[Congressional Record Volume 144, Number 84 (Wednesday, June 24, 1998)]
[House]
[Pages H5275-H5287]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                ON MEDICARE CUTS TO HOME HEALTH SERVICES

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 7, 1997, the gentleman from Massachusetts (Mr. McGovern) is 
recognized for 60 minutes as the designee of the minority leader.
  Mr. McGOVERN. Mr. Speaker, tonight I join my House colleagues to 
discuss the home health care cuts contained in last year's Balanced 
Budget Act. While I have pushed this issue in Congress, and with the 
Clinton administration since November, time is running out.

                              {time}  2045

  If Congress is going to find the will to fix this problem, all sides 
are going to need to act quickly and move this issue forward and move 
it forward now.
  Mr. Speaker, a hastily conceived and ill-considered provision in last 
year's Balanced Budget Act mandated deep cuts in the Federal 
Government's commitment to home health care. My colleagues and I take 
to the floor tonight to shed some light on this national crisis.
  When the Balanced Budget Act of 1997 was passed into law, it cut 
Medicare by $115 billion over five years. Between $16 and $17 billion 
of the Medicare cuts came out of home health care through the 
institution of a per-beneficiary cap under an interim payment system. 
The new formula for home health care in the act will cap Medicare 
payments to home health care

[[Page H5276]]

agencies based on costs from four or five years ago, regardless of how 
efficient or wasteful an agency was at that time.
  Now, try going to your local car dealer and telling them that you are 
only willing to pay 1993 prices for your new car. Rightly so, they 
would laugh you off the lot. But that is exactly what the Balanced 
Budget Act does to home health care providers throughout this country 
in order to save money.
  Further, agencies are caught in a Catch-22 under this act. They are 
forced to cut agency costs back to 1993 levels, but Federal law 
prevents them from cutting back on the care they provide today.
  In addition, eligibility requirements for people to receive home care 
services have not changed at all. Those who qualified for home health 
care before the Balanced Budget Act qualify for home health care today, 
and under law, they must be treated.
  How do agencies cut back their costs some 20 percent without cutting 
back care? Well, in Massachusetts they have been closing their doors to 
everyone and getting out of the home health care business altogether. 
The rationale for the cuts in the Balanced Budget Act was that costs in 
home health care were spiraling out of control because of waste, fraud 
and abuse. And while we are all against waste, fraud and abuse, the 
Balanced Budget Act that passed this Congress made no distinction 
between wasteful providers and efficient ones.
  The fact that my home State of Massachusetts has been nationally 
recognized as a leader in providing efficient home health care was 
apparently lost on the budget negotiators. The Balanced Budget Act cut 
wasteful agencies and efficient agencies at nearly identical rates. In 
Massachusetts and many other States where there is very little fat to 
trim, these cuts are going right to the bone. And even in traditionally 
inefficient States, the providers that did the right thing and kept 
costs down are being punished for that action. It is as if this 
Congress is saying to these agencies, these efficient agencies, shame 
on you for being efficient. Shame on you for being cost-effective. 
Shame on you for putting patients first. It is crazy.
  Waste was rewarded in the Balanced Budget Act, and fraud and waste 
and abuse were not attacked. In fact, HCFA's own statistical data for 
1994 shows that Massachusetts has the fourth lowest cost per home 
health care visit of any State. Further, Massachusetts passed a State 
initiative to encourage the use of home health care, avoiding the more 
costly alternative of moving seniors to a nursing home and, thus, 
saving tax dollars. But under the Balanced Budget Act, we are being 
punished for our forethought.
  I strongly support balancing the budget. I recognize the need to 
crack down on waste, fraud and abuse. But the version of the Balanced 
Budget Act that passed was an example of what happens when legislation 
is negotiated in back rooms and pushed through Congress without 
appropriate hearings, without committee oversight and without the 
opportunity for Members to examine closely the bill that they are about 
to vote on.
  We are now beginning to see the effects of that provision, both in my 
home State of Massachusetts and across this Nation. Just a few months 
ago the Massachusetts legislature and the Governor of my home State 
worked together to investigate the impact of the Balanced Budget Act on 
the State.
  In May the Commissioner of the Division of Health Care Finance and 
Policy in Massachusetts issued a report which stated that the Balanced 
Budget Act may result in, and I quote, ``a large number of chronically 
ill patients being admitted to long-term care facilities at 
significantly greater cost to both the Medicare and Medicaid 
programs.''
  In essence, Congress passed an unfunded mandate on the States last 
year. By cutting home health care, seniors and the disabled will be 
placed in nursing homes. While the exact dollar cost to Massachusetts 
taxpayers is still unclear, I would like to commend my State's leaders 
for their efforts to shed more light on this issue and bring concrete 
information to the debate.
  Attorneys General from across the Nation have also recognized the 
depth of the problem in home health care. Nineteen of them have 
endorsed H.R. 3205, a bill that I have introduced to fix the home 
health care crisis. At least three independent studies have assessed 
the impact of the interim payment system enacted in the Balanced Budget 
Act. The results are chilling. All the studies show that the interim 
payment system will most deeply harm patients with chronic, complex and 
incurable illnesses. The studies also show that the agencies that 
provide these services will be hurt.
  According to the report by the Massachusetts Division of Health Care 
Finance and Policy, the Balanced Budget Act will result in a $111 
million cut to Massachusetts citizens needing home health care, and 
some have estimated that the Balanced Budget Act is threatening 1.5 
million doctor-prescribed home health care visits in Massachusetts this 
year alone.
  While only one in 10 Medicare beneficiaries use home health care 
services, those who do are poorer, sicker, more often female, more 
likely to live alone and have more mobility problems than the Medicare 
population generally.
  Approximately 25 percent of these, quote, frail elderly in 
Massachusetts are over the age of 85. These are the people who are 
currently at risk for premature institutionalization since the 
enactment of the Balanced Budget Act.
  There is also an economic component to this issue. Last year the home 
health care industry employed 18,000 people and was one of the major 
employers in Massachusetts. This year the numbers will be far less. To 
date, in Massachusetts the home health care community has laid off well 
over 600 staff and these reductions in staffing levels, particularly 
direct care staff, dramatically decrease patient access to quality 
care. Many of the people losing jobs are women who are trying to stay 
off of welfare or who were on welfare at one time. This is a 
particularly hard time to turn these workers out, given Federal changes 
under welfare reform.
  According to a survey by the Home & Health Care Association of 
Massachusetts, 60 percent of their member agencies anticipate staff 
reductions over the next fiscal year. But numbers, of course, do not 
tell the whole story. And there is an enormous human cost to this 
crisis.

  There is the story of Massachusetts Easter Seals. Massachusetts 
Easter Seals provides critical assistance to some of my State's most 
frail residents, and they do a tremendous job. But because of what 
Congress passed, they are being forced to eliminate their home health 
care program which served patients suffering from multiple sclerosis, 
Alzheimers, cancer, as well as those who are disabled or suffer from 
serious medical problems.
  Mr. Speaker, over 500 patients will now be thrust into a shrinking 
home health care industry. Because of the Balanced Budget Act, very few 
agencies are looking for new patients, especially those with chronic 
and severe illnesses or disabilities. And 120 employees are being laid 
off as a result of Massachusetts's Easter Seals home health care agency 
closing its doors.
  Now we have another victim in Massachusetts. The Assabet Valley Home 
Health Care Association in Marlborough, Massachusetts was trying to 
merge with a local hospital because they could not survive under the 
Balanced Budget Act as a freestanding agency. Two and a half months ago 
they asked the Health Care Finance Administration for a determination 
of what their reimbursement level will be under the new formulas in the 
act.
  Until the gentleman from Massachusetts (Mr. Meehan) and I intervened 
last week, they had not received an answer and the prospect of a merger 
was terminated. One hundred thirty people have lost their jobs. Over 
400 people will have to find a new provider of home health care 
services. The same scenario is occurring all over this Nation, and the 
efficient nonprofits are repeatedly the first to go.
  Mr. Speaker, many of my House colleagues have recognized and are 
responding to how these costly errors in the Balanced Budget Act are 
affecting home health care. Over 100 Members of the House from both 
parties have cosponsored legislation, sent letters to the 
administration or stood up for home health care in their communities. 
Several Members of the other body have also begun looking for a 
solution to this issue.

[[Page H5277]]

  And this pressure is having an effect here in Congress. Many Members 
who were most opposed to changing the Balanced Budget Act and who 
believed that these cuts were necessary are now beginning to change.
  In the House, we have seen motion on this issue. I want to commend my 
colleagues from both sides of the aisle who have pushed this issue 
forward.
  At a Senate Finance Committee meeting in Washington on March, 12, 
Senators gathered to review the mistakes caused in the Balanced Budget 
Act as it relates to home health care. After months of pressure, I am 
pleased to tell you that at a meeting earlier this month, Christopher 
Jennings, Deputy Assistant to President Clinton for Health Policy, 
promised me that the White House will work with Congress to solve this 
crisis and will help move a bill through this Congress for passage.
  I want to especially commend the grass roots efforts to solve this 
crisis for all they have done so far. Every day Members of Congress are 
hearing from senior citizens or patients in their district, from the 
medical community and from home health care providers. As an example, 
just today I received a letter from 22 national organizations that are 
members of the Consortium for Citizens with Disabilities, which I will 
enter in the Congressional Record.
  They endorse my bill and they have asked Congress to change the home 
health care provisions of the Balanced Budget Act this year.
  Clearly people across the Nation are becoming educated on this issue. 
Home health care is in critical condition. Time is running out. Our 
most vulnerable citizens are at risk. Congress must act now, if we are 
to keep people at home with their families.
  I believe home health patients should be comfortable, at home, and 
should stay with their loved ones for as long as possible, not 
institutionalized in more expensive nursing homes. I believe that those 
are the family values that this Congress should stand for.
  Mr. Speaker, Congress must act to resolve this crisis before we 
adjourn this year. People are being hurt now, and we cannot afford to 
wait. I call upon my colleagues and the leadership of this House, and I 
call upon Speaker Gingrich to move quickly on this issue to allow us 
the opportunity to debate this issue on the floor, to bring this issue 
up so we can correct the mistakes that were made a year ago in this 
Congress.
  Mr. Speaker, I yield to the gentlewoman from Michigan, (Ms. 
Stabenow), a leader in trying to correct the mistakes in the Balanced 
Budget Act, who has been very outspoken on behalf of home health care 
agencies in her district and across this country and somebody who has 
put patients first.
  Ms. STABENOW. Mr. Speaker, I thank the gentleman from Massachusetts 
(Mr. McGovern) for yielding to me.
  I first want to thank him for very quickly moving, when this was 
brought to our attention, to put in his bill, H.R. 3205.
  I was very pleased to be an original cosponsor with him to delay the 
interim payments system, as he has indicated there are other bills as 
well that change the formula.
  The gentleman from New Jersey (Mr. Pappas) has a bill that also would 
right many of the wrongs, and there are certainly a number of options 
for us.
  I rise also, coming from a State that is extremely efficient. We 
have, as a State, been serving people in their homes for a little over 
$3800 per user, which is less than the national average of a little 
over $4600, $3800 versus $4600. And we know that there are providers 
that are using as much as $9000 per user, per patient.
  One of the difficulties with the way that the Health Care Finance 
Administration has begun to implement the changes in the balanced 
budget agreement is by doing it across the board, as opposed to looking 
at the high-user States or the high-user providers and addressing them.
  Instead they are penalizing everyone. In States like Michigan, where 
we have very dedicated small businesses, nonprofits, visiting nurses 
associations, Easter Seals, that have been working very diligently to 
keep costs down and yet provide very high quality care, they are being 
penalized. We are going to see a reduction of some 27 percent, and we 
are looking at possibly as high as 80,000 people in my home State over 
the next 2 years that will not be able to receive service.
  This is a critical issue. As you have indicated, this is one that 
needs to be addressed now. It needs to be addressed tomorrow. As soon 
as possible. We have changes taking place July 1 that will greatly 
impact these home health care providers, and we need to make this a top 
priority.
  I want to speak for a moment, if I might, about the kinds of 
responses and the kinds of conversations I have had with families in my 
district, not just now around home health care but over the last 2 
years representing the people of the 8th district.

