[Congressional Record Volume 145, Number 65 (Thursday, May 6, 1999)]
[Senate]
[Pages S4898-S4902]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BAUCUS (for himself, Mr. Daschle, Mr. Thomas, Mr. Harkin, 
        Mr. Grassley, Mr. Conrad, Mr. Roberts, Mr. Frist, Mr. Johnson, 
        Mr. Rockfeller, Mr. Jeffords, Mr. Wellstone, and Mr. 
        Murkowski):
  S. 980. A bill to promote access to health care services in rural 
areas; to the Committee on Finance.


              promoting health in rural areas act of 1999

  Mr. BAUCUS. Mr. President, I rise today to introduce the Promoting 
Health in Rural Areas Act of 1999.
  All Americans deserve access to quality health care. But in rural 
America health care delivery is often difficult, given the great 
distances and extreme weather conditions that typically prevail. That's 
why Senator Daschle and I, along with bipartisan group of Senators, are 
introducing this important legislation. Its provisions are many, but it 
purpose is singular: to correct the federal government's tendency to 
view all areas--urban and rural--with a one-size-fits all lens.
  Before I begin explaining what this bill does, I want to recognize 
the tremendous contributions of some of the cosponsors' staff who have 
worked on the bill.
  The Minority Leader is known in the Senate not only for this 
tremendous leadership, but for the quality of his staff. Elizabeth 
Hargrave is no exception. On loan from the Department of Health and 
Human Services, she has worked tirelessly to see this bill through to 
introduction. With her expertise and attention to the intricate details 
of health policy, we have come up with a solid, comprehensive bill, 
much improved from that which was introduced last year.
  Tom Walsh on the Senate Aging Committee has also done tremendous 
work. His knowledge of Medicare law is vast, and his parent demeanor 
has done wonders toward making negotiations on this bill amicable and 
fruitful. Heidi Cashman with Senator Roberts, Neleen Eisinger with 
Senator Conrad, Diane Major and Stephanie Sword with Senator Thomas, 
Sabrina and Bryan with Senator Harkin, The list goes on. The Promoting 
Health in Rural Areas Act is the product of many long meetings, 
extensive research, and a great deal of cooperation. Would that we 
could all work so well together.
  So why is this bill important? As you know, Mr. President, a couple 
of years ago Congress passed the Balanced Budget Act. In it we extended 
the life of Medicare for several years and passed some important rural 
health provisions, including Medicare reimbursement for telemedicine 
and the Medicare Rural Hospital Flexibility Program to establish 
Critical Access Hospitals (CAHs).
  Under the new CAH law, rural hospitals can convert to limited-service 
hospital status and received flexibility with Medicare regulations 
designed for full-size, full-service facilities. They are reimbursed by 
Medicare based on actual costs, not fixed or limited payments; in 
exchange, CAHs agree to a limit of 15 hospitals beds and patients stays 
of limited duration. The model for the new program was based largely on 
Montana's Medical Assistance Facility Program. CAHs show well the 
progress we can make if rural areas are afforded the flexibility to 
develop solutions to the problems they know best. They also illustrate 
a creative means by which we can use the Medicare program to keep rural 
hospitals open--and rural communities alive.
  But not all of the Balanced Budget Act was positive for rural areas. 
Far from it. Montana health care facilities, including hospitals, home 
health agencies and nursing homes, are suffering.
  In 1997, even before the BBA cuts, small rural hospitals in Montana 
lost 6.5% treating Medicare patients. And although we do not yet have 
complete data on the impact of the BBA changes, anecdotal evidence 
tells me that the situation in rural Montana has gotten even worse. In 
rural areas where many, usually most, patients are of Medicare age, we 
cannot expect these facilities to stay open without paying them enough 
to break even. We must do something to ensure the integrity of our 
rural health care systems.
  This bill is a good first step. Among other things, the bill provides 
rural communities with assistance in recruiting health care providers; 
expands the range of services that can be provided with telemedicine; 
increases payments to hospitals in rural areas; expands access to 
mental health services in rural areas; changes the formula by which 
managed care payments are calculated to attract more managed care 
health plans to rural areas; and increase rural representation on the 
Medicare Payment Advisory Commission.
