[Congressional Record Volume 145, Number 117 (Friday, September 10, 1999)]
[Senate]
[Pages S10729-S10735]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




          STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS

      By Mr. CONRAD (for himself, Mr. Feingold, and Mr. Chafee):
  S. 1574. A bill to amend title XVIII of the Social Security Act to 
improve the interim payment system for home health services, and for 
other purposes; to the Committee on Finance.


        the fairness in medicare home health access act of 1999

  Mr. CONRAD. Mr. President, today I am pleased to be joined by 
Senators Feingold and Chafee in introducing the Fairness in Medicare 
Home Health Access Act of 1999. I am proud to say that the Governing 
Board of the North Dakota Home Care Association, as well as the 
Visiting Nurse Association of America, have endorsed this legislation 
as a crucial step toward ensuring beneficiaries retain access to vital 
home care services.
  As you know, home health care has proven to be an important component 
of the Medicare package because it allows beneficiaries with acute 
needs to receive care in their home rather than in other settings, such 
as a hospital or nursing home. In my state of North Dakota, home health 
care has been particularly important because it has allowed seniors 
living in remote, frontier areas to receive consistent, quality health 
care without having to travel long distances to the nearest health care 
facility.
  Over the last three decades, we have witnessed significant increases 
in home health utilization as medical practices have shifted care from 
an inpatient to outpatient setting. To help address rising health care 
spending, the Congress included targeted measures in the Balanced 
Budget Act of 1997 (BBA) to reduce costs and give providers incentives 
to become more efficient. In particular, the BBA directed the Health 
Care Financing Administration to implement an interim payment system 
for home health care until which time a prospective payment system 
could be instituted. While the interim payment system has allowed 
agencies to become more cost-effective, there are also concerns that it 
may be having some unintended consequences on agencies' ability to 
deliver quality, appropriate home care services to Medicare 
beneficiaries.
  Mr. President, this legislation takes definitive steps to address 
various unintended consequences of the interim payment system and of 
the BBA in general.
  Home health providers serving rural beneficiaries have been 
particularly affected by the interim payment system. As you know, home 
health care delivery is unique because unlike most other services, the 
health care provider must travel to the patient. Compared to urban 
agencies, rural home care providers must travel longer distances to 
serve beneficiaries and they often face poor weather and road 
conditions. Due to these constraints, agencies serving rural 
beneficiaries must visit patients less frequently; but during an 
isolated visit aides tend to spend more time with beneficiaries to 
ensure that they are receiving appropriate levels of care. 
Unfortunately, the per visit limits included in the interim payment 
system do not adequately account for the unique challenges of serving 
rural beneficiaries. This legislation revises the per visit cost limit 
to ensure agencies have the resources to deliver care to beneficiaries 
living in rural and underserved areas.
  It also appears that the interim payment system does not adequately 
account for the needs of medically-complex beneficiaries. Various 
reports have

[[Page S10730]]

suggested that the interim payment system has resulted in restricted 
access to home health services for high-acuity, high-cost patients. In 
a recent survey conducted by the Medicare Payment Advisory Commission, 
nearly 40 percent of agencies reported that they are less likely to 
admit patients identified as those with long-term or chronic needs. In 
addition, many beneficiary advocates have raised concerns that home 
health agencies are denying access to care because they believe 
Medicare will no longer cover the high costs of providing services to 
medically complex individuals. When it is implemented, the prospective 
payment system will include a measure to account for the treatment of 
medically-complex beneficiaries. In the interim, this legislation will 
allow agencies to receive more appropriate payments for treating high-
acuity, high-cost beneficiaries.