                              {time}  2100

  When I first was campaigning 2 years ago, I was amazed at the number 
of homes as you walk down the street that had ramps on the front of 
their homes. The number of people that were asking me about home health 
care for their mother, their father, their husband, their wife, another 
loved one, this is one of the top issues on the minds of the people 
that I represent.
  We all know of loved ones who need care. It is not only better for 
them and for the family to support them at home, but we know it saves 
tax dollars. So it is really amazing to me that we would be looking at 
these kinds of drastic cuts in something that saves money as well as 
providing quality care for families, for individuals. This just makes 
no sense at all.
  I supported the balanced budget agreement. I want to have the budget 
balanced. I support going after fraud and abuse, but I can tell my 
colleagues, in Michigan, with my home care providers, they are not the 
folks that we ought to be focusing the attention on, because they are 
providing quality care at very low cost.
  I did want to mention one other issue as well, and that is the whole 
issue of surety bonds. This is something that HCFA can address 
themselves right now if they choose to do that tomorrow morning. I 
would call on the administration of HCFA to do this.
  We put in place a requirement to protect, for new home health 
agencies that were opening, requiring a surety bond of $50,000 or 15 
percent. The maker of that amendment indicated that she meant whichever 
was less.
  Instead, we are seeing efforts that have gone into place that are 
requiring people to go for a higher amount, whichever is more, 50,000 
or 15 percent, whichever is more rather than whichever is less.
  What does that mean? Right now, only 41 percent of the home health 
care agencies across our country have been able to get a surety bond. 
The rule regarding having to have a surety bond takes effect July 1.
  Time is running out. We have got to see some kind of a response that 
is reasonable to those that are on the frontlines providing home health 
care. We have got to make sure that it is done in a timely manner.
  So I join with the gentleman from Massachusetts (Mr. McGovern) 
calling on the Speaker of the House. There are vehicles. We have the 
gentleman's bill. We have other bills. We do not care if it is a 
Republican bill. We do not care if it is a Democratic bill. We just 
need action now because the people at home are going to be feeling the 
effects. We are going to see businesses closing, home health care not 
provided. And this is one of the most critical issues facing our 
families.
  So I am pleased to join with my colleagues tonight, calling for 
action.
  Mr. McGOVERN. Mr. Speaker, I thank the gentlewoman for her comments, 
and she raises two points that I think deserve to be emphasized again; 
and that is that if we are truly trying to save money, and that is what 
one of the goals of the balanced budget act was about, this is not the 
way to do it.
  You do not need to be a mathematician or an expert in health care to 
know that it is a lot cheaper to provide somebody good quality care at 
home than to have that person in a long-term nursing care facility or a 
nursing home.
  The other thing that my colleague raises, which I think is very 
important, and that is this whole issue of how do you encourage 
efficiency and cost effectiveness. Massachusetts has some

[[Page H5278]]

great home health care agencies, visiting nurse associations who have 
been very good, who have been very efficient.
  But the way this whole thing has been put together, in essence, we 
are punishing those who have been good. It is almost as if we are 
saying to these people you should have been bad. You should have padded 
the books. You should not have been cost efficient and effective; 
because if you violated all of the things that we asked you to do, you 
would be okay right now, because you would only be trimming the fat.
  It is the good agencies that are being put out of business. I think 
that is sad, and it goes against and it contradicts what this Congress 
is supposed to be all about. It contradicts what this administration 
says its goal is in health care.
  So I commend the gentlewoman for her comments. We are going to make 
sure we work together; that something happens. We are all dedicated in 
this here. We need to convince our leadership in this Congress that 
this issue is important enough to have a vote now.
  I sent a letter to Speaker Gingrich, which I would like to enter into 
the record now, saying maybe we can bring this up during the technical 
corrections billion. We need to do this quickly. Clearly, this issue is 
of such importance that I think it takes precedence even over some of 
the things we have been doing in this Congress. So I thank the 
gentlewoman for her comments.
  Mr. Chairman, I yield to the gentleman from Rhode Island (Mr. 
Weygand) who has been an effective leader in this issue. I was with him 
at Warwick, Rhode Island in a health care agency, and it was a great 
rally with over 200 people all protesting these cutbacks and demanding 
that Congress fix it.
  I yield to my colleague the gentleman from Rhode Island (Mr. 
Weygand).
  Mr. WEYGAND. Mr. Speaker, I want to thank the gentleman from 
Massachusetts (Mr. McGovern) for yielding me this time.
  Mr. Speaker, the discussion we are embarking on is very important for 
a lot of reasons. Home health care is, indeed, without a question, a 
kind of health care system right now in deep peril.
  A lot of times, people will look at the home health care system and 
think about just the numbers and the dollars and the cents. Something 
that we fail to recognize often unless you had a family member or 
friend who has been receiving home health care is that home health care 
providers provide a lot more than just simply the medical services.
  They come into our homes, they come into our families, and they 
provide a friendship and a warmth and the kind of camaraderie that goes 
along with the health care system and the provisions that they are 
giving to our seniors, to our disabled.
  They reduce the cost of health care tremendously, as we have heard 
from the gentlewoman from Michigan (Ms. Stabenow) and from the 
gentleman from Massachusetts (Mr. McGovern).
  The average cost throughout the country is only approximately $4,600 
per year. Many States like the gentleman's State and my State have 
tremendously cut those costs. My State, in 1996, had a cost of 
approximately $4,000 per year per patient for home health care.
  The wonderful thing about home health care is that it prevents many 
people from going into acute care facilities and long-term care 
facilities. But if we want to talk about dollars and cents, let us talk 
about them. Talk about what it costs for an average per patient cost 
per year; $4,600. In Massachusetts, it is $3,800 per year. In Rhode 
Island, it is $4,000. In Michigan, I think it is around $3,900 per 
year.
  If that same person is forced into acute care facility or even a 
long-term care facility, the average cost on a national basis is around 
$40,000 per year for a Medicaid recipient. That is shared about 50 
percent by the State government and 50 percent on the Federal 
Government. That means, on the Federal side, we would be spending 
$20,000 out of the Federal budget per year per patient.
  It does not take much to determine that home health care is the far 
better bargain for the taxpayers and the Federal Government. We want to 
make sure that they stay in home health care versus a far more 
expensive acute care or nursing home facility. Granted, we have great 
facilities like that; and where they are needed, they are there for our 
patients. But it is far better to have someone at home.

  At home, they get more assistance from home health care, but they 
also get assistance from family and friends. The unique thing about it 
is we are giving them a life of dignity and independence.
  A lot of times, we talk about numbers and providers without seeing 
the faces of these people. The gentleman from Massachusetts (Mr. 
McGovern), the gentlewoman from Michigan (Ms. Stabenow), and the 
gentleman from Maine (Mr. Allen) and I have all visited, as well as 
other people on the other side of the aisle, many different people in 
many different places to try and find out the real problem.
  Let me tell you about a young lady that I visited with about a month 
and a half ago. Her name is Genevieve Weeser. Genevieve lives in 
Warwick, Rhode Island in the middle of the second congressional 
district in Rhode Island.
  I went over and met with her. Genevieve is 98 years young. She is at 
home. She is in an apartment that she has, a Federally subsidized 
apartment unit, and she has friends who assist her. She is 98. She 
receives one nurse who comes in once a week to try to take care of her 
medications and monitor her various vital signs to be sure she is okay.
  On top of that, she gets some small homemaker service. She has 
friends who come in and help her. She has family who comes in and helps 
her. But without that kind of activity, without that kind of home care, 
she would be, without a doubt, in a far more expensive acute care 
setting or nursing home.
  Her care has been cut nearly in half now because of the IPS system. 
She is going to be receiving half the number of visits and half the 
care. Eventually what will happen is she will end up in the nursing 
home some place, costing the taxpayers of Rhode Island and the Federal 
Government far more money than what we would have had with home health 
care.
  Last year, when we made that revision in the budget and we put in a 
system that we thought would, indeed, try to give us a transition into 
a new prospective payment system from home health care, it did a lot of 
things that we were not familiar with, and that is why we need to 
change it.
  First of all, home health care only represents 9 percent of the 
entire Medicare budget. Yet, it was targeted for over 14 percent of the 
cuts. It took a large hit. On top of that, it was the manner in which, 
as we have all heard tonight, that home health care agencies were 
targeted. It was one swoop across the top.
  We had in Rhode Island one VNA already go out of business. It had 
been in business for 87 years, a nonprofit agency providing quality 
home health care at a cost of less than $3,600 per year per patient. It 
had to close its door. Kent County VNA had to lay off 11 people. It cut 
most of its visits in half.
  Do my colleagues know what? All of these good quality, very cost 
effective agencies have been driven to virtually close their doors, cut 
down on their employees. Yet, there is a unique part of the IPS system 
that many people do not know about, that if the gentleman or I started 
a new agency last year, and only had a 1-year track record and had 
costs of around $5,000 or $6,000 per year per patient, and we bought up 
those other agencies, those great cost effective agencies, acquire them 
somehow, we would now get, not the old rate that they are now required 
to keep, the 1993 rates or 1994 rates, but if I were a new agency 
buying up these older agencies, I would get a brand-new rate.
  We are, in fact, saying to these new companies, gobble up the most 
cost effective companies and become fat and wasteful; but to the cost 
effective nonprofits and the ones that have been providing services for 
decades, we are closing the door on them. But more importantly, we are 
closing the door on patients.
  Patients come first. It is not about jobs. It is not about agencies. 
It is about people. What we have done here is drastically wrong.
  We have a bill, the McGovern-Weygand bill. We have other bills, the 
Pappas bill. There are a lot of bills out there that will help correct 
it. Just last month, in the Committee on the

[[Page H5279]]

Budget hearing on the resolution on the budget, I was able to put in 
amendment to the budget, one of only two amendments that were allowed 
as a sense of Congress that said the following.
  First, the interim payment system for home health care services was 
adversely affected and has adversely affected home health care agencies 
and particularly Medicare beneficiaries.
  Second, if home health care is threatened and further reduced, the 
overall health care costs of our people are going to rise. As we push 
down on home health, the cost of acute care facilities and long-term 
care facilities is going to go up. It is only a matter of time when the 
cost for HCFA and Medicare are going to rise if we allow this system to 
stay in place.
  Third, we have asked all the committees of jurisdiction, particularly 
the Committee on Ways and Means, to come up with a revision on the 
interim payment system this year in this Congress before we go home so 
that we can make revisions that are appropriate to take care of the 
people at home.
  Lastly, on the overall picture, we must have in place a prospective 
payment system no later than October 1 of 1999.
  It is going to take the requirements of both parties and particularly 
the leadership on the Republican side to make this occur. In the 
Committee on Ways and Means, we need to have the chairman and the 
subcommittee chairman work with us on both sides of the aisle to come 
up with a revision.
  It is not for us as Democrats or for them as Republicans. This is for 
people at home that need quality care at a cost effective way. We need 
to do it now.
  I want to thank the gentleman from Massachusetts for having us this 
evening for this discussion. I particularly want to thank our friends 
on the other side of the aisle who have done a tremendous job to bring 
this to the forefront. We cannot let this go. We must provide the kind 
of dignity and independence that our people deserve.
  Mr. McGOVERN. Mr. Speaker, I thank the gentleman for his comments and 
his leadership and for reminding this Congress that patients do come 
first and should come first.
  The gentleman gave an example of somebody that he had visited. I had 
a similar situation. I went on a home health care visit with an agency 
in my district and visited a gentleman in Hopkinton, a retired fire 
chief in Hopkinton named Arthur Stewart.
  This was in January, and it was a cold wintry day, and he was sitting 
by his fireplace. He said to me, ``You know, a lot of things I want to 
do in life are right here, even if it is just poking this darn fire. I 
would be totally wiped out financially if I had to be in a nursing home 
or rehab. And I cannot say enough about what the visiting nurses are 
doing for me. And I just cannot see how shortsighted Congress can be.''
  It is people like Arthur Stewart, and there are hundreds, if not 
thousands, of Arthur Stewarts in Massachusetts and throughout the 
country who should compel this Congress to fix this mistake.
  The gentlewoman from Michigan said it and the gentleman from Rhode 
Island said it that we need to act now. I mean, this needs to be done 
now. We cannot put this off until next year. If we do not do something 
now, the cuts are going to adversely impact these home health care 
agencies to the point where people are going to lose their care. They 
are going to be forced into nursing homes. Families are going to be 
devastated. I mean, this is just not right.
  Mr. WEYGAND. Mr. Speaker, if the gentleman will yield just a minute, 
I know my friend, the gentleman from Maine, wants to speak on this 
subject as well. One of the things we have just seen come out of HCFA 
is that the rate of reimbursement that we have right now with this cut, 
HCFA and the people have acknowledged within Medicare that they are 
receiving far less, 93 percent actually is what they are receiving in 
terms of what they should be receiving. They are only receiving 93 
cents on the dollar minimum. In many cases, they are cutting more.