  As Dennis Farney, a reporter from Kansas once wrote: ``A prairie is 
not any old piece of flat land in the Midwest. No a prairie is wine-
colored grass, dancing in the wind. A prairie is a sun-splashed 
hillside, bright with wild flowers. A prairie is a fleeting cloud 
shadow, the song of the meadowlark. It is the wild land that has never 
felt the slash of the plow.'' For me, this conjures up images of an 
idyllic rural setting, far removed from the commotion of city life. And 
certainly that is in the minds of many who live in these sparsely-
populated areas--that they are inhabiting a part of the world that is 
in many ways pristine and untouched.
  Of course there is a price to pay for that. Rural folks should not 
expect to have all the amenities of city life: opera houses and 
professional sports teams are just a couple of things that rural areas 
must simply do without. Rural Montanans can't expect to have a subway 
system--or even a Subway sandwich shop for that matter--because 
economies of scale dictate as much.
  And even in the area of health care, rural Americans realize they 
give up something. Full-service hospitals and dental clinics are the 
stuff of populated areas, and will probably remain so. But although you 
won't find a full-service acute-care hospital in Choteau, Montana, you 
can find a CAH. And though you don't find a full-service dental clinic 
in Eureka, you can find a rural health clinic. Rural residents cannot 
expect to have the most extensive health care facilities or access to 
the array of specialists typical of urban settings, but they should 
expect a minimum standard of quality care. This bill is a step in the 
right direction towards raising that standard.
  Whether it's helping rural areas with highway dollars, preventing 
small post offices from moving to towns' outskirts, or keeping 
hospitals open, I think most of us agree that saving rural areas is 
something that ought to be done. Regardless of how hard we try, 
however, we cannot do so without ensuring the integrity of these 
communities' health care systems. I urge my colleagues to join the 
Minority Leader and I in doing just that.
  Mr. DASCHLE. Mr. President, today I introduce a bill intended to 
improve health care for Americans living in rural areas. The Promoting 
Health in Rural Areas Act of 1999 would improve the viability of rural 
hospitals and clinics, help rural communities attract and retain health 
care providers and health plans, and make optimal use of the 
extraordinary medical and telecommunications technology available 
today.
  One-fifth of Americans live in rural areas. They experience the same 
health care access problems that Americans in cities and suburbs face--
plus some problems that are uniquely rural. Issues of geography and 
transportation, which rural Americans face all the time, can make it 
difficult to visit the doctor or get to a hospital. These problems are 
made worse by the short supply of health care professionals in rural 
areas.
  Rural communities are striving to improve access through telehealth 
and the recruitment of health care professionals. At the same time, 
they must also struggle to maintain what they have, to ensure that 
providers who leave their area are replaced, and to keep their 
hospitals' doors open. This

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bill contains several provisions that will help them do this--by 
improving Medicaid and Medicare reimbursements to rural providers, 
strengthening recruitment programs, and encouraging the development of 
telehealth. These are important steps to improve access, increase 
choice, and improve the quality of care provided in more isolated parts 
of the country.
  One problem rural areas face is reimbursement systems that favor 
urban areas, or that do not take the special needs of rural providers 
into account. For example, Medicare payments to hospitals are based on 
formulas that are biased toward urban areas. The Medicare Payment 
Advisory Commission, and its predecessor, the Prospective Payment 
Advisory Commission, have been pointing out these inequities for years. 
This bill would correct the formulas and pay hospitals more fairly.
  Another reimbursement problem in rural states is payment for health 
plans in Medicare+Choice. The bill includes a provision to guarantee 
that plans in rural counties get the increased reimbursement promised 
in the Balanced Budget Act. This provision is important to ensure that 
beneficiaries in rural areas have some of the health plan choices 
available to urban seniors.
