily interesting initiatives along these
lines--one called the Renaissance Zone Concept, which essentially does
the same thing we are proposing in this legislation; it just doesn't
have the Federal component. Obviously, the State could not include us
in the mix. But what the State has done is to say that, within a
certain number of zones in the State, in economically distressed
areas--and they range from inner-cities to rural areas, Mr. President--
we will dramatically reduce the burdens of taxes and regulations in
order to try to stimulate economic development. And we are doing that
with tremendous results.
Another approach that is somewhat similar is being done in an effort
to get people off of the welfare rolls and onto the job rolls. In fact,
we have a country in Michigan which, because of this kind of State and
local cooperative effort, the county of over 200,000 people has
virtually nobody left on the welfare rolls because of the innovative
approach that is being taken.
It is time to learn from these ``laboratories,'' these experiences at
the State level. We believe this legislation moves us in that
direction. So as we proceed forward with this Renewal Alliance agenda,
I intend to work very hard on that component of it to find us economic
empowerment. We want to give the Members of the Senate a chance to
decide whether or not the business-as-usual approach is the way we want
to enter the 21st century, or whether we want to augment what we do in
Federal programs, as well as private sector initiatives, by providing,
through the legislation we will offer, an opportunity to reduce the
impediments to starting new business opportunities in our economically
distressed areas, as well as providing incentives to create more of
those businesses that obviously provide more people with a chance to
get on the first rung of the economic ladder.
Mr. President, let me conclude, because other members of the Alliance
are here. I thank Senator Coats for his leadership on this. I look
forward to working with all of our colleagues as we try to move this
agenda forward this year.
Mr. COATS. Mr. President, I thank the Senator from Michigan for his
invaluable contributions to this effort. I now turn to another key
member of our Renewal Alliance, someone who has offered additional
invaluable contributions, for further explanation of the package we are
introducing, Senator Santorum of Pennsylvania.
[[Page S3718]]
The PRESIDING OFFICER. The distinguished Senator from Pennsylvania is
recognized.
Mr. SANTORUM. I thank the distinguished Presiding Officer for his
recognition.
Mr. President, let me thank Senator Coats for his tremendous
leadership on what is, really, a new paradigm. Those listening to the
debate on the Senate floor and the discussion of the Renewal Alliance
agenda--renewal, empowerment, achievement learning for life--may be
hearing some things for the first time, as to a different approach.
One of the things that I know Senator Coats talked about and, in a
sense, schooled many of us in here on this side of the aisle and on the
other side of the aisle, I might add, is the importance of
understanding the problems of this country, the real intractable
problems, the ones that we sort of don't believe that there are any
quick fixes to and are not going to be fixed in Washington. In fact,
many of us would argue that many were exacerbated by attempts by
Washington to fix those problems.
As a result of Senator Coats' urgings, the more I have gotten out
into the neighborhoods in the last few years--poor neighborhoods, in
particular, in Pennsylvania--to see what works and what doesn't: What
are people doing at the local level that is making a difference in
people's lives, that is taking absolute hopelessness and despair and
turning it into productivity and optimism?
What I see is that, almost without exception, they are not Government
programs and, almost without exception, they don't take Government
dollars because, in so doing, it would corrupt what works for them
because the Government would have some way of dictating to them how
this program must work or what hoops they must jump through. And they
have designed a program that meets the needs of the people in that
community, designed by people in that community who have, in many, if
not most, cases experienced the same kind of hopelessness and despair
before they arrived where they are today--in a state of now helping
those come out of the problems they have.
So what I have learned from my discussions with those very people is
that we need to look here in Washington as to how we can help them,
help them do the mission--and it is a mission, it is not a job. I don't
know of anybody I have met in these communities who is making any
money, who is getting a good night's sleep at night, who is profiting
in any real financial way from, or any tangible way from, their work,
but profiting enormously in the intangibles that are, frankly, the most
satisfying.
It is a true labor of love for people in these communities, whether
they are in the economic development area, or in the community
development area, or in dealing with homelessness, or abused women, or
doing a charter school, or running a small parochial school. Whatever
the case may be, these are people who are convicted, who care deeply--
not about education, not about homelessness, not about drug abuse; they
care about that person sitting across the table from them. It is not a
macroissue. It is a one-to-one, person-to-person challenge to save
someone's life. They do it because they care. They do it because they
love that person. That is the magic that no Government program can
provide.
What Dan Coats, Spencer Abraham, and Sam Brownback--those of us who
are members of the alliance having looked into the eyes of those who
care, not those who appropriate money here in Washington who say we
care, but those who are there across the table shedding the tears,
holding the hands, embracing those in real pain, those people who
care--how can we help them? How can we help the world ministries, the
real healing agents of our society to solve those intractable problems
that, believe it or not, they solve, and do so so well? How did we help
them do it better? How can we help them turn more lives around and
replicate the great accomplishments they have made to so many
neighborhoods? There isn't a neighborhood in America where there is not
at least one person or one organization--whether it is a school or
whether it is a rehab center or whether it is a homeless shelter or a
soup kitchen--that isn't touching and changing people.