                              {time}  2115

  The other matter is that the amount of surplus that we have seen 
generated from these massive cuts far exceeds what was estimated by CBO 
and everybody else. We are in fact cutting a system so drastically so 
that we can provide tax cuts to other people. That is the terrible 
shame that we have before us. We are taking people that are in dire 
need and we are cutting them to provide tax cuts to other people.
  Mr. McGOVERN. The other irony is that in this Chamber, not a day goes 
by when someone does not rise and talk about unfunded mandates on 
States. Ironically, this provision in the Balanced Budget Act is the 
biggest unfunded mandate on States that we have ever seen. This will be 
devastating to States if they have to pick up an increased cost of 
Medicaid to provide for long-term care. Every single governor has an 
interest in making sure this Congress acts on this issue and acts on it 
now.
  Mr. Speaker, I yield to the gentleman from Maine Mr. Allen) who has 
been a leader on campaign finance reform, who has been a leader on this 
issue as well.
  Mr. ALLEN. I thank the gentleman for yielding. I just want to say to 
the gentleman from Massachusetts Mr. McGovern), the gentleman from 
Rhode Island Mr. Weygand), the gentlewoman from Michigan Ms. Stabenow) 
and the gentlewoman from Texas Ms. Jackson-Lee) that what you are all 
doing in terms of home health care is very important, not just for the 
people in your district, for people all around the country. The 
gentleman from Rhode Island was right. This is at the end of the day 
not just about a few agencies and not just about the Federal 
Government. This is about some of our most vulnerable citizens.
  I have been thinking about this issue a little bit and thinking of so 
many people that I run into in Maine. I have to say that of the people 
who come through my office, probably 25 percent of them are concerned 
in one way or another with health care. When I go out to seniors events 
or senior centers or talk to senior groups throughout the State of 
Maine, health care is always right at the top of their agenda. For most 
people that I talk to who are on that borderline, where the question 
is, can I continue to stay and live at home, or do I need to move into 
some sort of facility, almost all of them want to stay at home as long 
as they can. That seems to be an almost universal desire. The service 
that allows them to stay at home is some form of home health care. So I 
find, I believe, that not only is home health care critically important 
to how well we manage costs at the Federal budget level, but it is also 
critically important to all of those people, unlike us, for whom this 
is a real issue in terms of their health, their quality of life and 
their future.
  Last year we took aggressive action to balance the Federal budget and 
through the Balanced Budget Act deal with the rapid growth and 
perceived fraud and abuse in Medicare's home health benefit.
  I wanted to say a few words about some of the conversation that is 
going on. If we look back at the Balanced Budget Act, we were trying to 
get control of runaway costs in part of our health care system. It was 
not irrational to do that. We have to control fraud and abuse. We have 
to control the explosion of costs in our health care system. I want to 
go back and just look at what was going on. I think all of us have seen 
some figures about the growth of home health care in different States 
around the country. In every State, it has been significant. There has 
been significant growth. But the growth has varied dramatically from 
State to State. You can think about that growth in several ways.
  First in terms of the number of home health care agencies. In just 
the last 4 years, in some States there has been a 20 percent increase 
or a 40 percent increase. But in some States, the increase has been 
several hundred percent in just 4 years, an explosion in the number of 
health care agencies. Second, you can look at the number of visits to 
an individual patient. In some States it is a fairly modest increase 
and in some States it is a very rapid increase. Third, you can look at 
the cost per visit. Again in some States it is fairly modest and in 
other States it is a dramatic increase in the cost of visits. So what 
the Congress did was to say, ``Wait a minute, put the brakes on, let's 
try to deal with this, because if we can't get control of home health

[[Page H5280]]

care costs, we are in big trouble in terms of what is happening to the 
Federal budget.''
  So we took some action. But that action has included unintended 
consequences for people who are receiving home health care benefits and 
for the agencies that provide that service. We have to weed out fraud 
and abuse in this system. We have to find ways to cut costs in the 
Medicare system. But it is wrong to make cuts at the expense of our 
most vulnerable citizens, our homebound seniors who are relying for 
health care services provided in their home.
  I want to talk about three of those services right now, or three of 
the changes we made. First, the removal of blood drawing as a Medicare 
covered service, what is called venipuncture. That is one. Second, 
there is a requirement of surety bonds. The gentlewoman from Michigan 
referred to that. That is an added cost for home health care agencies. 
Sometimes it may be appropriate, but other times it is simply an added 
expense which is not covered. And, third, the new interim payment 
system. Those three, I believe, are changes we have made where we have 
really gone too far and we need to fine-tune those changes. That is 
really what the McGovern bill does and why I am a cosponsor.
  I want you to think about Maine for a moment, not just because it is 
the State I represent but because it highlights some of the issues that 
we have here. If you are in Portland, Maine, you are closer to New York 
City than you are to the northern communities in Maine. If you drive an 
hour north to Augusta, the capital city, you are still closer to New 
York City than you are to the northern Maine towns of Mattawamkeag and 
Fort Kent. It is a very big State. It is a rural State, like so many in 
this country, and you cannot have a hospital on every corner. So what 
you have is home health care agencies across the State which have 
sprung up to provide services to seniors, many of them in rural areas, 
and for many of whom a trip to the hospital is quite a hike. So I think 
it is unreasonable to require seniors to take a one-hour or two-hour 
trip to a hospital just to have blood drawn once a week when you can 
have a home health care nurse moving through a community providing this 
kind of service to many people who need it. And for many people, the 
drawing of blood, the testing of that blood is essential to monitoring 
their medications. Really it is a very important health care service. 
It is too expensive for them. It is too inconvenient for them. I 
believe we need to support the restoration of venipuncture as a 
Medicare covered home health benefit.
  The second issue, the gentleman from Rhode Island referred to it in 
particular, the new Interim Payment System, IPS, bases Medicare 
reimbursement rates on agency and regional costs in 1993. Let us look 
at that for a moment. We have, in Maine especially, nonprofit agencies 
which have been around for a long period of time which, of necessity, 
have had to hold their costs down. You look at the cost per visit or 
the number of visits of those agencies, and then compare them to some 
of the newer, for-profit agencies around the country, and there is a 
dramatic contrast. That dramatic contrast is one that represents a case 
where we should say to the nonprofit, well-established, low-cost 
agency, ``You are doing a great job. Keep it up.'' But what have we 
said? No. We have said in 1998 through this IPS system, ``You've got to 
go back to the cost you had in 1993 or 1994 and we're going to base 
what you get paid now on what your costs were then, not on what the 
costs are across the region, but on what your individual costs were 
back then.'' There is a problem there. Because if you have inflated 
costs, if you are a new agency, a for-profit agency or an agency which 
for whatever reason has inflated costs, you are going to get 
compensated for your current costs. If we are going to be cost-
effective, what we need is a formula that will reward cost-efficient 
agencies, those agencies that provide quality care at an appropriate 
price. We need a formula that does that. That is why I support the 
McGovern bill, the Medicare Home Health Equity Act of 1998. It provides 
a fairer formula for reimbursement to efficient home health agencies.

  I really believe that the bottom line is this. We have got to root 
out fraud and abuse in this system. We have got to contain costs, but 
we have to be smart about it. When it comes time, as it has, to look 
back at what we did last year and fine-tune that product and make it 
work better for home health care agencies and for seniors who are 
homebound, we need to do it. We have no business penalizing reputable 
providers and the seniors that their programs serve. That is why I am 
very glad to be here tonight with all my colleagues and to urge the 
Republican leadership in this House to bring this issue up, because 
time is a-wasting, our home health care agencies are hurting, our 
seniors need the assistance, there is no time to waste, we can do it 
now, we have got the time, and we should move ahead.
  Ms. STABENOW. If the gentleman will yield, I just wanted to emphasize 
one point that the gentleman from Maine said so eloquently again, and 
that is the fact that we are talking about States and areas that have 
long-established, well-run home health providers who it does not make 
sense in my mind to be asking them to do a surety bond when they have a 
record of what they have been providing and what they have been 
receiving and billing for and so on, and it does not make sense when 
there has been an explosion in some areas, and certainly we need to be 
concerned about those explosions of areas as it relates to costs and 
number of visits and so on. Why do we not just focus on those? Let us 
focus on the problem areas and not in turn require everyone to have to 
take a cut when we know that some are doing an outstanding job 
operating well below the national average. I think it is just a point 
that we need to reemphasize over and over again. We want to go after 
waste, fraud and abuse, of course we want to do that, but let us do it 
in a way that makes sense. I am sure that in Texas as well, we are 
talking about a situation where we need to be focusing on those, in 
fact, who are abusing the system and not focusing on those who have 
been providing quality service at low cost.
  Mr. McGOVERN. I could not agree with the gentlewoman more. In fact 
this, what we are talking about today, is not fraud, waste and abuse, 
because we all are in agreement that we need to crack down on these 
agencies that are engaged in fraud, waste and abuse. I do not think 
anybody in this Chamber is in favor of fraud, waste and abuse. Those 
agencies that abuse the system deserve to be held accountable. But as 
the gentlewoman points out in Michigan and the gentleman from Maine 
points out in Maine and in Massachusetts, we have some agencies that 
are models, that are cost effective, that put patients first, that are 
good. These agencies are being punished in essence for being good. That 
is not fair and that is not right, and a lot of people are going to 
suffer if we do not do something about it.
  Mr. Speaker, I yield to the gentlewoman from Texas (Ms. Jackson-Lee) 
who has been a passionate spokesperson for so many issues impacting 
working families and senior citizens. I am delighted that she is here 
tonight.
  Ms. JACKSON-LEE of Texas. I thank the gentleman from Massachusetts 
very much for yielding and for his leadership on this issue, 
recognizing the extreme importance of confronting the issue of health 
care in general and the home health care agencies.
  Frankly I would like to speak on behalf of our neighbors, because 
that is what we are speaking about. We are speaking about the American 
people, but we are speaking about our neighbors that are in our 
neighborhoods, that own these home health care agencies in particular. 
It is extremely important that we recognize that we are doing damage to 
those people that we know, the small businesses, the people who take 
care of our neighbors. It is extremely important that your legislation 
comes quickly to the floor of the House.
  We realize that Congress, as we all have stated, needed to take care 
of fraud, waste and abuse. When we began about the first Congress that 
I was here, the 104th Congress, we were talking about Medicare. 
Everyone was talking about fraud, waste and abuse. Those who wanted to 
completely overhaul Medicare wanted to do extremist type cutting to the 
Medicare system, when in fact the fraud, waste and abuse

[[Page H5281]]

was a mere, or a simple $89 billion that we could have handled easily 
without totally remodeling the Medicare system. The same thing happens 
with the home health care agencies. We know that we have to take care 
of those issues. But does it mean that because there are rising costs, 
does it mean that the system is broken? Or does it mean that more 
people are availing themselves of home health services in an effort to 
stay in better health and remain with their families? That is the 
philosophical question that we should ask. If we are trying to make 
sure that we keep the good home health care agencies, so many of whom 
have come to my office, I have met with them, we visited at the Beale 
Senior Citizen Village when I gathered, home health care agencies from 
around the southern region where my district is located, people as far 
to the south as different areas and then well into Houston came to meet 
with me to talk about how they were being mistreated, if you will, and 
not being able to take care of their patients.