  Rural communities also face difficulty recruiting and retaining 
health care providers. Despite great increases in the number of 
providers trained in this country over the past 30 years, rural 
communities have not shared equitably in the benefits of this 
expansion. As a result, about 22 million rural Americans live in areas 
considered Health Professional Shortage Areas because they do not have 
enough doctors to serve their community.
  Our bill addresses obstacles in current law to the recruitment and 
training of providers in rural areas. One obstacle is the current 
requirement that communities actually lose a physician before they 
qualify for recruitment assistance to replace that provider. This bill 
would let communities get assistance for up to 12 months in advance 
when they know a retirement or resignation is pending. Another 
provision in the bill ensures that new Medicare reimbursement rules for 
medical residents, enacted as part of the Balanced Budget Act, do not 
discriminate against areas that train residents in rural health clinics 
or other settings outside a hospital.
  Telehealth is another promising tool to bring medical expertise to 
rural communities. Through telehealth technology, rural patients can 
significantly shorten their travel time to see specialists, and they 
can have access to doctors they would otherwise never encounter. The 
benefits of telehealth extend to rural health professionals as well, 
providing them with technical expertise and interaction with peers that 
can make practicing in a rural area more attractive.
  Our bill addresses some of the barriers that have limited the 
development of telehealth. It would expand Medicare reimbursement for 
telehealth to all rural areas, and to all services Medicare currently 
covers. The bill also would make telehealth more convenient, by 
allowing any health care practitioner to present a patient to a 
specialist on the other side of the video connection. The bill also 
includes a grant program to help communities establish telehealth 
programs.
  Mr. President, rural America deserves appropriate access to health 
care--access to hospitals, access to providers, and access to quality 
services. Providing this care in rural communities raises unique 
challenges, but we can--and must--overcome those challenges. The bill I 
introduce today, along with my colleague Senator Baucus and other 
members of the Rural Health Caucus, takes important steps toward that 
goal.
  Mr. CONRAD. Mr. President, today, I am pleased to join Senator 
Baucus, Senator Daschle, and other Senators to introduce the Promoting 
Health in Rural Areas Act of 1999 (PHIRA). This legislation will 
improve access, increase choice and improve the quality of health care 
in rural America.
  As you know, Mr. President, the Balanced Budget Act (BBA) of 1997 
produced real savings for the Medicare program and helped to extend 
solvency of the program. However, since passing the BBA, we have heard 
concerns from many rural health care providers that they are facing 
serious financial pressures due in large part to reductions that were 
enacted as part of the BBA.
  During the BBA debate, I was very concerned that across-the-board 
cuts in Medicare would have a disproportionate impact on rural health 
care. Rural hospitals rely heavily on Medicare and in my state of North 
Dakota, Medicare accounts for 70 percent of hospital revenue. This 
means that Medicare reimbursement reductions have a bigger direct 
impact on rural hospitals than on other hospitals. It also means that 
rural hospitals have fewer other sources of revenues where they can 
increase margins to make up for losses in Medicare revenue.
  To help protect access to health care in rural areas, I and a 
coalition of other Senators, worked hard to fight for provisions in the 
BBA to protect our rural areas. We made positive steps toward ensuring 
that health care in rural areas is affordable and accessible.
  Our victories included, for the first time, requiring Medicare 
reimbursement for telehealth. Also included was the creation of the 
Critical Access Hospital program. The BBA also helped to reform managed 
care reimbursement to make it more equitable to rural areas and added 
Graduate Medical Education language to protect rural residency 
programs.
  Despite our efforts, BBA reductions are having an unfair and 
disproportionate impact on rural health care systems--these cuts have 
caused real pain for providers and threaten to reduce access to health 
care for seniors, particularly in rural areas.
  To help address these concerns, we have worked hard to develop 
legislation that will ensure our rural areas have access to quality 
care. The Promoting Health in Rural Areas Act of 1999 will improve 
Medicaid and Medicare reimbursement to rural providers, strengthen 
health professional recruitment programs, and encourage the development 
of telehealth.