We have come forward with this agenda that is not, as the speaker
said before, a Washington-based solution to the problem. But it is, in
fact, a way that Washington can, one, get out of the way; two, maybe
help with some of the things in a legal sense to get out of the way;
three, give financial resources to those organizations that need those
resources to either help the community or help the economy; and, next,
give resources to the hands of parents and children so they can have
the opportunity to hope through an education that gives them the tools
to be able to be successful in our society.
But I am going to focus my couple of minutes more to talk in the area
of education. I cannot tell you the number of employers I talked to
just within the southeastern Pennsylvania area the other day,
Philadelphia. Employer after employer, factory or industry, they told
me how they desperately need skilled people. They desperately need
people who are even semiskilled who can be trained. There are such
shortages in the workplace today. Then I asked--the unemployment rate
in the city of Philadelphia, the center city, or in Chester, or in
Levittown, or places like that is very high, and there is available
work? They say, ``Yes, there is. We have job fares. We ask people to
apply, and they don't.'' I said, ``Why don't they?'' They said, ``Well,
by and large, they don't have the education. They can't, in many cases,
fill out applications, or they just simply don't have the education
necessary to even meet what is a minimal skilled job.''
The jobs are there. But we just do not have people who are educated
enough to take advantage of those opportunities. That is, in fact, a
shame, and, as a result of a variety of factors, a breakdown in the
family, the breakdown in the community, and, yes, the breakdown of the
educational structure.
There are lots of things we can do to solve the first two problems
that have been talked about. I am going to talk about the third, which
is the breakdown of the education structure. I am not going to profess
to you I have the answer--the silver bullet to make public education
work in America's poor neighborhoods. I do not have a silver bullet. I
can sit up here and suggest a variety of things that may or may not
work to solve that intractable problem in educating poor students in
poor schools. I do not have that answer off the top of my head. What I
do have is a solution that will give children and families the
opportunity to send their child to school where they can get a good
education tomorrow. We have to step back and say, ``Well, is that good
enough?'' Some may say, ``Senator, you are not solving the big problem
tomorrow in public education in the poor neighborhoods of our
country.'' I will answer, You are right. I am not. I am not going to
solve that problem tomorrow. But what I am going to start to do today
is to give that young person who may have a dream, or that mother or
father who sees the spark in that young child's eye and believes that
spark can lead them to somewhere in life if given the educational
tools. I am going to give them the chance to get that child a chance.
That is all we can do right now--to give them a scholarship, to send
them to a school where they will have the opportunity to see that spark
catch fire, to feed them what they need to take on the world.
Our program, called Educational Opportunities for Low-Income
Families, is to provide scholarships through existing block grants that
go to the States right now. We would allow that block grant to be used
for scholarships to go to low-income children and 185 percent of
poverty and below in the poorest neighborhoods in our country so that
it will give low-income kids in poor neighborhoods the opportunity to
have a scholarship that pays up to 60 percent of the cost of their
tuition and would give them the opportunity to go to school and learn.
I think it is a great opportunity for us to help one child at a time. I
believe that in the long run helping one child at a time and giving
that choice will, in fact, cause dramatic reforms in the whole
educational system in those communities.
I have been given the high sign here. I will follow my chairman's
lead. Again, I thank Senator Coats for his tremendous leadership on
this.
[[Page S3719]]
Mr. COATS. Mr. President, it is very difficult to ask the Senator
from Pennsylvania to wrap up his remarks because he, obviously, has
such a deep-felt and heartfelt passion for these issues. I appreciate
his work with us. We are under some time constraint.
I now turn the floor over to the Senator from Kansas, Senator
Brownback, who has also been a very key instrumental member of the
development of this package.
The PRESIDING OFFICER. The distinguished Senator from Kansas is
recognized.
Mr. BROWNBACK. Thank you very much. Mr. President, I am delighted to
be able to work with the distinguished Senator from Kansas, who is
presiding today, and also the distinguished Senator from Indiana, who
has put forth this new alliance. It is a cadre of members who are
putting forth these points that we think have not been sufficiently
debated nor brought forward in the overall debate in America about what
we should do about the crying issues of poverty that has so hit and
harmed our Nation in so many places, both urban and rural.
More than 30 years after the United States first declared the War on
Poverty, most signs point to failure. The United States has spent
hundreds of billions of dollars--by some accounts we have spent nearly
$4 trillion--to fight poverty only to find poverty in America has grown
more widespread, more entrenched, and more pathological. The solution
is not to expand more Government but rather to go a different way, and
to say, ``Look, we have tried that route. We have spent nearly $4
trillion trying that route. We have tried every program you possibly
can with that route. Maybe there is another way that we should be
going.''