                              {time}  2130

  And they asked a real question:
  Is the rising cost a basis of abuse or fraud, or is it because we 
have been doing such a good job that in fact we have been having rising 
costs because so many people are using it?
  I do believe there are certain issues that we need to emphasize, and 
that is, as you have said, I say to the gentleman from Massachusetts 
(Mr. McGovern), there are effective, safe and caring home health care 
agencies, and my concern is what do we do when we lose those facilities 
in our neighborhood, what about the teacher who comes home during the 
lunch hour, who comes home at dinner time, who stays up all night to 
take care of her elderly parent? What is going to happen to that person 
who at some point in time has been able to access a home health care 
professional? What happens when that working single parent with that 
elderly parent in their home has no resources, no sort of assistance 
from a home health care agency because the resources, the Medicare 
process, has totally torpedoed, if you will, those particular neighbors 
and small business out of the system?
  You are very right that the poor, sicker and certainly those with 
less, the less ability to be mobile, are the ones that use the home 
health care system, and again I would like to emphasize these are our 
friends.
  One of the issues that has been discussed with me, of course, is in 
whole question of the interim payment system, and I would like to just 
briefly explain what the difficulty is, as my other colleagues have 
already mentioned.
  Prior to the Balanced Budget Amendment, the home health care agencies 
were reimbursed after services were provided. Beginning in October 1, 
1999, the agencies will be paid before services are rendered and at a 
level significantly lower than that in place before the Balanced Budget 
Amendment.
  The prospective payment system is a monumental change for the 
Medicare system. Setting aside temporarily the merits of the new 
payment system, a very logistical problem has developed. Congress 
enacted a 2-year interim payment system for home care that will be 
effective until the prospective payment system is implemented in 
October 1999.
  Under the IPS, home health care agencies are reimbursed according to 
a new beneficiary limit. The problem is, as my colleague from Maine has 
already said, that home health care agencies have been provided with 
little or no guidance as to what this per beneficiary limit is. What 
the agencies do know is that the new limits do not accurately reflect 
the amount agencies spend to provide services.
  In fact, as they have said to me, they are flying in the blind, and 
when you fly in the blind, you are apt to make mistakes. When you are 
apt to make mistakes, what happens? The regulatory agencies come down 
on you, our neighbors, the small business.
  So, in fact we are in a catch 22. It is extremely important that we 
recognize that the new per beneficiary limits will reduce per-visit and 
per-patient costs, however patients' health may be compromised. We 
cannot establish unrealistic arbitrary cost-cutting measures without 
experiencing reduced quality and quantity in the home health system. At 
the same time again we are asking our friends, our neighbors, the small 
businesses, people who take care of our family members, we are asking 
them to make decisions and to make guesstimates and not do their work 
well.
  Another point that I would like to mention that was a very strong 
point of discussion amongst my many agencies that visited with me on 
this issue, and that is why I am so grateful for this opportunity and 
your leadership, and that is the venipuncture, the removing of blood. 
Many people do not think of that as a serious element, if you will. 
Well, the recovering of blood gives all kinds of data to the physician, 
and the home bound person is in need of the ability for blood to be 
taken so that diagnosis can be made on whether their blood sugar level 
is up or down, what is going on with hypertension, what kind of 
infection they may be having, and necessarily that person is home bound 
and is in need of that service. The venipuncture service that was 
mentioned by my colleague is another one that was excluded from the 
availability of the home health agency.
  And I received a call from a constituent whose mother is in her 
nineties, lives with him in Houston. She is home bound but happy that, 
thanks to her doctor's ability to monitor certain medication and blood 
levels through venipuncture she is able to remain at home with her son. 
She is not, if you will, incarcerated in the hospital. My good friends 
who run hospitals, you know that I respect you a great deal. But how 
many of our senior citizens say I want to be at home, I am well enough, 
I want to be at home?
  Well, Mr. Speaker, this home bound, elderly person, their son called 
me and said because of the changes made by the Balanced Budget 
Amendment her venipuncture coverage was drastically reduced and her 
ability to remain at home may be compromised. We should do all that we 
can to encourage our seniors to stay at home, and if their families are 
capable of taking care of them with assistance from home health care 
agencies, removing this coverage, it just skews the whole system, takes 
away the independence that these senior citizens are enjoying, the 
comfort of their home and the low cost.
  Another constituent called and said I am desperate, I will even pay 
for the service in order for them to be able to utilize it at home, and 
of course we know that when you interfere with the Medicare system and 
offer to pay, that will not work because these home health care 
agencies are related very closely to the Medicare structure and system.
  So my concern is that we do move H.R. 3205, but more importantly that 
we emphasize how much home health care saves us as compared to the 
$40,000 a year we pay if you were home bound, not at home but in a 
nursing home.
  I think the important as well is we care for our friends in the 
nursing homes, we respect them, but I cannot tell you how valuable the 
home health care professionals have been to our communities, how 
important it is to make sure that these agencies continue, and that 
they exist and that they continue to service in our neighborhoods.
  I would hope that Speaker Gingrich listens to the letter that you 
have sent and that we all join in pressing forward on both this 
legislation, the venipuncture legislation that we tried to reform the 
interim payment system that will be moving to the October 1, 1999, 
where we will be asking our home health care agencies to guess at what 
they will need and to take moneys ahead of time, which necessarily cuts 
down on the kind of treatment that the recipients need to get.
  We need to thank those who brought health care costs down, and I do 
not think we are thanking them right now. We are putting a lot of 
burdens on them. In fact, they are frightened, they are fearful of 
closing their doors, they are fearful of having to lay off their 
employees, they are fearful of no longer being the kind of citizens 
that they have been by contributing to the community as businesses that 
are active at the partnerships and chambers. They are just plain 
fearful, and I, for one, want to see us do something about it.

  And so I thank the gentleman from Massachusetts for his leadership on 
this, and hopefully we can push this

[[Page H5282]]

after the district work recess that we will be venturing onto. I would 
like to see this done before we leave here in August, and hopefully we 
will have that opportunity.
  Mr. McGOVERN. Mr. Speaker, I appreciate the comments of my colleague 
from Texas. As always, they are right on target, and again I hope that 
we can press this issue to a vote shortly after the July 4th recess.
  This is and should be a bipartisan issue. One of my chief cosponsors 
on this bill is the gentleman from Utah (Mr. Cook) a Republican who has 
been very helpful in advocating passage of this bill. This should not 
be a partisan issue, and I hope we can move on it very quickly.
  Let me summarize my remarks today and what everybody has so patiently 
and so importantly said here today by saying that I think that this 
issue comes down to three important points:
  One, we need to find ways to provide incentives for high quality and 
good quality home care. The fact of the matter is that the way the 
Balanced Budget Act was constructed and the way the provisions with 
regard to home health care have been constructed the opposite is true. 
We actually provide incentives for home health care agencies and 
visiting nurse associations to be bad, to not be cost efficient, to not 
be effective, to not put patients first. Well, that is wrong. I mean 
that goes against everything that all of us believe.
  So we need to fix the Balanced Budget Act so that we turn that 
around, so that we reward and recognize the good agencies and we do not 
reward the bad agencies.
  Secondly, I think the issue here is that we need to prevent another 
unfunded mandate on States. I mean, as I said before, every Governor in 
this country should be up in arms over what is about to be thrust on 
them. If we do not do something, then more and more patients in States 
all across this country, who right now enjoy good quality home health 
care, are going to be thrust prematurely into long-term nursing care. 
Nothing wrong with nursing homes and nursing care in this country, but 
it is much better, it is much better for the patient, it is much more 
cost effective for the taxpayers if we can keep them at home, if we can 
keep them with their families.
  If we do not do something, there is going to be a greater cost that 
Medicaid is going to have to bear, and that means that States are going 
to have to contribute more, and again I would encourage all those 
Governors out there and all the State legislators to weigh in with 
their respective Members of Congress so we can get this bill passed 
quickly.
  Thirdly, I think that this issue is about family values. I mean every 
time I turn on C-Span or every time I am on the floor, someone is 
getting up and talking about family values, how we have to put families 
first and how important it is to provide families with opportunities 
and security. Well, this is about family values, allowing a loved one 
to stay at home, you know, with their son or daughter. Allowing family 
units to stay together is important and is something we should try to 
preserve.
  So, you know, this issue that we are talking about today is about 
saving money for taxpayers, it is about family values, it is about 
putting patients first, it is about what this Congress should stand 
for, and I hope that we can convince Speaker Gingrich to make this one 
of his priorities. I hope that we can convince Speaker Gingrich to put 
this on the schedule to direct the appropriate committees to act on 
this now. I mean I hope that we can convince Speaker Gingrich and the 
Republican leadership in this Congress that this is not a partisan 
issue, that it is in their interests that we fix this mistake and we 
fix it now before anybody else in this country has to suffer.
  And so I thank the gentlewoman from Texas for her comments, and I 
will yield to her.
  Ms. JACKSON-LEE of Texas. Your passion has captured the real key. 
There is a massive constituency for this legislation, and it goes 
across party lines. It is to keep families together, it is to keep 
senior citizens and the disabled at home in a loving environment, and 
it is, of course, to applaud and respect the many small businesses like 
home health care agencies who go into neighborhoods knowing their 
neighbors, providing the service, providing the warmth, and the 
nurture, and good health care at a reasonable cost.
  What more can we ask for? I think it is extremely important.
  I appreciate the gentleman and his concepts of trying to get this to 
the floor very quickly.
  Mr. McGOVERN. Mr. Speaker, I thank again my colleague from Texas for 
her remarks, and I would just conclude by saying that I am going to do 
everything I can, and I hope all those watching will do everything they 
can to urge this Congress to move quickly on this legislation. We 
cannot afford to let this year go by, this session go by without 
acting. If we do, then people are going to suffer, more and more home 
health care agencies and visiting nurse associations are going to 
close.
  That is not what we want, that is not what we should stand for, and 
we need to redouble our efforts in the coming months to make sure that 
this legislation gets to the floor for a vote.
  And again I would urge the Speaker, if he is listening, to please 
listen to what we are saying here today, to do the right thing and to 
move this issue and move it quickly.
  I thank my colleague from Texas.
  Mr. DELAHUNT. Mr. Speaker, I am pleased to join with my friend, Mr. 
McGovern, and our other colleagues in this special order on the home 
health care crisis.
  The Balanced Budget Act has had a devastating effect on home health 
care programs in many parts of the country. But the impact has been 
especially severe in Massachusetts and other New England states, which 
already provide more visits, at a lower cost per visit, than agencies 
in other states.
  In Massachusetts, the new per beneficiary limit means a loss this 
year alone of $100 million. That translates into 1.5 million fewer home 
visits for the elderly and disabled.
  On April 30, the South Shore Visiting Nurses Association was forced 
to eliminate 50 positions as a direct result of the $4 million in cuts 
it was forced to absorb. Home care providers across our state are 
facing cuts this year of 25 percent.
  What does all this mean for the people who need these services? 
Listen to some of the letters I have received:
  From a woman in Quincy:

       I take care of my elderly mother. She has Alzheimer's 
     Disease and has had several minor strokes. At the present 
     time I am fortunate enough to have home health care for her 
     three mornings a week through Quincy Visiting Nurses. Without 
     this assistance, my mother would probably be in a nursing 
     home. I cannot praise the nurses and aides that I have dealt 
     with enough. My mother is unable to dress herself, take a 
     shower by herself, or make her own breakfast. This is what 
     her home health aide does three mornings a week. I do the 
     same on the other four mornings. The release that I feel 
     having three mornings of not having to do these deeds helps 
     me keep my sanity. I am a full-time teacher in Quincy and I 
     also work two other part-time jobs.