  One problem that rural areas face is reimbursement systems that favor 
urban areas, or that do not take the special needs of rural providers 
into account. Medicare payments to hospitals are currently based on 
formulas that are biased toward urban areas. The first element of PHIRA 
would correct these formulas and pay hospitals more fairly. In the BBA, 
Medicaid funding for Community Health Clinics (CHCs) and Rural Health 
Clinics (RHCs) was changed, leaving no guarantee that states will 
adequately fund these facilities. This bill would create a new payment 
system for CHCs and RHCs that will help ensure continued support for 
these essential facilities. The bill would also guarantee that 
Medicare+Choice plans in rural counties get the increased reimbursement 
promised in the BBA. This provision is important to ensure that 
beneficiaries in rural areas have at least some of the health plan 
choices that are available to urban seniors.

  The second element of our bill includes provisions to attract and 
bring more health care providers into our communities. Rural 
communities face difficulties in recruiting and retaining health care 
providers. In my state, over 85% of counties are designated as either a 
partial or full health shortage profession area (HPSA). Nationwide, 22 
million rural Americans live in HPSAs. We must do more to attract 
qualified health care providers into our rural areas. Currently, 
communities must actually lose a physician before they qualify for 
recruitment assistance to replace that provider. This bill would let 
communities get assistance for up to 12 months in advance when they 
know someone is going to retire. In addition, this bill will take 
positive steps to ensure that our future health care providers choose 
to serve in HPSAs. Currently, students in our National Health Service 
Corps program, a program helps students pay for their medical education 
or re-pay their medical student loans in return for serving in HPSAs, 
are facing undue hardship due to the fact that they are being taxed on 
scholarships they receive to participate in the NHSC. This bill will 
reward students for their commitment to working in HPSAs by exempting 
them from being taxed on their NHSC scholarships.
  The third element of PHIRA will go even further to ensure that the 
most important medical services are available in our communities by 
expanding access to telehealth services. The

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promise of telehealth is becoming increasingly apparent. Throughout the 
country, providers are experimenting with a variety of telehealth 
approaches in an effort to improve access to quality medical and other 
health-related services. Those programs are demonstrating that 
telecommunications technology can alleviate the constraints of time and 
distance, as well as the cost and inconvenience of transporting 
patients to medical providers. Many approaches show promising results 
in reducing health care costs and bringing adequate care to all 
Americans. For the first time, technological advances and the 
development of a national information infrastructure give telehealth 
the potential to overcome barriers to health care services for rural 
Americans and afford them the access that most Americans take for 
granted. But it is clear that our nation must do more to integrate 
telehealth into our overall health care delivery infrastructure.
  This bill would expand Medicare reimbursement for telemedicine to all 
rural areas, and to all Medicare services. Medicare reimbursement 
policy is an essential component of helping to integrate telehealth 
into the health care infrastructure and is particularly important in 
rural areas, where many hospitals do as much as 80% of their business 
with Medicare patients. Because the Secretary defined reimbursable 
services so narrowly in the BBA, this legislation clarifies that all 
services that are covered under Medicare Part B will be covered if they 
are instead delivered vial telehealth. In particular, it clarifies that 
the technology called ``store and forward'', which is a cost-effective 
method of transferring information, is included in this reimbursement 
policy.
  This bill will also help communities build home-grown telehealth 
networks. It will help to build telehealth infrastructure and foster 
rural economic development, and it incorporates many of the most 
important lessons learned from other grant projects and studies on 
telehealth from across the Federal government. Because so many rural 
and underserved communities lack the ability to attract and support a 
wide variety of health care professionals and services, it is important 
to find a way to bring the most important medical services into those 
communities. Telehealth provides an important part of the answer. It 
helps bring services to remote areas in a quick, cost-effective manner, 
and can enable patients to avoid traveling long distances in order to 
receive health care treatment.
  Mr. President, I am confident that the Promoting Health in Rural 
Areas Act will take important steps toward ensuring those in our rural 
and underserved communities have access to quality, affordable health 
care. I urge my colleagues to support this legislation.