This is what the Renewal Alliance, this program, is about--about
rewarding self-help and not Government help. It is about encouraging
charity rather than encouraging Government. It is about encouraging
volunteerism rather than putting more people on the taxpayer rolls to
solve problems that we have failed to be able to solve. Family
breakdown, crime, poor education performance, and a lack of opportunity
in the inner cities, and many other areas, including many rural areas,
are now national problems. But many of the solutions are to be found on
a local level and not in Washington, through personal contacts that
people can make between individuals and the dedicated involvement of
families, churches, schools, and neighborhood associations. These small
groups, not big Government, but rather small groups, often referred to
as the ``little platoons'' in a civil society, can often accomplish
what no Government program could dream of or ever been able to do. They
have the soft hearts and the willing hands to be able to reach out and
touch people directly in a community where they are in there with the
families working with them.
Last December, I had the chance to visit several of these small,
private charities in my home State of Kansas. To me, they are living
proof of the amazing effectiveness of small, local charities that lead
with heart, that lead with love.
Mr. President, in this very body, in this very room, as you enter
into the main doorway coming in here, there is a sign above the door
mantle which reads ``In God We Trust.'' As I visited these small
charities in Kansas, I was reminded at that time and was thinking about
how many people say that versus how many people do that. These are
charities, which ``In God We Trust'' they live every day.
I visited Good Samaritan Clinic in Wichita, which serves around 300
patients a month from Wichita's poorest neighborhood. This tiny clinic
operates on less than a shoestring budget. With the exception of a fax
machine and one piece of furniture, everything in the clinic is
donated. The clinic's staff, a dedicated and accomplished group of
doctors, are mostly volunteers. They are reaching out and touching
people, and helping and healing people with their skills and with their
hearts.
I visited the Topeka Rescue Mission and the Union Rescue Mission of
Wichita, both of which serve thousands of people each year.
These missions are not merely assigning people to bunks, but they
challenge them personally and spiritually, and they are challenged to
change their hearts and their souls along with helping them out in
their lives.
I visited the Crisis Pregnancy Outreach Program in Topeka and a
maternity home in Wichita and saw firsthand the love and personal
attention devoted to each woman who passes through those doors.
Contrast that with the large Government solution that we have tried
for the past 30 years that gets millions of people flowing through the
door but constantly keeps them flowing back out the door and never
really changes things in a person's life, continues to hand them
something but doesn't put arms around them and hug them, doesn't put
arms around them and give them heart and soul and say, ``Here is my
phone number; call anytime.''
It is not that we don't have a lot of good and dedicated servants; we
do, but they are limited in what they can do. This is a mission for
them. They must not see the number of people who are walking through;
they must see a soul at a time. They must see another and another, to
reach out and touch and help them. We need to encourage these groups
and not discourage them.
As the past 35 years of our history has shown, the Federal Government
is limited in its capacity to solve the problems of poverty and
pathology, But it can eliminate perverse incentives that reward
irresponsibility and fuel the flight of capital from the inner cities,
and it can encourage entrepreneurialism, charitable giving and
investment in the inner cities and its inhabitants, investment in the
inhabitants of those areas and rural areas as well. It can do these
things and it should. And through the renewal alliance REAL Life
legislation, it will.
That is why I am delighted to be associated with the Senator from
Indiana in this package that we have put forward. It is a different
way. It is a way that people every day are proving can and is working,
and we need to encourage it and lift it up and move it forward. I am
delighted to be a part of this legislation.
Mr. COATS. Mr. President, I thank the Senator from Kansas for his
invaluable support and effort in helping craft this legislation.
Mr. President, I know the time allocated to us is just about up.
I send to the desk three pieces of legislation, one that I am
introducing, another that Senator Abraham is introducing, and a third
that Senator Santorum is introducing, all of which encompass the three
major components of the renewal alliance package. I would ask for its
immediate referral.
Mr. President, I also ask unanimous consent if it is possible--a
qualified unanimous consent request--to have these numbered
sequentially since these three pieces of legislation are part of a
package. If it is possible, we would like to have them numbered
consecutively.
The PRESIDING OFFICER. Is there an objection? The Chair hears none,
and the bills will be so numbered. They will be received and
appropriately referred.
Mr. COATS. Mr. President, I believe that wraps up our time. I think
the Senator from Iowa is in the Chamber prepared to speak within a
moment or two. Let me ask unanimous consent for 2 additional minutes to
wrap up.
The PRESIDING OFFICER. The Senator has 2 additional remaining on his
time.
Mr. COATS. That is propitious then. The Senator will take all 2 of
those minutes. I thank the Chair.
Mr. President, in summary, let me state that what we are attempting
to accomplish here is a third alternative. We believe that the well-
intentioned, well-motivated programs of the past, at great cost to the
taxpayers, have failed to successfully address some of the most
difficult social problems facing our Nation, and particularly problems
facing low-income urban communities where in many situations nothing
but crime and drugs are the prevalent activities of those
organizations. By the same token, the argument that no Federal policy
is the best policy to address these problems is something that we as a
group cannot accept.