  From a man in Harwich:

       My wife is 78 and has Alzheimer's Disease. I am also 78 
     years of age and have spinal stenosis. I am her care giver 
     and wish to continue to care for her at home and not in a 
     nursing home. . . . Presently we have the assistance of two 
     [home health] aides, two hours in the morning and one hour in 
     the afternoon which is covered by Medicare. . . . With over 
     100,000 Massachusetts residents with Alzheimer's Disease or 
     related neurological disorders and other related elderly 
     problems, we are not alone, but it feels that way with no 
     future long term home health care.

  From a husband and wife in Whitman:

       We read with dismay of the federal cuts affecting home 
     health care. For those of us in our older years, being able 
     to stay in our own home is the only bright light on the 
     horizon. Anything else is unthinkable.

  From a woman in Weymouth:

       I take care of my mother and have for the past eight years. 
     The last four years have been 24 hours a day, seven days a 
     week. We have [a home health care aide who] comes in twice a 
     day for a total of four hours. . . . My mother has 
     Progressive Supranuclear Palsy which is a devastating 
     neurological disease. It takes everything but your mind. She 
     is literally a prisoner in her own body. The rest of the 
     family has chosen to give up on my mother, thinking the way a 
     lot of people do, that she should be put in a nursing home. 
     Congressman Delahunt, would you want to be put in a nursing 
     home if the only people that understood your needs were the 
     aide and your daughter? . . . My mother still wants to be 
     alive and if she was to go into a nursing home she would die. 
     She communicates with us sometimes by blinking . . . or 
     breathing a certain way. Sometimes it takes a long time to 
     figure out what she wants. In a nursing home they wouldn't do 
     that. I promised her I would never put her in one, and I vow 
     to keep that promise no matter what. I'm not well myself and 
     these cut-

[[Page H5283]]

     backs might kill us both. . . . I appreciate you taking the 
     time to read this letter and know you will do all you can to 
     stop these cut-backs, for all those in need of home-care, for 
     someday we may all need to depend on this system for love, 
     care, and support because we have no one else to turn to or 
     that cares.

  And finally, Mr. Speaker, one of the letters I have received from 
nurses and physicians. This one comes from an emergency physician from 
Hingham:

       As an emergency physician . . . I deal with the human side 
     of health care financing decisions on a daily basis. . . . 
     Most medical problems, recognized early enough, can be 
     treated effectively in an outpatient setting. . . . At the 
     present time . . . I am able to safely send elderly patients 
     home with close nursing follow up rather than to admit to the 
     hospital. I am afraid the proposed Medicare cuts will 
     severely jeopardize this sensible medical option. There is 
     also a human side to this issue. Frail, elderly patients do 
     better in their own familiar home surroundings. I can attest 
     by my own personal experience with my mother that her medical 
     health and quality of life were markedly enhanced by having 
     her medical care at home. Although she had multiple medical 
     problems, she did not require a single hospital visit or 
     admission in the last eight months of her life.

  These are but a few of the letters I have received from my 
constituents about this situation. In addition, I ask unanimous 
consent, Mr. Speaker, to place in the Record a series of articles that 
appeared recently in the Mariner Community Newspapers based in 
Marshfield, Massachusetts, and a transcript of the calls from readers 
that were recorded on their response line.
  Mr. Speaker, this testimony speaks far more eloquently than I can 
about the plight of those affected by this situation. But what is to be 
done about it?
  I know that a number of bills have been introduced to try to fix this 
problem. I have cosponsored H.R. 3205, which was introduced by the 
gentleman from Massachusetts (Mr. McGovern) and the gentleman from Utah 
(Mr. Cook), which would delay implementation of the per beneficiary 
limit for one year. The extra time would enable home health agencies to 
minimize disruptions in services by gradually reducing costs.
  Mr. Speaker, I voted against the Balanced Budget Act, largely because 
of the cuts it inflicted on the Medicare program. I continue to believe 
that those cuts were a terrible mistake. The least we can do now is 
help cushion the blow.

              [From the Weymouth (MA) News, June 10, 1998]

               Losing Patients Over Home Health Care Cuts

                           (By Alison Cohen)

       Millie and Mattie B. started their life-long love affair 
     when she asked her aunt to see if Mattie would take her to 
     the high school prom.
       ``I didn't have a date and there were four boys living 
     across the street,'' Millie said. (The couple did not want 
     their identities revealed.)
       She watched from her front windows while her aunt dutifully 
     went across the street.
       ``I could see him come to the window--he'd been shaving--
     and then I saw him nod his head yes, so I knew I was set,'' 
     Millie said.
       Mattie smiles and gives his take on the request.
       ``I had the only car on the street, a '34 Lafayette.'' he 
     said. ``That's why she asked me.
       That was more than 50 years ago and their dancing days are 
     behind them now. Mattie, who turned 77 last week, spends his 
     days in a wheelchair, the result of 12 years battling 
     Parkinson's disease.
       Someone once said growing old isn't for sissies. Mattie and 
     Millie are living proof. As Parkinson's progressively 
     immobilizes Mattie's once-powerful body, it takes all his 
     strength to get through what used to be the simplest tasks. 
     It's only one of many medical problems that leave him weak 
     and vulnerable.
       Millie, 75, wears a weight-lifter's truss around her waist. 
     The weight she lifts is Mattie.
       More than once she's been forced to pick him up off the 
     floor after he's fallen. Once she suffered a slipped disc in 
     the process and permanently weakened her back. Every night 
     she transfers him from his wheelchair to the bed. Now her 
     spine curves and the discs along her lower back project out 
     like ragged mountain peaks.
       ``I got this taking care of him,'' she says, as she shows 
     the nurse her ravaged back.
       Worse yet, Mattie's voice dwindled to a mere whisper about 
     six months ago. By the end of the day, he's exhausted from 
     trying to communicate and she's exhausted from trying to hear 
     what he's saying.
       ``It's frustrating,'' he says.
       Parkinson's is a chronic, progressive disease. Millie 
     doesn't want to think what the future holds if she becomes 
     too frail to help her husband get in and out of his 
     wheelchair.
       ``I hate to think about it,'' she says. ``I don't think 
     about it.''
       Another challenge lurks in Mattie's near future. After four 
     years serving his country in time of war and 37 years toiling 
     to maintain Boston's schools. Mattie has discovered the 
     federal government wants to balance Medicare's budget by 
     imposing a cap on the amount of money home health care 
     providers can receive for taking care of him and other 
     patients.
       The cost-containment method chosen by the Health Care 
     Financing Administration (HCFA), a division of the U.S. 
     Department of Health and Human Services, caps reimbursement 
     for each patient at a percentage of the agency's 1993-94 
     budget. Although South Shore agencies have yet to receive 
     official notification of their maximum reimbursement level 
     per patient, similar agencies in other parts of the country 
     have been told they must serve even the most challenging 
     patients for no more than $1,500 to $4,000. (See related 
     story.)
       According to Meg Doherty, executive director of Norwell 
     Visiting Nurse Association, some of the patients on her 
     roster cost as much as $50,000 a year to maintain at home. 
     And the fallout is already happening. On May 7, Easter Seals 
     of Massachusetts announced it could not afford to provide 
     home health care services with such unreasonable cuts.
       Life, for Mattie, already has dwindled to the size of the 
     small summer cottage on the South Shore they winterized and 
     moved to four years ago when it become impossible for him to 
     maneuver the stairs in their South Boston home. Getting 
     outside is a production--Mattie must move from his wheelchair 
     to a walker to traverse the step separating the dining room 
     from the back entry and a shallow flight of stairs leading 
     outdoors.
       Getting to bed is an even greater challenge. Together they 
     position his wheelchair near his bed. Millie struggles to 
     push him up out of the chair as best she can.
       ``I fall right in,'' he says. ``She straightens my legs out 
     and covers me with the blankets.''
       Most of his days are spent watching television and talking 
     with Millie. On weekends, he looks forward to spending time 
     with the two of their six children who live nearby.
       The man who once prided himself on his ability to ``fix 
     anything,'' now relies on a cadre of home health aides who 
     come five days a week to assist him with the activities he 
     once took for granted, things like showering, shaving and 
     getting dressed. On the weekends, he must ask his son to 
     handle that duty. A visiting nurse comes once a week to check 
     his blood pressure and monitor his health.
       It's hard to put a price tag on continuity of care. 
     Sometimes symptoms are subtle. An older patient doesn't 
     experience the crushing chest pain that alerts middle-aged 
     men they are having a heart attack.
       ``I start to lose my breath,'' explains Adolph Wacker, 84, 
     a home health care patient.
       A visiting nurse checks Wacker once a week, looking for 
     clues that would show whether trouble is looming.
       Wacker had five heart attacks, including a cardiac arrest, 
     within a 15-month span. He also has a pace maker to regulate 
     his heart rhythm. The hands that once deftly wielded 
     butcher's knives tremble uncontrollably from Parkinson's 
     disease. Wacker also suffers from diabetes. He's tethered to 
     an oxygen pump because of chronic obstructive lung disease 
     that leaves him vulnerable to pneumonia.
       His rapid decline made it necessary for Wacker and his now-
     deceased wife, Stephanie, to leave his Connecticut home and 
     move in with their daughter, Barbara Steiglitz.
       ``It was obvious he couldn't go home and care for my mother 
     any more,'' Steiglitz says.
       Steiglitz couldn't do it alone, either. A registered nurse, 
     Steiglitz works three days a week for a long-term care 
     facility in Dorchester. Although her mother, who suffered 
     from advanced Parkinson's disease, could be left alone for 
     short periods of time at first, it didn't last long.
       ``She wandered,'' she said. ``She would get to the end of 
     the driveway and wouldn't know how to get back to the house--
     and there's a swamp across the street and conservation land 
     goes almost to Norwell.''
       At the end, both Stephanie's mind and body failed badly.
       ``She needed total care,'' Steiglitz said. ``She was in 
     diapers, she was senile and she could barely walk.''
       Steiglitz put together a patchwork of family care, home 
     health services and what Wacker himself calls ``my private 
     baby-sitter'' to keep the two of them safe and healthy.
       Stephanie Wacker died Sept. 27, just a week shy of their 
     59th wedding anniversary.
       Wacker says they met when a fire alarm went off.
       ``She asked me what happened,'' he recollected. ``We got to 
     talking, I walked her home. We started dating and a year 
     later we got married.''
       The two were very close, he says. It remains a marvel to 
     him, perhaps because his father died when he was two, his 
     mother when he was seven.
       ``My brothers and sisters took care of me until I was 16. 
     Then I was on my own,'' he explains. ``We got married when I 
     was 24.''
       Wacker is a favorite with his caregivers.
       Home Health Aide Anne Marie Foley comes two mornings a 
     week. She helps Wacker get up and dressed, brings him 
     downstairs and makes his breakfast. The two of them swap 
     recipe tips.
       ``He's an incredible cook,'' Foley says. ``His soups are 
     wonderful. I'm trying to get him to write a cook book.''