  Mr. THOMAS. Mr. President, I rise today to join several of my 
colleagues in introducing the ``Promoting Health in Rural Areas Act,'' 
a bill designed to increase access to quality health care services in 
rural areas. I am pleased to have worked with my colleagues--Senators 
Baucus, Roberts, Grassley, Harkin, Daschle, Conrad and Collins--in 
crafting this bill for rural America.
  Rural health care has been a top priority for me throughout my 
service in the House and Senate. As co-chairman of the Senate Rural 
Health Care Caucus, I am pleased that rural health care is an issue 
that we have always addressed in a bipartisan way in the Senate.
  Rural health care is at a crossroads. Many communities are left 
short-handed through no fault of their own. The lack of physicians, 
nurses and other health professionals make it difficult for rural 
individuals to receive the most basic primary care. Further, inadequate 
and, more importantly, unequal reimbursement by federal agencies 
multiplies these unique challenges and leaves rural individuals and 
families without access to vital medical care.
  The Promoting Health in Rural Areas Act of 1999 offers clear and 
sensible solutions to these problems. It increases reimbursement rates 
for rural hospitals and clinics, it offers communities additional 
assistance in recruiting physicians, it promotes the use of 
telemedicine services, it expands coverage of mental health services in 
rural areas and it ensures adequate representation of rural health care 
on a national Medicare advisory board. It is a long-term solution 
tailored to the needs of rural areas.
  The bill incorporates many of the best ideas and recommendations that 
emerged from the Wyoming Health Care Policy Forum I hosted in Casper on 
August 26-27, 1998. Wyoming's health care providers, health care 
recipients, elected representatives and concerned citizens assembled to 
evaluate and assess the direction of Wyoming's health care delivery 
system and to chart a blueprint for its future.
  This bill increases payments to Sole Community Hospitals, Rural 
Health Clinics and private health plans contracting with Medicare by 
exempting them from a proposed prospective payment system for 
outpatient hospital services. Facilities would be reimbursed on actual 
costs, providing a higher reimbursement rate. It would also update the 
cost reporting year, or ``rebase,'' the data Medicare uses to calculate 
costs and reimbursements.
  Most hospitals in Wyoming are designated as Sole Community Hospitals 
because of isolation, weather, travel conditions and the absence of 
other health care facilities. They are crucial for health care delivery 
in Wyoming.
  Further, the bill would expand the eligibility for hospitals to 
become Critical Access Hospitals. Critical Access Hospitals are a newly 
designated class of hospitals in rural areas that have been given 
greater flexibility and relief from federal regulations so they can 
organize their staff and facilities to meet the immediate emergency 
care needs of their small communities. They can tailor or reconfigure 
their services without losing their Medicare certification.
  Rural communities through the United States are federally designated 
health professional shortage areas (HPSA). Wyoming has 22 of them. This 
means there is less than one primary care physician for every 3500 
persons living in those areas. The Promoting Health in Rural Areas Act 
helps solve this dilemma by offering effective solutions to recruit and 
retain health care providers.
  It revises Medicare's Graduate Medical Education (GME) programs by 
raising the cap on the number of residents that will be allowed to 
participate in family practice residency programs. In addition, it 
provides added recruiting assistance to communities in HPSAs. Current 
law places rural communities at risk because it requires that a 
community first lose a physician before it qualifies for recruitment 
assistance. This bill recognizes pending physician resignations and 
retirements so communities have access to assistance before they lose 
their provider.
  Further, it enhances the National Health Service Corps (NHSC) by 
giving tax relief to those receiving scholarships and loans under the 
program. The NHSC is an important component in the rural health care 
delivery system and additional tax relief would encourage recipients to 
remain in rural areas.
  Telehealth technologies play a key role in bridging the barriers of 
time and distance that prevent access to medical care. We must ensure 
that the technology is practical, affordable, accessible and maintains 
privacy. The bill expands the types of telemedicine services that will 
be reimbursed under Medicare, which will be very useful in establishing 
a well-coordinated network of physicians, mid-level practitioners, 
hospitals and clinics. It also encourages solutions to telemedicine 
questions that have been raised about practicing interstate medicine by 
authorizing a Joint Working Group on Telehealth that would identify, 
monitor and coordinate federal telehealth projects and issue an annual 
report to Congress.