We think this third alternative, providing REAL Life meaningful
solutions to the areas of community renewal, economic empowerment and
educational opportunities for low-income families offers real hope. It
does so not through Government organizations,
[[Page S3720]]
Government structures or even significant Government funding. It does
so by encouraging those community volunteer, nonprofit, often faith-
based organizations that already exist and should exist in greater
numbers to take a much greater role in addressing these problems. We
want to make the Federal Government not the dominant partner but a
junior partner, an entity that can assist through the provision of Tax
Code changes, primarily tax credits and other incentives, to encourage
individuals and other organizations to contribute to these nonprofit
groups to allow them to do a better job. They have demonstrated success
at an efficiency rate and at a cost-effectiveness that far exceeds
those current programs in place.
Are we calling for a dismantling of the safety net? No, we are not.
We are calling for a better use of dollars, a better commitment,
stronger commitment to organizations which have demonstrated real
success in providing hope to individuals, transformation and renewal of
communities.
Mr. President, I believe the time is probably expired, and with that
I yield the floor and encourage my colleagues to take a look at the
REAL Life Renewal Alliance initiative which we are happy to provide and
discuss with our colleagues.
______
By Ms. MIKULSKI (for herself and Mr. Faircloth):
S. 1997. A bill to protect the right of a member of a health
maintenance organization to receive continuing care at a facility
selected by that member; to the Committee on Labor and Human Resources.
THE ``SENIORS' ACCESS TO CONTINUING CARE ACT OF 1998''
Ms. MIKULSKI. Mr. President, I rise today to introduce the ``Seniors'
Access to Continuing Care Act of 1998'', a bill to protect seniors'
access to treatment in the setting of their choice and to ensure that
seniors who reside in continuing care communities, and nursing and
other facilities have the right to return to that facility after a
hospitalization.
As our population ages, more and more elderly will become residents
of various long term care facilities. These include independent living,
assisted living and nursing facilities, as well as continuing care
retirement communities, which provide the entire continuum of care. In
Maryland alone, there are over 12,000 residents in 32 continuing care
retirement communities and 24,000 residents in over 200 licenced
nursing facilities.
I have visited many of these facilities and have heard from both
residents and operators. They have told me about a serious and
unexpected problem encountered with returning to their facility after a
hospitalization. Many individuals have little choice when entering a
nursing facility. They do so because it is medically necessary, because
they need a high level of care that they can no longer receive in their
homes or in a more independent setting, such as assisted living. But
residents are still able to form relationships with other residents and
staff and consider the facility their ``home''.
More and more individuals and couples are choosing to enter
continuing care communities because of the community environment they
provide. CCRC's provide independent living, assisted living and nursing
care, usually on the same campus--the Continuum of Care. Residents find
safety, security and peace of mind. They often prepay for the continuum
of care. Couples can stay together, and if one spouse needs additional
care, it can be provided right there, where the other spouse can remain
close by.
But hospitalization presents other challenges. Hospitalization is
traumatic for anyone, but particularly for our vulnerable seniors. We
know that having comfortable surroundings and familiar faces can aid
dramatically in the recovery process. So, we should do everything we
can to make sure that recovery process is not hindered.
Today, more and more seniors are joining managed care plans. This
trend is likely to accelerate given the expansion of managed care
choices under the 1997 Balanced Budget Act. As more and more decisions
are made based on financial considerations, choice often gets lost.
Currently, a resident of a continuing care retirement community or a
nursing facility who goes to the hospital has no guarantee that he or
she will be allowed by the MCO to return to the CCRC or nursing
facility for post acute follow up care.
The MCO can dictate that the resident go to a different facility that
is in the MCO network for that follow up care, even if the home
facility is qualified and able to provide the needed care.
Let me give you a few examples:
In the fall of 1996, a resident of Applewood Estates in Freehold, New
Jersey was admitted to the hospital. Upon discharge, her HMO would not
permit her to return to Applewood and sent her to another facility in
Jackson. The following year, the same thing happened, but after strong
protest, the HMO finally relented and permitted her to return to
Applewood. She should not have had to protest, and many seniors are
unable to assert themselves.
A Florida couple in their mid-80's were separated by a distance of 20
miles after the wife was discharged from a hospital to an HMO-
participating nursing home located on the opposite side of the county.
This was a hardship for the husband who had difficulty driving and for
the wife who longed to return to her home, a CCRC. The CCRC had room in
its skilled nursing facility on campus. Despite pleas from all those
involved, the HMO would not allow the wife to recuperate in a familiar
setting, close to her husband and friends. She later died at the HMO
nursing facility, without the benefit of frequent visits by her husband
and friends.
An elderly couple in Riverside, California encountered the same
problem when the husband was discharged from the hospital and retained
against her will at the HMO skilled nursing facility instead of the
couple's community. At 25 miles apart, it was impossible for his wife
and friends to visit at a time when he needed the tenderness and
compassion of loved ones.
Another Florida woman, a resident of a CCRC fractured her hip. Her
HMO wanted her to move into a nursing home for treatment. She refused
to abandon her home and received the treatment at the CCRC. Her HMO
refused to pay for the treatment, so she had to pay out of her pocket.