[[Page H5284]]

       A male home health aide, Frank Serra, comes once a week to 
     help Wacker shower. Although Wacker would like to have a 
     shower more frequently, especially in the hot, humid season, 
     Medicare won't cover the costs because he isn't incontinent.
       The combination of lung disease and Parkinson's makes him 
     increasingly frail.
       ``I try to walk up to the end of the driveway and back for 
     exercise,'' he says. ``I have to stop twice on the way up. 
     And I can't talk and walk at the same time or I run out of 
     breath.''
       Falling is an ever-present risk because Parkinson's disease 
     affects both balance and gait.
       ``He fell in February and cracked his sternum,'' says his 
     daughter. ``I really have to hire someone to be here when I'm 
     not home.''
       Wacker is philosophical about his own failing health.
       ``As long as you know your own capabilities, you get along 
     pretty good. You have to accept the idea you can't do what 
     you used to do. If you don't you go nuts and you end up in 
     the hospital any way.''
       As Wacker's health inevitably deteriorates, his daughter 
     promises to advocate for the services he needs, and as long 
     as there is a Medicare certified home health care agency 
     providing services in * * *, he'll continue to get what he 
     needs.
       That's the kicker.
       Home health agencies aren't run on volunteer power. Without 
     a realistic reimbursement schedule to pay the nurses, 
     therapists and home health aides for services delivered those 
     agencies say they cannot continue in business.
       The U.S. Congressional delegation from Massachusetts hopes 
     to derail the new system before it drives any more home 
     health care agencies out of the business. Rep. James P. 
     McGovern, D-Worcester, and Sen. Edward M. Kennedy have filed 
     companion bills in the House and Senate to address the 
     problem.
       The bills will delay the effective date of the caps until 
     Oct. 1, 1998, to allow time for agencies to adjust to the 
     system. Additionally, the bills change the base year for 
     calculating benefit limits from 1994 to 1995.
       ``This change means that payments will more accurately 
     reflect the type of home care that is currently delivered,'' 
     explains Kennedy.
       In testifying about his bill, McGovern has said that the 
     one in 10 Medicare beneficiaries who use home health care 
     services are ``poorer, sicker, more often female, more likely 
     to live alone, and have more mobility problems than the 
     Medicare population generally. Approximately 25 percent of 
     these ``frail elderly'' in Massachusetts are over age 83.''
                                  ____


            [From the Scituate (MA) Mariner, June 18, 1998]

                   Paying the Price for Mismanagement

                           (By Alison Cohen)

       According to many home health care providers and advocates, 
     Medicare officials created a classic example of the law of 
     unintended consequences when they embarked on their campaign 
     to root out fraud, waste and overutilization in the home 
     health care system.
       The federal government decided large increases in home 
     health care were caused by waste and fraud following a two-
     year investigation, known as Operation Restore Trust. That 
     study focused on the five states that account for 40 percent 
     of Medicare payments; California, New York, Florida, Texas 
     and Illinois.
       The subsequent report by the Office of the Inspector 
     General of the U.S. Department of Health and Human Services 
     said that one-fourth of home health agencies in those states 
     received nearly half the Medicare payments for home health 
     care. The report placed the blame on for-profit, closely held 
     corporations where owners engaged in a web of interlocking 
     companies that referred patients among themselves. Texas was 
     cited as the biggest offender.
       A similar study conducted in Massachusetts and Connecticut 
     in 1997 uncovered no such pattern of fraud.
       According to Julie Deschenes, legislative and public 
     affairs coordinator for the Home & Health Care Association of 
     Massachusetts, ``No fraud was uncovered in the 20 
     Massachusetts agencies that were audited.''
       Deschenes said the worst that federal auditors could find 
     were examples of technical billing errors, mostly stemming 
     from failure of an attending physician to update medical 
     records to reflect the need for the higher level of services 
     patients were receiving and for which Medicare had been 
     billed.
       Rather than conducting audits to identify and penalize 
     agencies guilty of intentional fraud or overutilization, 
     Congress believed the solution to spiraling costs nationwide 
     and wildly disparate costs among the states should be a 
     standardized, flat rate according to diagnosis. This system, 
     known as the ``prospective payment system,'' is similar to 
     the system Medicare uses in paying for hospital care.
       When the federal Health Care Financing Administration 
     (HCFA) said it couldn't develop the complex formula necessary 
     to reward efficiency by providers as quickly as Congress 
     wanted, the interim payment system based on per patient caps 
     was set in motion. This payment plan--set to run through Oct. 
     1, 1999--basically freezes spending at 1993-94 levels, before 
     Operation Restore Trust began.
       The projected caps fall hardest on frugal, non-profit 
     agencies and rewards those that spent lavishly at taxpayers' 
     expense. Home health care agencies in Massachusetts 
     consistently deliver care cheaper than the national average 
     both in terms of Medicare's cost per visit and per patient. 
     Relying on data provided by HCFA itself, The Wall Street 
     Journal reported earlier this year that Massachusetts' home 
     health care providers served 119,000 patients in 1995 at an 
     average cost of $50 per visit, which was 19 percent below the 
     national average of $62. The average annual cost per patient 
     worked out to $4,730, or less than six percent above the 
     national average of $4,473.
       Across New England, the regional cost per visit undercut 
     the national average by 15 percent and the annual average 
     cost per patient was only $4,400.
       Donna (who didn't want her last name used) has been a home 
     health care worker for more than 20 years and says she can't 
     understand with those kind of figures why Massachusetts 
     people have to suffer. She says she's outraged by what's 
     happening.
       ``We're the ones on the front lines and we're the ones who 
     have to deal with the patients,'' she said. ``Do you know 
     what it's like when you have to tell them this is you're last 
     day with them. Some of these people have been my clients for 
     a long time.''
       Donna spoke of a 50-year-old patient she has been 
     assisting. The man, a father of two young children, is 
     primarily bed-ridden, he has to be fed and has come to rely 
     on home health care workers to maintain some semi-balance of 
     a normal life.
       ``I was overcome on my last day with him,'' she said. ``I 
     felt awful. It was so hard to tell him it would be my last 
     day helping him. You feel so much guilt. What am I supposed 
     to say, `gee, good luck?' How could this be happening?''
       If there is fraud and over-spending, Donna says she is all 
     for fixing it. But if Massachusetts and several other states 
     have been spending reasonably, she can't see why others can't 
     pay the price.
       HCFA identified the big spenders among the states as 
     Louisiana, Oklahoma, Texas, Tennessee, Utah and Mississippi. 
     On average, home health care providers in these states spent 
     $5,488 per patient in 1995, or almost 23 percent more than 
     the national average. The biggest offender was Louisiana with 
     an average cost per patient of $7,867, almost 76 percent more 
     than the national average.
       Officials at the Texas Association of Home Care have 
     justified their higher costs, saying they have a high rate of 
     poor elderly who have never had proper health care.
       Costs are driven up by the increasing number of Americans 
     considered ``frail'' or the ``old old''--those aged 85 or 
     older. Additionally, medical technology has improved survival 
     rates for individuals who survive head and spinal chord 
     injuries and degenerative diseases such as Alzheimer's, 
     Multiple Sclerosis, heart failure and severe diabetes.
       The resulting ``per beneficiary limit'' guarantees, in 
     HCFA's own words, that 90 percent of all home health agencies 
     will be reimbursed at a rate below the cost of 
     delivering services. Providers say it will put them on the 
     road to financial ruin. How quickly they arrive at that 
     destination depends on the number of high-cost patients an 
     agency serves. These are the patients with degenerative, 
     progressive diseases such as Multiple Sclerosis, Muscular 
     Dystrophy, Parkinson's Disease, Alzheimer's Disease, 
     advanced diabetes and other conditions that require 
     intensive levels of care.
       Apparently loathe to slash services to America's most 
     vulnerable citizens, the frail elderly and persons with 
     disabilities, Congress and HCFA announced to recipients of 
     home health services and their advocates that no patient was 
     to be denied services, terminated from care or have the level 
     of care reduced unless medically justified. That puts home 
     health care providers in a Catch-22 bind: they cannot reduce 
     costs through reductions in services or cutbacks in direct 
     care staff. Already several home health providers have chosen 
     to abandon ship rather than risk bankruptcy.
       Cynics might find this governmental ``solution'' to 
     spiraling costs reminiscent of the village pacification 
     campaign of the Vietnam War years. That official ``solution'' 
     led to an American officer explaining. ``It became necessary 
     to destroy the town in order to save it.''
       According to Deschenes, home health care is being asked 
     ``to assume an unfair proportion of Medicare cuts.'' While 
     home health care consumes only 9 percent of total Medicare 
     expenditures, it is targeted to assume 14 percent of the 
     total five-year cut and close to 18 percent of the provider 
     cost enacted in the Balanced Budget Act of 1997. A recent 
     HCFA forecast has increased the home health ``savings'' to 
     $20 million, or 25 percent more than the original estimate by 
     the Congressional Budget Office at the same time that the 
     population of older Americans continues to grow.
       Home health care providers and people who receive the care 
     aren't buying this theory that no one will lose benefits. It 
     just doesn't add up, they say.
       Community Newspaper Company's Reader Response line was 
     flooded with calls last week regarding the potential cuts in 
     home care. More than half the calls came for people who were 
     losing some form of care, or family members of those who were 
     expected to lose their care.
       A Marshfield resident told the story of her grandmother who 
     has already been denied additional care. Her grandmother has 
     been cut back to one visit per day from a home

[[Page H5285]]

     health aide and now the family is forced to provide care that 
     was once handled by professionals. It is now up to 
     grandchildren to come at night and put their grandmother to 
     bed, change her and put her in diapers.
       ``It is devastating to her,'' the woman said in her call. 
     ``She cries every night when she sees us coming. She's so 
     humiliated her grandchildren have to do this. It's a disgrace 
     to see what these poor old people have to go through. These 
     people have worked all their lives and this is what it has 
     come down to. It's just ridiculous.''
       Experts say saving money in home health care may even be 
     counter-productive. If home health services dry up, patients 
     will be forced into more expensive nursing home placements or 
     extended hospital stays. The pocket may change, but taxpayers 
     will still be paying the bill.
       While home health care isn't cheap, it certainly provides a 
     cost-savings when compared to a year's stay in a nursing home 
     which Deschenes estimates at $60,000 per year. More 
     importantly, it allows older American and disabled citizens 
     to remain linked to their families and their communities.
       The importance of that connection to home, family and 
     community can't be quantified, but it is of immeasurable 
     value to all of us in determining our quality of life. That 
     message came through loud and clear in the messages on the 
     Reader Response line during the past week.
       A number of callers said they feared they might be forced 
     to put their mother, father or elderly relative in a nursing 
     home. And they held out little hope for their ``golden 
     years,'' as one caller put it.
       How can this be?'' questioned a Weymouth resident. ``I 
     won't be able to care for my husband if we can't maintain the 
     current level of care, that would be devastating to us, both 
     financially and emotionally. We have been together for 55 
     years. I can't bear the thought of being separated like that. 
     We are getting along fine at home right now, but that could 
     all change. Please don't let it.''
       Edward J. Flynn, executive director of South Shore Elder 
     Services, Inc., says if the current policy remains unchanged, 
     its primary victims will be the nation's elders. In a recent 
     newsletter, Flynn urged Congress and HCFA to reconsider the 
     cuts and clarify eligibility criteria.
                                  ____