  Mental health care is a priority in this bill. Individuals in rural 
areas often have limited access to mental health services. As a result, 
rural states license additional categories of mental health 
professionals than are recognized by Medicare. This bill ensures more 
of the services will be covered by Medicare.
  Two years ago, Congress established the Medicare Payment Advisory 
Commission to make important policy recommendations on Part A and Part 
B of the Medicare program. Unfortunately, of the current 15-member 
board, only

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one health care professional is from a rural area. Our bill requires 
that the Commission include at least two representatives from Rural 
Areas. This will help ensure that the board members fully understand 
the implications of their policy decisions.
  In conclusion, the Promoting Health in Rural Areas Act provides the 
answers many rural communities are looking for to ensure quality health 
care for their residents. I look forward to discussing and actively 
debating rural health this Congress. It is possible that Medicare 
reform legislation will be debated this year and the Senate Rural 
Health Care Caucus will work to attach many of these provisions to such 
legislation. We understand the impact recent Medicare changes are 
having on our nation's fragile rural health system.
  We need to act now. This bill is a great start.
  Mr. HARKIN. Mr. President, I am pleased to join my distinguished 
colleagues, Senators Daschle, Baucus, Thomas, Conrad, Roberts, 
Grassley, Collins, and Frist in introducing a critical piece of 
legislation for America's rural communities, the ``Promoting Health in 
Rural Areas Act of 1999''. As co-chairs of the Senate Rural Health 
Caucus, Senator Thomas and I convened this bipartisan group last fall 
to craft a comprehensive rural health bill, building on the hard work 
of Senators Daschle and Baucus from the 105th Congress. I am very proud 
that today we are able to come together across party lines to introduce 
a bill that will improve the ability of rural Americans to access good 
quality health care.
  Today, the health care system in rural Iowa is on the verge of being 
admitted to an intensive care unit. Iowans living in small towns and 
rural areas are facing too many barriers to quality health care. But 
seniors living in New Hampton, Iowa, pay the same Medicare taxes as 
those who live in New York City--they should get the same quality 
health care.
  This bill aims to improve access, increase choice, and improve the 
quality of care provided in rural towns in Iowa and around the nation. 
Current formulas for Medicaid and Medicare payments to hospitals are 
biased towards urban areas. This bill raises payments for rural 
hospitals by making it easier for them to qualify for special 
designations. The bill also strengthens health professional recruitment 
programs, helps expand access to mental health services in rural areas, 
requires that rural areas be represented on the Medicare Payment 
Advisory Commission and expand the range of Medicare-reimbursed 
services that can be provided via telemedicine.
  Health care providers in rural areas like Iowa practice a 
conservative, cost-effective approach to health care. They should be 
rewarded for their resourcefulness, not penalized with unfair 
reimbursement rates. But Medicare payments to hospitals are currently 
based on formulas that give urban areas an advantage. This bill 
corrects these formulas so that hospitals can be paid more fairly. It 
also includes provisions specifically targeted to small, rural 
hospitals and the unique problems they face.
  In addition, the bill guarantees that Medicare+Choice plans in rural 
counties get the increased reimbursement promised in the Balanced 
Budget Act of 1997. This provision will help ensure that seniors in 
rural areas have some of the same health plan choices available to 
urban seniors. These changes will help to address some of the inequity 
that exists for Medicare managed care.
  And I will soon introduce legislation that will take the next 
critical step: fixing the inequity in Medicare fee-for-service. The 
vast majority of seniors living in rural areas will continue to receive 
their care through Medicare fee-for-service, yet the reimbursement rate 
for rural providers is woefully inadequate. My bill will address the 
imbalance between rural and urban fee-for-service rates, and I hope to 
introduce it in the next several weeks.