Collington Episcopal Life Care Community, in my home state of
Maryland, reports ongoing problems with its frail elderly having to
obtain psychiatric services, including medication monitoring, off
campus, even though the services are available at Collington--how
disruptive to good patient care!
On a brighter note, an Ohio woman's husband was in a nursing
facility. When she was hospitalized, and then discharged, she was able
to be admitted to the same nursing facility because of the Ohio law
that protected that right.
Seniors coming out of the hospital should not be passed around like a
baton. Their care should be decided based on what is clinically
appropriate, not what is financially mandated. Why is that important?
What are the consequences?
Residents consider their retirement community or long term care
facility as their home. And being away from home for any reason can be
very difficult. The trauma of being in unfamiliar surroundings can
increase recovery time. The staff of the resident's ``home'' facility
often knows best about the person's chronic care and service needs.
Being away from ``home'' separates the resident from his or her
emotional support system.
Refusal to allow a resident to return to his or her home takes away
the person's choice. All of this leads to greater recovery time and
unnecessary trauma for the patient.
And should a woman's husband have to hitch a ride or catch a cab in
order to see his recovering spouse if the facility where they live can
provide the care? No. Retirement communities and other long term care
facilities are not just health care facilities. They provide an entire
living environment for their residents, in other words, a home. We need
to protect the choice of our seniors to return to their ``home'' after
a hospitalization. And that is what my bill does.
It protects residents of CCRC's and nursing facilities by: enabling
them to return to their facility after a hospitalization; and requiring
the resident's insurer or managed care organization (MCO) to cover the
cost of the care, even if the insurer does not have a contract with the
resident's facility.
[[Page S3721]]
In order for the resident to return to the facility and have the
services covered by the insurer or MCO: 1. The service to be provided
must be a service that the insurer covers; 2. The resident must have
resided at the facility before hospitalization, have a right to return,
and choose to return; 3. The facility must have the capacity to provide
the necessary service and meet applicable licensing and certification
requirements of the state; 4. The facility must be willing to accept
substantially similar payment as a facility under contract with the
insurer or MCO.
My bill also requires an insurer or MCO to pay for a service to one
of its beneficiaries, without a prior hospital stay, if the service is
necessary to prevent a hospitalization of the beneficiary and the
service is provided as an additional benefit. Lastly, the bill requires
an insurer or MCO to provide coverage to a beneficiary for services
provided at a facility in which the beneficiary's spouse already
resides, even if the facility is not under contract with the MCO,
provided the other requirements are met.
In conclusion, Mr. President, I am committed to providing a safety
net for our seniors--this bill is part of that safety net. Seniors
deserve quality, affordable health care and they deserve choice. This
bill offers those residing in retirement communities and long term care
facilities assurance to have their choices respected, to have where
they reside recognized as their ``home'', and to be permitted to return
to that ``home'' after a hospitalization. It ensures that spouses can
be together as long as possible. And it ensures access to care in order
to prevent a hospitalization. I urge my colleagues to join me in
passing this important measure to protect the rights of seniors and
their access to continuing care.
______
By Mr. HATCH (for himself, Mr. Bennett, and Mr. Bingaman):
S. 1998. A bill to authorize an interpretive center and related
visitor facilities within the Four Corners Monument Tribal Park, and
for other purposes; to the Committee on Indian Affairs.
THE FOUR CORNERS INTERPRETIVE CENTER ACT
Mr. HATCH. Mr. President, I rise today to introduce legislation that
would authorize an interpretive center and visitor facilities at the
Four Corners National Monument. As my colleagues know, Four Corners is
the only place in our country where four state boundaries meet. Over a
quarter of a million people visit this monument every year.
The Four Corners area is also unique for reasons other than the
political boundaries of four states. Once inhabited by the earliest
Americans, the Anaxazi, this area is rich in historical,
archaeological,and cultural significance as well as natural beauty.
Currently, however, there is nothing at Four Corners that would help
visitors to fully appreciate and learn about the area. And, at a
national monument that has 250,000 visitors a year, one would expect
certain basic facilities to exist--restrooms, for example. But, there
is no electricity, running water, telephone, or permanent structure at
Four Corners.
The bill I am introducing today is simple: We propose a Federal
matching grant to build an interpretive center and visitor facilities
within the boundaries of Four Corners Monument Tribal Park.
We are not suggesting a museum the size of the Guggenheim. But,
exhibits on the history, geography, culture, and ecology of the region
would significantly enhance the area and Americans' appreciation of
this unique part of their country and their heritage. And, I daresay
that some very basic guest amenities would enhance their enjoyment of
it.
There is, as you can imagine, a great deal of excitement and
enthusiasm for this project from many fronts. Currently, the Monument
is operated as one of the units of the Navajo Nation Parks and
Recreation Department. And, since there has been so much debate about
``monuments'' recently, I should clarify that the Four Corners
``Monument'' is merely a slightly elevated concrete slab at the
juncture of our four states.
The Navajo Nation owns the land in the Arizona, New Mexico, and Utah
quarters and the Ute Mountain Ute Tribe owns the quarter in Colorado.