                  Calls from CNC Reader Response Line

       1. John Murphy, Weymouth. Why isn't Sen. Kerry speaking out 
     loudly on what government is doing to cut reimbursement to 
     health care providers? Where is the senator on this issue? He 
     should be at the forefront of the battle to protect Medicare.
       2. Louise Cipriano, Weymouth. I was informed by my 
     healthcare, I have a home health aide now and my insurance 
     pays for it, in September, I will be 65 and I'll be on 
     Medicare and Medex and they said they wouldn't cover me 
     because I'm a chronic patient. I'm unable to walk or stand, I 
     have severe rheumatoid arthritis and osteoporosis. I can't 
     even wash my face. I need a complete sponge bath. I can't get 
     in the shower and my husband also is disabled with his hip. 
     He had a serious operation and hip replacement. He would have 
     to take care of me and they would not send anyone to give me 
     personal care with this new Medicare thing. I am a chronic 
     case they said and unless I need a nurse they cannot send me 
     Medicare help. Please don't let this happen to us. It would 
     be devastating. I don't think we could take it.
       3. Nancy W. Clapp, Marshfield. I am adamantly opposed to 
     the Medicare cuts and I would like to see the congressmen if 
     necessary establish a fraud squad to sort out Medicare's 
     problems which would quickly pay for itself and look for some 
     other way to balance the budget and not on the backs of those 
     who need help most.
       4. Karen Ruginski, So. Weymouth. I work for ZNA Associates 
     in the office and I see (health care) cuts on these patients 
     and I also have a father-in-law who is very ill with lung 
     cancer and can barely do anything on his own. I have a 
     handicapped child and I need to go out and help my father in 
     law, because he's so ill and no one else can who's home. So 
     it's very difficult for us and if the home health care 
     agencies could provide more care and get more benefits from 
     Medicare and the other insurance carriers, this burden 
     wouldn't be so difficult. I'm hoping they'll make changes to 
     this. Home health care is definitely needed. They're 
     discharged early from the hospital and they need care at 
     home.
       5. June Sutcliff, Weymouth. I'd like to add my voice saying 
     Congress needs to find other ways to reduce expenses. Home 
     care should be the last place they cut. Some of the pork 
     barrel projects we read about should be eliminated first.
       6. Thomas F. and Elaine Cahill, Pembroke. We totally object 
     to cuts in home health care. Our own family has suffered on 
     account of that and we are totally against it.
       7. Lynn White, Hanover. My brief comment is that even if 
     people get worse and deteriorate under this plan, the 
     Medicare has made it that it will make no difference. The 
     amount of money spent will be the same. So what this says is 
     that the federal government doesn't care whether people 
     deteriorate or not, because they've set their budget and 
     locked in their cuts. Visiting nurses all these years have 
     kept people stable, and now without them people will be 
     unstable but it will make no difference as far as cost to the 
     government.
       8. Ann Martin, Braintree. I'm calling to protest Congress's 
     attempt to cut Medicare's health care program. Please tell 
     them not to do this. Because most of us can't afford 
     outrageous home health care. 843-7325.
       9. Joan Golden, Hanover. I'm calling with regard to the 
     Healthcare cuts. My grandmother is 92 years old living in a 
     nursing home and because of healthcare cuts she may be in 
     jeopardy of being taken out of the nursing home, and they're 
     saying she can be put into the community or in a lesser 
     scaled facility. It's just disgraceful because she spent her 
     whole life putting money into this system and now everthing 
     she had is gone and we're depending on the system. I'm 
     scared. I'm her granddaughter, I don't know what I'm going to 
     do if she doesn't have that facility to depend on. It's a 
     very scary thing, and like you said it's the people who need 
     it the most. Thanks and I hope we can do something for the 
     number of people who I'm sure are in the same predicament.
       10. Mary S. McElroy, N. Weymouth. I would like to say to my 
     congressmen--Have the courage to stop sending billions of 
     dollars to the Middle East for Israel and Egypt. Spend the 
     money on our senior citizens who have paid taxes in this 
     country and deserve decent health care. We get nothing back 
     from Egypt or Israel, take care of our own before we keep 
     throwing our money away. Have some courage.
       11. Lorraine McGrath, East Weymouth. I am a former 
     supervisor of home health care services. My comment is 
     briefly that the entire purpose of home care is to keep 
     patients out of hospitals and nursing homes and at home as 
     long as possible and to cut down on trips to emergency rooms 
     etc. I wonder if the government has done any study on the 
     cost of these patients being hospitalized and re-hospitalized 
     numerous times or placed in nursing homes. The cost of 
     hospitalization and nursing home placement is far more than 
     home care has ever been. I think they're putting the cart 
     before the horse because while they think they're going to 
     save money here, they're really going to pay more in the long 
     run with more frequent hospitalizations and long term care 
     placement.
       12. Joan Kyler, Marshfield. I want to comment I have two 
     elderly parents who are in a nursing home and it seems 
     ridiculous to me that because of Medicare and Medicare cuts, 
     and because they didn't have enough money to afford to stay 
     in their home, the state is willing to pay $5,000 to $6,000 a 
     month per person as opposed to keeping them in their own 
     home, with home health care. I don't care how good a nursing 
     home is, it's not a place I really want my parents to be. 
     It's our future as well, and in another quarter century you 
     and I may be in a nursing home. That's something I shudder to 
     think of.
       13. Sandra Sweetzer, Duxbury. In regard to cutting home 
     health care aid to the elderly, I take care of my mother, 
     she's a diabetic. She's had a heart attack. She's almost 
     wheelchair bound now. She's on a walker, I have to learn now 
     to give insulin shots and mix insulins. I'm not a nurse. I 
     don't know how to take a blood pressure. I do the best I 
     can and pretty soon the home health aid nurse who comes 
     once a week said she won't be coming anymore and I think 
     this is a crime. It'll force people into nursing homes who 
     should still be at home. It's terrible.
       14. Mary O'Neil, Scituate. I just read your article in the 
     Scituate Mariner about the cutbacks and I think it's 
     disgusting. I know of some people who have been hurt by it. I 
     just wanted to let you know.
       15. Ann Tarallo. My husband Joseph and I are really 
     appalled at any cuts that are being made to home care and 
     Medicare. I firmly believe there are other things that can be 
     cut, so that these don't have to be.
       16. Annabelle Burlinback. I'm replying to the response line 
     against the ill-advised cuts in home health care.
       17. Tina Degust, Marshfield. I read your article in the 
     paper and I just wanted to let you know it's affecting two 
     people I know. My grandmother who has the home health care 
     and also my father-in-law. It's absolutely terrible what's 
     happening, to see just the horrible things that are going on. 
     My grandfather now only receives one aide during the day and 
     in turn all the kids and grand-kids have to come at night to 
     put my grandmother to bed. She actually cries every night to 
     see us coming in because she has no legs and we have to 
     change her. She's in diapers, and she's so humiliated by 
     this. Not to mention my father-in-law who now has two home 
     health aides coming in also, who's cut back to absolutely 
     nothing, will have nothing during the week and his wife (my 
     mother-in-law) has only one kidney. Right now she needs a 
     serious operation on the one kidney that she has because it's 
     not functioning right, and they expect her to put him to bed. 
     He's had a stroke and he's paralyzed on one side. It's 
     absolutely devastating to see what these poor old people have 
     to go through. It's affecting two sides of my family. 
     Something really has to be done, these people shouldn't have 
     to go through this, they've worked all their lives. My 
     grandfather's a veteran. It's just ridiculous.
       I guess what I'm trying to say is that these people 
     shouldn't have to go to nursing homes, they should be able to 
     live in their houses until whenever the time comes for them 
     to go and they should be able to live in comfort and not have 
     to worry about who's coming to change them and take care of 
     them. They should be able to have the help they need and not 
     have to worry about it

[[Page H5286]]

     every day who's going to be able to put them into bed and 
     who's going to have to change them and the embarrassment. 
     They should be able to leave the world with a little bit of 
     dignity. They just worked too hard for their houses and 
     everything they have. I think it's just absolutely 
     devastating. I can't imagine how this is going to affect my 
     family alone. I have my father-in-law and my grandmother. And 
     my grandfather who has a colostomy and is 78 years old, he 
     has to help lift my grandmother to put her into bed. It's 
     just a matter of time before it takes its toll on him and 
     then what's going to happen to my grandmother. It's just 
     really sad and not fair.
       19. Rev. Steve Harvester, Church Hill United Methodist 
     Church, Norwell. I'm calling to say the elderly and frail 
     members of my congregation would, in most cases, rather die 
     than be put in a nursing home. Home health care is their 
     spiritual survival line and I hope and I pray that our 
     congressmen will do everything in their power to keep home 
     health care alive and well.
       20. Louise Penny, Rockland. I think it's very necessary 
     that they do not cut home health care.
       21. Beverly Thomas, Marshfield. My husband is receiving a 
     home health aide two times a day, seven days a week. It's 
     about the only way we can manage and I certainly would 
     encourage the legislators to do what they can to help people 
     who need to receive this kind of assistance.
       22. Jacqueline Harrington, Scituate. I am begging our 
     congressmen to do something about these Medicare cuts to our 
     most fragile people who need the care the most. I'm in the 
     field so I know what I'm talking about. They can't be left 
     out on the limb, there's got to be some other way to do it. 
     Please find a way.
       23. Mary Anne Spilache, Abington. I work for Home Health 
     and Childcare in Brockton as a home health aide and I don't 
     think it's right that they're making all these cuts on these 
     poor elderly. They need so much of our help. That's all I've 
     got to say.
       24. Jo Duvall, Hingham. I'm calling in response to the 
     article in the Hingham Journal yesterday and I wanted to 
     definitely join you in speaking out against the ill-advised 
     cuts in home health care. As a health care worker I'm finding 
     this devastating to my patients and I certainly hope that 
     something can be done about this as soon as possible because 
     it's going to be very detrimental to our whole society.
       25. Pat Peters, Abington. I'd like to express my opinion on 
     the way the government is treating the elderly by cutting 
     back on their services. I'm a home health aide and I don't 
     understand if you leave elderly people who are sick and need 
     services by themselves, and you don't provide them, 
     ultimately they're going to fall or end up in nursing home 
     and that's going to cost the government more. I think this is 
     a real tragedy.
       26. Joseph McCue, Hingham. How are senators acting on this 
     question? Is it a feat a complete or do we send the 
     information to the lady that has one the cutting?
       27. Eunice and George Pope. We are now receiving home 
     health care services that will be cut off shortly due to the 
     Medicare cutback. I would like to speak to someone and 
     complain further if someone would return my call. xxxxxxxxxx
     xxxx.
       28. Gus Duffy, Scituate. I want to lend my support to 
     people trying to get home health care and keep it from being 
     cut, and express the opinion that without a Democratic 
     congress, you're not going to have any luck, because they're 
     going to balance the budget on the backs of the poor and 
     serve the wealthy. Get the Republicans out and you'll be 
     in good shape.
       29. Dolores Murphy, Rockland. I read your article and I 
     guess I could sum it up with ``There but for the grace of God 
     go I.'' And hopefully make an impact.
       30. Bill Parr, Weymouth. I think cuts for home health care 
     are despicable since there's so much government waste. They 
     should look at their own inefficiencies to be cut versus home 
     health care that's serving a wonderful service.
       31. Elizabeth Greenwald-Centani, Hingham. The reason why I 
     am especially interested in this article is that I am a home 
     health worker, a nurse, and I also have an elderly mother who 
     suffers from Alzheimer's. I've been impacted in both ways. 
     And I was very pleased that your article brought up both 
     situations, both scapegoating of home health agencies and the 
     plight of the elderly.
       32. Ralph and Polly Gosnick, Marshfield. We want to be 
     recorded in favor of efforts you are putting forward, and 
     want our congressmen to know that we are opposed to the cuts.
       33. Mary Alice Flynn, Scituate. I think that the plan they 
     have on cutting the budget back on the helpless people who 
     are citizens and who have served our country so well over the 
     years is reprehensible, and I feel it's imperative that it be 
     turned around. I thank you for your efforts on this behalf.
       34. Sophia Jackson, Weymouth. I think they should stop 
     spending so much money on investigating sex scandals that 
     make no difference to us and put the money where it belongs, 
     for the elderly.
       35. Christine Whitehouse, Marshfield. I have been affected 
     by the Medicare cuts and I would be interested in what you 
     hope to offer. I would like to write a letter as well, so any 
     information you could be of assistance for I'd appreciate.
       36. Suzanne Naustilius, Marshfield. I wanted to call after 
     reading the article in the newspaper to say that I am very 
     much opposed to cutting federal spending in the area of 
     Medicare home health, and I would like you to add my name to 
     any kind of letter or whatever kind of program you're going 
     to undertake, to try to give this message to our congressmen 
     and senators.
       37. Dolores L. Johnson, Hanover. I've been a volunteer for 
     the South Shore Visiting Nurses Association for several 
     years. They've been forced to move to Braintree from Hanover. 
     The whole thing disgusts me. I am writing today to my 
     senators and representatives.
       38. Dorothy R. Field, Kingston. Our seniors should come 
     first. I work in a nursing home and some of our clients are 
     devastated, having to leave their homes when all they need is 
     a home health care worker to come by and see to their needs.
       39. Alice and David Katema, Holbrook. We're very concerned 
     about the possibility of cutting the budget by cutting 
     Medicare home health programs. We feel that if you don't need 
     them today you may need them tomorrow. Everybody's getting 
     older and we're all so concerned that they may not be there 
     when we need them. We also want to have the legislature think 
     about the fact that if they don't spend at that level, they 
     may need to spend more at another level which is hospital 
     care.
       40. Mary McDonald, Hingham. Thank you for the opportunity 
     of leaving a message for the congressmen. I'm an RN who 
     provides infusion therapy in the home. In have come across 
     and my company has had to deny providing antibiotic therapy, 
     just basic therapy, for these patients in their home because 
     Medicare doesn't cover that cost. I just don't understand 
     where the cost cutting comes in. We are hurting our most 
     fragile population in that to send a nurse out to them to 
     teach them how to do procedures themselves, a lot of times 
     we can get them independent. To me that's a bigger cost-
     cutting measure than keeping them in the hospital and 
     having them take up a bed. So, send that message to the 
     congressmen. I appreciate that you afford us this 
     opportunity. I would just like someone to explain how this 
     is cutting costs by denying people benefits.
       41. Marilyn Keegan, Holbrook. I am calling in response to 
     Congress's attempt to balance the federal budget by cutting 
     Medicare's home health care program. This is positively 
     absurd. We pay taxes all our lives and then if we end up in 
     the position where we need help, you are suggesting we are 
     not able to receive it. My brother-in-law just died. He was 
     bedridden with cancer of the legs along with other cancers. 
     His wife died years ago, he had no children. He positively 
     needed help with home health care and it was minimal. Along 
     with anything friends and neighbors could do, this helped him 
     to live as normal a life as he could. Would it have made more 
     sense to put him in a nursing home and the government would 
     have had to pay that expense rather than the much lesser 
     expense of home health care. What Congress is proposing in 
     the face of making these kinds of cuts is both inhumane and 
     unnecessary. Many of these infirm and elderly have fought for 
     their country and served their fellow man in many capacities. 
     How can we turn our backs on them when they are in need. 
     Please do not stop Medicare's home health care program. It is 
     a real necessity.
       42. Ruth Spiegel, Holbrook. My mother lives with me, she is 
     87 years old and handicapped. She's diabetic, she can't do 
     anything for herself and for several years through Medicare 
     the home health agency was taking care of her. They 
     terminated her March 19 of this year and I would appreciate 
     it if something could be done for her. Her name is Sally 
     Barman.
       43. Pam Bernard, Kingston. I'm very concerned about this. I 
     have three elderly people who need this service. One is 95, 
     one is 91. They've been cut back to five days, then to three 
     days, then no days. Some of these people can't afford to have 
     private duty care come in. Very concerned about it.
       44. Mrs. Robert C. Wright, Hingham. I think it's 
     unconscionable what Congress has done to cut Medicare to the 
     bone. They just cut $17 billion more out, gave millions of 
     dollars more than was asked for the road and bridge 
     construction bill and they're balancing the budget on the 
     backs of the poor and elderly and people who really need 
     help. They will take care of other countries in all 
     directions but don't take care of their own. I think 
     something has got to be done about this because people are 
     suffering.
  Mr. MENENDEZ. Mr. Speaker, I want to thank Congressman McGovern for 
reserving time this evening to afford us an opportunity to discuss a 
critical situation for many of our states' home health agencies.
  As we all know, last year's Balanced Budget Amendment contained 
language which would move Medicare home health payments to a 
prospective payment system, effective October 1, 1999. Until that date 
an Interim Payment System (IPS) for the home health agencies was to be 
put into place.
  Unfortunately, the formula which has been approved to implement this 
IPS has unfairly penalized those states, like New Jersey, who have been 
prudent with their funds. New Jersey ranks fourth nationwide in terms 
of visits per beneficiary, averaging just 43 visits per person, 
compared to the national average of 73.9 visits per person.
  New Jersey's home health agencies provide support services for over 
50,000 patients and