  Mr. President, the health care system in this country is undergoing 
dramatic changes and our rural health care infrastructure is struggling 
to keep pace with the new landscape. The bill we are introducing today 
is the product of a bipartisan commitment to make sure that rural 
Americans have access to the same high quality health care that all 
Americans have come to expect. I am proud to be a part of this effort.
  Mr. ROBERTS. Mr. President, I rise today to join my colleagues in 
introducing the Promoting Health in Rural Areas Act of 1999.
  Health care today is at a crossroads. Rural communities face 
significant challenges in their efforts to recruit and retain health 
care providers. Hospitals and other health care facilities are facing 
increasing pressure from Medicare reductions. In 1997, Congress passed 
significant changes to the Medicare program in an effort to preserve 
the program for future generations. A new Congressional Budget Report 
says we are exceeding our expectations. In fact, since the beginning of 
the fiscal year in October, Medicare spending was $2.6 billion less 
than the amount spent in the similar period last year.
  While this is good news for the fiscal integrity of the Medicare 
program, I am concerned about the unintended effects these reductions 
are having on the beneficiaries who depend on Medicare for health care 
services. It doesn't do much good to ``save'' the program if providers 
can no longer afford to deliver the services and beneficiaries are no 
longer able to access these services.
  A new review by Ernst & Young reports that total hospital Medicare 
margins are expected to decline from 4.3 percent in fiscal year 1997 to 
only 0.1 percent in this fiscal year and remain below three percent 
through 2002.
  Even more shocking is that total hospital margins for small, rural 
hospitals are expected to fall from 4.3 percent in fiscal year 1998 to 
negative 5.6 percent by fiscal year 2002, an amazing decline of 233 
percent. Kansas hospitals are expected to lose over $530 million. I 
simply don't think our rural health system can survive any more 
reductions.
  The Promoting Health in Rural Areas Act of 1999 will help to improve 
access, increase choice, and improve the quality of care provided in 
rural America.
  Health care providers in rural areas generally serve a large number 
of Medicare patients. However, Medicare reimbursement to rural 
providers is not adequate to cover the costs of these services. This 
measure takes steps to ensure fair Medicare and Medicaid payments to 
rural providers by targeting those hospitals with special designations 
in rural areas. Provisions are included to increase payments and 
improve the Sole Community Hospital, Medicare Dependent Hospital, and 
Critical Access Hospital programs. In addition, these special 
facilities are exempt from a new outpatient reimbursement system that 
is being developed by the Health Care Financing Administration.
  The Promoting Health in Rural Areas Act of 1999 also strengthens 
health professional recruitment programs and gives communities a chance 
to begin recruitment efforts before a crisis hits. Under current law, a 
community must effectively lose a physician before they qualify for 
recruitment assistance as a shortage area.
  This measure also takes steps to encourage the use of telehealth, a 
critical piece of the rural health infrastructure. Under current law, 
HCFA limits reimbursement to four groups of services. This bill will 
expand reimbursement to include any services currently covered by 
Medicare in a rural area. In addition, the bill authorizes a new grant/
loan program for telemedicine activities in rural areas.
  Compromise is a way of life for rural Americans. Rural residents have 
fewer choices of physicians or hospitals. Rural providers must settle 
for fewer medical colleagues to rely on for consultation and support.
  However, rural communities can no longer compromise. The regulatory 
burden is too much. Payments are too low. There simply isn't any more 
``fat'' in the system.
  Mr. President, I fear this is only the tip of the iceberg. As payment 
changes continue to be implemented and HCFA continues to issue new 
regulations and paperwork burdens, rural communities are going to 
suffer the most. In fact, many may not survive. We are already losing 
home health agencies at an alarming rate. Are hospitals the next to go?
  I am committed to efforts to preserve access to health care services 
for all Kansans. We can do this if we simply focus on practical reforms 
that take

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into account the realities of practicing medicine in rural states like 
Kansas. We can guarantee access to quality health care services if we 
make changes now. We can't afford to wait. I urge my colleagues to join 
me today in supporting this legislation and look forward to working 
together to enact common sense solutions--before it's too late.
                                 ______