Although the Navajo Nation and the Ute Mountain Ute Tribe are fully
supportive of the project and have entered into an agreement with one
another in order to facilitate planning and development at the Four
Corners Monument, neither Tribe has the necessary resources to improve
the facilities and create an interpretive center at the Monument.
The bill, however, does not contemplate federal government give-away.
The bill requires matching funds from nonfederal sources and for the
two tribes to work collaboratively toward the development of a
financial management plan. It is intended that the Interpretive Center
become fully self-sufficient within five years.
The bill requires that proposals meeting the stated criteria be
submitted to the Secretary of the Interior. These criteria include,
among other things, compliance with the existing agreements between the
Navajo and Ute Mountain Ute Tribes, a sound financing plan, and the
commitment of nonfederal matching funds. The federal contribution would
not exceed $2.25 million over a 5 year period.
Over the past several years, the Navajo Nation has met with many of
the local residents of the area and has found overwhelming support to
improve the quality of the services provided at the Four Corners
Monument. The local area suffers an unemployment rate of over 50
percent and any development which would create employment opportunities
and would encourage visitors to stay longer in the area would be
welcomed.
Another important participant in the development of this proposal is
the Four Corners Heritage Council. This Council, which was established
in 1992 by the governors of the four states, is a coalition of private,
tribal, federal, state, and local government interests committed to
finding ways to make the economy of the Four Corners region sustainable
into the future. The mission of the Heritage Council is to guide the
region toward a balance of the sometimes competing interests of
economic development, resource preservation, and maintenance of
traditional life ways.
Back in 1949, nearly 50 years ago, the governors of the states of
Arizona, Colorado, New Mexico, and Utah assembled at the Four Corners
in a historic meeting. Each governor sat in their respective state and
had what is probably the most unusual picnic lunch in history. They
pledged to meet often at the Four Corners Monument to reaffirm their
commitment to working together. Clearly, the governors understood that
they shared stewardship of a unique piece of western real estate.
Mr. President, the heritage of this area belongs to all Americans.
The small investment requested in this legislation will help bring it
to life.
Mr. President, I ask unanimous consent that the text of the bill be
printed in the Record.
There being no objection, the bill was ordered to be printed in the
Record, as follows:
S. 1998
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Four Corners Interpretive
Center Act''.
SEC. 2. FINDINGS AND PURPOSES.
(a) Findings.--Congress finds that--
(1) the Four Corners Monument is nationally significant as
the only geographic location in the United States where 4
State boundaries meet;
(2) the States with boundaries that meet at the Four
Corners area are Arizona, Colorado, New Mexico, and Utah;
(3) between 1868 and 1875 the boundary lines that created
the Four Corners were drawn, and in 1899 a monument was
erected at the site;
(4) a United States postal stamp will be issued in 1999 to
commemorate the centennial of the original boundary marker;
(5) the Four Corners area is distinct in character and
possesses important historical, cultural, and prehistoric
values and resources within the surrounding cultural
landscape;
(6) although there are no permanent facilities or utilities
at the Four Corners Monument Tribal Park, each year the park
attracts approximately 250,000 visitors;
(7) the area of the Four Corners Monument Tribal Park falls
entirely within the Navajo Nation or Ute Mountain Ute Tribe
reservations;
(8) the Navajo Nation and the Ute Mountain Ute Tribe have
entered into a Memorandum of Understanding governing the
planning and future development of the Four Corners Monument
Tribal Park;
[[Page S3722]]
(9) in 1992 through agreements executed by the governors of
Arizona, Colorado, New Mexico, and Utah, the Four Corners
Heritage Council was established as a coalition of State,
Federal, tribal, and private interests;
(10) the State of Arizona has obligated $45,000 for
planning efforts and $250,000 for construction of an
interpretive center at the Four Corners Monument Tribal Park;
(11) numerous studies and extensive consultation with
American Indians have demonstrated that development at the
Four Corners Monument Tribal Park would greatly benefit the
people of the Navajo Nation and the Ute Mountain Ute Tribe;
(12) the Arizona Department of Transportation has completed
preliminary cost estimates that are based on field experience
with rest-area development for the construction of a Four
Corners Monument Interpretive Center and surrounding
infrastructure, including restrooms, roadways, parking,
water, electrical, telephone, and sewage facilities;
(13) an interpretive center would provide important
education and enrichment opportunities for all Americans.
(14) Federal financial assistance and technical expertise
are needed for the construction of an interpretive center.
(b) Purposes.--The purposes of this Act are--
(1) to recognize the importance of the Four Corners
Monument and surrounding landscape as a distinct area in the
heritage of the United States that is worthy of
interpretation and preservation;
(2) To assist the Navajo Nation and the Ute Mountain Ute
Tribe in establishing the Four Corners Interpretive Center
and related facilities to meet the needs of the general
public;
(3) To highlight and showcase the collaborative resource
stewardship of private individuals, Indian tribes,
universities, Federal agencies, and the governments of States
and political subdivisions thereof (including counties);
(4) to promote knowledge of the life, art, culture,
politics, and history of the culturally diverse groups of the
Four Corners region.