[[Page H5287]]

families each year. The new iPS implemented by HCFA will cut Medicare 
reimbursement to most agencies in New Jersey anywhere from $500,000 to 
several million dollars per agency in 1998 alone. Cumulatively, 
Medicare home health payments to New Jersey's agencies in 1998 will be 
over $25 million less than in 1997. For patients in New Jersey, cuts of 
this magnitude will mean they will receive fewer visits.
  Mr. Speaker, who are these patients who will suffer because of this 
formula? According to the Institute for Health Care Research and Policy 
at Georgetown University, home health patients are more likely to 
report fair or poor health. Twenty-five percent of users are 85 years 
of age or older, and 69% of all users of home health services have 
incomes below $15,000. These people are the among the neediest of our 
neighbors for whom a home health visit may well mean the difference 
between life and death.
  The problem with the current IPS is that it singles out the most 
efficient providers and subjects them to the deepest cuts. This is 
neither fair nor prudent. Where is the equity in asking responsible 
agencies to accept deeper cuts than those states whose home health 
agencies have billed Medicare for more dollars? What is the sense in 
driving fiscally responsible home health agencies out of the provider 
market because of these inequitable cuts?
  There are several bills which have been introduced to correct the IPS 
formula. I am a co-sponsor of H.R. 3657, introduced by my colleague 
from New Jersey. The Medicare Home Health Equity Act of 1998 would 
level the playing field and recognize--not penalize--those home health 
agencies which have been prudent in their use of Medicare dollars.
  We need to address this problem now. Many of our home health agencies 
are in critical condition while they wait and hope that Congress will 
treat them fairly. The agencies in my state are not asking for 
preferential treatment; they are merely asking for fairness.
  Again, I thank the gentleman from Massachusetts for taking time 
tonight to focus attention on this very important issue.
  Mr. FROST. Mr. Speaker, I rise to express my strong concern with the 
current situation of home health care agencies across the country, and 
particularly of those in the State of Texas. Last summer Congress 
passed the Balanced Budget Act of 1997 and in doing so reduced Medicare 
payments to home health agencies. While the intent was to curb waste 
and abuse within the home health industry, it has now become quite 
clear that the BBA is negatively affecting thousands of home health 
agencies and those who use their services.
  I have serious concerns that these provisions affecting payment to 
home health agencies will force hundreds of agencies in the State of 
Texas out of business and thereby forcing patients into nursing homes 
and hospitals. It was reported in the Forth Worth Star Telegram on June 
23, 1998 that half of Texas' home health care agencies will soon being 
filing bankruptcy. It is imperative that Congress fix the problem with 
the home health care payment system, before this story in a newspaper 
becomes a reality.
  H.R. 3205, a bill introduced by my colleague from Massachusetts, Mr. 
McGovern, will fix part of the problem by delaying the implementation 
of the interim payment system for home health agencies. I support this 
bill, and urge my colleagues to work for its passage.
  The Texas Association for Home Care informed my office that in one 
day alone, twenty agencies reported to them that they were going out of 
business. This needs to stop. Congress needs to find solutions to the 
problems it created for this industry and for the thousands of people 
it serves.
  Mr. MANTON. Mr. Speaker, I rise to voice my support for improving the 
already high quality home health care services for Medicare 
beneficiaries. I thank my colleague, Congressman McGovern, for 
organizing this important and timely Special Order to address the need 
to fix a major formula issue for the home health care industry and 
those who rely on its services.
  The Balanced Budget Act of 1997, signed into law last year, moved 
Medicare's home health benefit package payment system to a prospective 
payment system (PPS). Although this system has worked well in the past 
for hospitals, it has not yet been implemented into the home health 
care industry, in turn, an interim payment system (IPS) was put into 
play until the PPS was ready. The IPS formula has since created 
problems for home health care providers and patients by unfairly 
burdening and penalizing home health businesses who are most cost 
effective.
  The impact this situation will have on home health in New York is 
astounding. Because providers in New York are currently having their 
1998 reimbursements based on 1993 experience, it will be a tremendous 
blow to the services the New York home health care industry has 
delivered so well to its patients in the past. Should the IPS continue, 
New York home care providers would see a $130 million reduction in 1998 
reimbursements.
  To remedy this unfortunate situation, a number of pieces of 
legislation have been introduced, including H.R. 3651 and H.R. 3567. 
Introduced by my good friend and colleague, Congressman Engel, H.R. 
3651, The Medicare Home Health Agency Efficiency Act of 1998 proposes 
to change the existing formula and make adjustments to the IPS which 
would treat efficient ag4ncies more fairly. In addition, H.R. 3567, The 
Medicare Home Health Equity Act of 1998, introduced by congressman 
McGovern, would help reinstate equitable reimbursements and allow home 
care agencies to make a less rocky transition the PPS.
  Mr. Speaker, the Balanced Budget Act of 1997 did a fantastic job 
addressing the waste and abuse within the home health care industry. I 
encourage my colleagues in joining me by taking one more step in 
improving the quality services the home health care industry has 
provided for so many Medicare beneficiaries by cosponsoring these vital 
pieces of legislation.
  Too many individuals rely on home health care for their livelihood. 
It would be devastating to both the home health care industry, the 
patients they serve, if the number of home care businesses continue to 
be unfairly burdened through the Interim Payment System contained in 
the Balanced Budget Act of 1997.
  Once again, I would like to thank Congressman McGovern and my other 
colleagues who have gone to great lengths to guarantee the Medicare 
beneficiaries of our nation receive the quality, affordable home health 
care services they deserve.
  Mr. McGOVERN. Mr. Speaker, I submit the following letter:

                                    U.S. House of Representatives,


                                Congress of the United States,

                                     Washington, DC, May 20, 1998.
     Hon. Newt Gingrich,
     Speaker of the House, U.S. House of Representatives, 
         Washington, DC.
       Dear Speaker Gingrich: With the support of the 
     administration, Congress worked to pass the Balanced Budget 
     Act of 1997 (BBA) last summer and in doing so reduced 
     Medicare payments to home health providers across the nation 
     by over $16 billion. The expressed intent of these cuts was 
     to curb waste and abuse within the home health industry. 
     Sadly, it is now clear that the provisions in the Balanced 
     Budget Act do not end such abuse, and actually punish non-
     wasteful home health providers across the nation. Because of 
     a funding formula buried in the BBA, previously efficient and 
     waste-free providers have been given a Medicare spending 
     ``cap'' that is below financially manageable levels, and, as 
     a result, many agencies in Massachusetts are facing 
     insolvency.
       One of the many examples of this phenomenon is 
     Massachusetts Easter Seals, which has provided quality home 
     health care to disabled citizens in my state for over fifteen 
     years. In Massachusetts, Easter Seals is an acknowledged 
     leader in devising and efficiently implementing coordinated 
     treatment plans for people with disabilities and complex 
     medical conditions. In fact, when audited by Operation Trust 
     in 1997, Easter Seals, like most home health providers in 
     Massachusetts, passed with flying colors.
       Massachusetts Easter Seals will no longer offer home health 
     services because of the Balanced Budget Act of 1997. Faced 
     with a projected deficit in excess of one million dollars, 
     the Board of Directors has chosen to exit home health care as 
     of August 31, 1998. This means that over 500 individuals, the 
     majority of whom have disabilities or chronic medical 
     conditions, will be forced to seek care elsewhere in the 
     Massachusetts home health market--which is already downsizing 
     dramatically. In the future, individuals with disabilities or 
     chronic conditions may well be unable to access appropriate 
     home health services. The net result will be that many 
     Massachusetts citizens will be institutionalized at high 
     personal cost and greater expenditure of public funds.
       Pressure to correct these unintended consequences is 
     growing in Congress. At a recent Senate hearing, twelve 
     Senators from both parties gathered to discuss the problems 
     this law created for home health care. They agreed that a 
     ``mistake'' had been made in the Balanced Budget Act and were 
     prepared to look at ways to solve the crisis. I have called 
     for a hearing in the House of Representatives, and on 
     February 12, 1998, I introduced a bipartisan bill, H.R. 3205, 
     ``The IPS Technical Correction Act of 1998.'' This bill, 
     which would ease the crisis in home health, currently has 
     over 40 cosponsors from both parties. Senators Kennedy and 
     Jeffords introduced the Senate companion, S. 1643, and 
     support is growing in the Senate as well.
       I would like to request that you include H.R. 3205 for the 
     House Calendar on technical corrections day. Seniors, the 
     disabled, and the medically complex individuals in our nation 
     are paying for this poorly-drafted provision to cut waste and 
     abuse in the home care industry. I support ending abuse and 
     pledge to work with you toward this goal, but patients should 
     never be the ones to suffer from such attempts. I look 
     forward to working with you to provide needed and efficient 
     home health care to our nation, and I thank you in advance 
     for your attention to my request.
           Sincerely,
                                                James P. McGovern,
                                               Member of Congress.





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