SEC. 3. DEFINITIONS.
As used in this Act--
(1) Center.--The term ``Center'' means the Four Corners
Interpretive Center established under section 4, including
restrooms, parking areas, vendor facilities, sidewalks,
utilities, exhibits, and other visitor facilities.
(2) Four corners heritage council.--The term ``Four Corners
Heritage Council'' means the nonprofit coalition of Federal,
State, and tribal entities established in 1992 by agreements
of the Governors of the States of Arizona, Colorado, New
Mexico, and Utah.
(3) Secretary.--The term ``Secretary'' means the Secretary
of the Interior.
(4) Recipient.--The term ``Recipient'' means the State of
Arizona, Colorado, New Mexico, or Utah, or any consortium of
two or more of these states.
(5) Four corners monument.--The term ``Four Corners
Monument'' means the physical monument where the boundaries
of the states of Arizona, Colorado, New Mexico and Utah meet.
(6) Four corners monument tribal park.--The term ``Four
Corners Monument Tribal Park'' means lands within the legally
defined boundary of the Four Corners Monument Tribal Park.
SEC. 4. FOUR CORNERS MONUMENT INTERPRETIVE CENTER.
(a) Establishment.--Subject to the availability of
appropriations, the Secretary is authorized to establish
within the boundaries of the Four Corners Monument Tribal
Park a center for the interpretation and commemoration of the
Four Corners Monument, to be known as the ``Four Corners
Interpretive Center.''
(b) Land for the Center shall be designated and made
available by the Navajo Nation or the Ute Mountain Ute Tribe
within the boundary of the Four Corners Monument Tribal Park
in consultation with the Four Corners Heritage Council and in
accordance with--
(1) the memorandum of understanding between the Navajo
Nation and the Ute Mountain Ute Tribe that was entered into
on October 22, 1996; and
(2) applicable supplemental agreements with the Bureau of
Land Management, the National Park Service, the United States
Forest Service.
(c) Concurrence.--Notwithstanding any other provision of
this Act, no such center shall be established without the
consent of the Navajo Nation and the Ute Mountain Ute Tribe.
(d) Components of Center.--The Center shall include--
(1) a location for permanent and temporary exhibits
depicting the archaeological, cultural, and natural heritage
of the Four Corners region;
(2) a venue for public education programs;
(3) a location to highlight the importance of efforts to
preserve southwestern archaeological sites and museum
collections;
(4) a location to provide information to the general public
about cultural and natural resources, parks, museums, and
travel in the Four Corners region; and
(5) visitor amenities including restrooms, public
telephones, and other basic facilities.
SEC. 5. CONSTRUCTION GRANT.
(a) Grant.--The Secretary is authorized to award a Federal
grant to the Recipient described in section 3(4) for up to 50
percent of the cost to construct the Center. To be eligible
for the grant, the Recipient shall provide assurances that--
(1) The non-Federal share of the costs of construction is
paid from non-Federal sources. The non-Federal sources may
include contributions made by States, private sources, the
Navajo Nation and the Ute Mountain Ute Tribe for planning,
design, construction, furnishing, startup, and operational
expenses.
(2) The aggregate amount of non-Federal funds contributed
by the States used to carry out the activities specified in
subparagraph (A) will not be less than $2,000,000, of which
each of the states that is party to the grant will contribute
equally in cash or in kind.
(3) States may use private funds to meet the requirements
of paragraph (2).
(4) The State of Arizona may apply $45,000 authorized by
the State of Arizona during fiscal year 1998 for planning and
$250,000 that is held in reserve by that State for
construction towards the Arizona share.
(b) Grant Requirements.--In order to receive a grant under
this Act, the Recipient shall--
(1) submit to the Secretary a proposal that meets all
applicable--
(A) laws, including building codes and regulations;
(B) requirements under the Memorandum of Understanding
described in paragraph (2) of this subsection; and
(C) provides such information and assurances as the
Secretary may require.
(2) The Recipient shall enter into a Memorandum of
Understanding (MOU) with the Secretary providing--
(A) a timetable for completion of construction and opening
of the Center;
(B) assurances that design, architectural and construction
contracts will be competitively awarded;
(C) specifications meeting all applicable Federal, State,
and local building codes and laws;
(D) arrangements for operations and maintenance upon
completion of construction;
(E) a description of center collections and educational
programming;
(F) a plan for design of exhibits including, but not
limited to, collections to be exhibited, security,
preservation, protection, environmental controls, and
presentations in accordance with professional museum
standards;
(G) an agreement with the Navajo Nation and the Ute
Mountain Ute Tribe relative to site selection and public
access to the facilities;
(H) a financing plan developed jointly by the Navajo Nation
and the Ute Mountain Ute Tribe outlining the long-term
management of the Center, including but not limited to--
(i) the acceptance and use of funds derived from public and
private sources to minimize the use of appropriated or
borrowed funds;
(ii) the payment of the operating costs of the Center
through the assessment of fees or other income generated by
the Center;
(iii) a strategy for achieving financial self-sufficiency
with respect to the Center by not later than 5 years after
the date of enactment of this Act; and
(iv) defining appropriate vendor standards and business
activities at the Four Corners Monument Tribal Park.
SEC. 6. SELECTION OF GRANT RECIPIENT.
The Secretary is authorized to award a grant in accordance
with the provisions of this Act. The Four Corners Heritage
Council may make recommendations to the Secretary on grant
proposals regarding the design of facilities at the Four
Corners Monument Tribal Park.
SEC. 7. AUTHORIZATION OF APPROPRIATIONS.
In General.--(a) Authorizations.--There are authorized to
be appropriated to carry out this Act--
(1) $2,000,000 for fiscal year 1999;
(2) $50,000 for each of fiscal years 2000-2004 for
maintenance and operation of the Center, program development,
or staffing in a manner consistent with the requirements of
section 5(b).
(b) Carryover.--Any funds made available under this section
that are unexpended at the end of the fiscal year for which
those funds are appropriated may be used by the Secretary
through fiscal year 2001 for the purposes for which those
funds were made available.
(c) Reservation of Funds.--The Secretary may reserve funds
appropriated pursuant to this Act until a proposal meeting
the requirements of this Act is submitted, but no later than
September 30, 2000.
SEC. 8. DONATIONS.
Notwithstanding any other provision of law, for purposes of
the planning, construction, and operation of the Center, the
Secretary may accept, retain, and expend donations of funds,
and use property or services donated from private persons and
entities or from public entities.
SEC. 9. STATUTORY CONSTRUCTION.
Nothing in this Act is intended to abrogate, modify, or
impair any right or claim of the Navajo Nation or the Ute
Mountain Ute Tribe, that is based on any law (including any
treaty, Executive order, agreement, or Act of Congress).
Mr. BINGAMAN. Mr. President, I am pleased to rise today to co-sponsor
this important legislation introduced by my friend from Utah, Senator
Hatch. The bill authorizes the construction of an interpretive visitor
center at the Four Corners Monument. As I am sure
[[Page S3723]]
all senators know, the Four Corners is the only place in America where
the boundaries of four states meet in one spot. The monument is located
on the Navajo and Ute Mountain Ute Reservations and operated as a
Tribal Park. Nearly a quarter of a million people visit this unique
site every year. However, currently there are no facilities for
tourists at the park and nothing that explains the very special
features of the Four Corners region. The bill authorizes the Department
of the Interior to contribute $2 million toward the construction of a
much needed interpretive center for visitors.
Mr. President, the Four Corners Monument is more than a geographic
curiosity. It also serves as a focal point for some of the most
beautiful landscape and significant cultural attractions in our
country. An interpretive center will help visitors appreciate the many
special features of the region. For example, within a short distance of
the monument are the cliff dwellings of Mesa Verde, Colorado; the Red
Rock and Natural Bridges areas of Utah; and in Arizona, Monument Valley
and Canyon de Chelly. The beautiful San Juan River, one of the top
trout streams in the Southwest, flows through Colorado, New Mexico, and
Utah.
In my state of New Mexico, both the legendary mountain known as
Shiprock and the Chaco Canyon Culture National Historical Park are a
short distance from the Four Corners.
Mr. President, Shiprock is one of the best known and most beautiful
landmarks in New Mexico. The giant volcanic monolith rises nearly 2,000
feet straight up from the surrounding plain. Ancient legend tells us
the mountain was created when a giant bird settled to earth and turned
to stone. In the Navajo language, the mountain is named Tse' bi t'ai or
the Winged Rock. Early Anglo settlers saw the mountain's soaring spires
and thought they resembled the sails of a huge ship, so they named it
Shiprock.
The Four Corners is also the site of Chaco Canyon. Chaco was an
important Anasazi cultural center from about 900 through 1130 A.D. Pre-
Columbian civilization in the Southwest reached its greatest
development there. The massive stone ruins, containing hundreds of
rooms, attest to Chaco's cultural importance. As many as 7,000 people
may have lived at Chaco at one time. Some of the structures are thought
to house ancient astronomical observatories to mark the passage of the
seasons. The discovery of jewelry from Mexico and California and a vast
network of roads is evidence of the advanced trading carried on at
Chaco. Perhaps, the most spectacular accomplishment at Chaco was in
architecture. Pueblo Bonito, the largest structure, contains more than
800 rooms and 32 kivas. Some parts are more than five stories high. The
masonry work is truly exquisite. Stones were so finely worked and
fitted together that no mortar was needed. Remarkably all this was
accomplished without metal tools or the wheel.
Mr. President, 1999 marks the centennial year of the first monument
at the Four Corners. An interpretive center is urgently needed today to
showcase the history, culture, and scenery of this very special place.
New facilities at the monument will attract visitors and help stimulate
economic development throughout the region. I am pleased to co-sponsor
this bill with Senator Hatch, and I thank him for his efforts.
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