  In addition, this legislation includes provisions to further ensure 
home care agencies have the appropriate resources to serve Medicare 
beneficiaries. To help slow the growth of home health expenditures, the 
BBA includes a provision to reduce home health cost limits by 15 
percent, beginning October 1, 2000. There is significant concern that 
the timing and level of the scheduled 15 percent reduction will result 
in reduced beneficiary access to health care. To address this concern, 
various industry representatives have requested a complete elimination 
of the scheduled reduction; however the cost of this reduction is 
estimated to be nearly $17 billion over ten years. Against the backdrop 
of impending insolvency of the Medicare program and the overall needs 
of the health care community as a whole regarding BBA-related relief, 
it will not be possible to completely eliminate this scheduled 
reduction. For this reason, this legislation suggests a middle-ground 
approach to this issue to ensure the scheduled reduction does not 
result in a reduction in beneficiary access.
  Primarily, this legislation would ensure that agencies receive 
adequate reimbursement by delaying the scheduled 15 percent reduction 
until the prospective payment system is fully implemented. This means 
that if implementation of the prospective payment system is delayed, 
the scheduled reduction would be delayed accordingly. In addition, to 
allow agencies to transition to the prospective payment system, and 
ensure they retain the necessary resources to serve beneficiaries, this 
legislation would reduce the scheduled reduction to 10 percent and 
would phase-in a further 5 percent reduction three years after the 
prospective payment system is implemented. These responsible measures 
will provide home health agencies additional resources to continue 
serving Medicare beneficiaries.
  In addition, this legislation would offer home health agencies relief 
from a particularly burdensome regulatory requirement. The BBA requires 
home health agencies to record the length of time of home health visits 
in 15-minute increments. This requirement is burdensome for agencies 
because time for travel and administrative duties related to this 
requirement are not compensated. Also, it is not clear that the 
collection of this data has a defined use. This provision eliminates 
the 15-minute reporting requirement and directs that any data 
collection regarding direct patient care have a defined purpose and not 
be unnecessary labor-intensive for home care providers.
  This bill would also take steps to address concerns regarding the 
provision of durable medical supplies to Medicare beneficiaries. The 
BBA requires implementation of consolidated billing for home health 
services. As part of consolidated billing, the BBA requires home care 
providers (rather than durable medical equipment suppliers) to provide 
durable medical equipment (DME) to Medicare beneficiaries during any 
episode of care by the home health provider. When a beneficiary seeks 
home health care, there is concern that they may experience a break in 
the continuum of care as they shift between receiving medical equipment 
from a DME supplier to receiving these supplies from a home health 
agency. In addition, many home health agencies are not currently 
equipped to provide and be reimbursed for the provision of durable 
medical equipment. This provision would ensure beneficiaries do not 
experience a break in serve with regard to durable medical equipment by 
allowing DME providers to continue delivering services to beneficiaries 
regardless of their home health status.
  Lastly, this legislation includes a provision that directs the 
establishment of a nationally uniform process to ensure that fiscal 
intermediaries have the training and ability to provide timely and 
accurate coverage and payment information to home health agencies and 
beneficiaries. This provision will be particularly important to home 
health reimbursement transitions to a new prospective payment system.
  I am confident that this legislation will ensure home health agencies 
can continue providing critical health care services to Medicare 
beneficiaries. I urge my colleagues to support this important 
legislation.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follow:

                                S. 1574

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``The Fairness in Medicare 
     Home Health Access Act of 1999''.

     SEC. 2. FINDINGS AND PURPOSES.

       (a) Findings.--Congress finds the following:
       (1) Home health care is a vital component of the medicare 
     program under title XVIII of the Social Security Act.
       (2) Home health services provided under the medicare 
     program enable medicare beneficiaries who are homebound and 
     greatly risk costly institutionalized care to continue to 
     live in their own homes and communities.
       (3) Implementation of the interim payment system for home 
     health services has inadvertently exacerbated payment 
     disparities for home health services among regions, 
     penalizing efficient, low-cost providers in rural areas and 
     providing insufficient compensation for the care of medicare 
     beneficiaries with acute, medically complex conditions.
       (4) The combination of insufficient payments and new 
     administrative changes has reduced the access of medicare 
     beneficiaries to home health services in many areas by 
     forcing home health agencies to provide fewer services, to 
     shrink their service areas, or to limit the types of 
     conditions for which they provide treatment.
       (b) Purposes.--The purposes of this Act are as follows:
       (1) To improve access to care for medicare beneficiaries 
     with high medical needs by establishing a process for home 
     health agencies to exclude services provided to medicare 
     beneficiaries with acute, medically complex conditions from 
     payment limits and to receive payment based on the reasonable 
     costs of providing such services through a process that is 
     feasible for the Health Care Financing Administration to 
     administer.
       (2) To ensure that the 15 percent contingency reduction in 
     medicare payments for home health services established under 
     the Balanced Budget Act of 1997 does not occur under the 
     interim payment system for home health services.
       (3) To reduce the scheduled 15 percent reduction in the 
     cost limits and per beneficiary limits to 10 percent and to 
     phase-in the additional 5 percent reduction in such limits 
     after the initial 3 years of the prospective payment system 
     for home health services.
       (4) To address the unique challenges of serving medicare 
     beneficiaries in rural and underserved areas by increasing 
     the per visit cost limit under the interim payment system for 
     home health services.
       (5) To refine the home health consolidated billing 
     provision to ensure that medicare beneficiaries requiring 
     durable medical equipment services do not experience a break 
     in the continuum of care during episodes of home health care.
       (6) To eliminate the requirement that home health agencies 
     identify the length of time of a service visit in 15 minute 
     increments.
       (7) To express the sense of the Senate that the Secretary 
     of Health and Human Services should establish a uniform 
     process for disseminating information to fiscal 
     intermediaries to ensure timely and accurate information to 
     home health agencies and beneficiaries.

     SEC. 3. ADEQUATELY ACCOUNTING FOR THE NEEDS OF MEDICARE 
                   BENEFICIARIES WITH ACUTE, MEDICALLY COMPLEX 
                   CONDITIONS.

       (a) Waiver of Per Beneficiary Limits for Outliers.--Section 
     1861(v)(1)(L) of the Social Security Act (42 U.S.C. 
     1395x(v)(1)(L)), as amended by section 5101 of the Tax and 
     Trade Relief Extension Act of 1998 (contained in Division J 
     of Public Law 105-277), is amended--
       (1) by redesignating clause (ix) as clause (x); and
       (2) by inserting after clause (viii) the following:
       ``(ix)(I) Notwithstanding the applicable per beneficiary 
     limit under clause (v), (vi), or (viii), but subject to the 
     applicable per visit

[[Page S10731]]

     limit under clause (i), in the case of a provider that 
     demonstrates to the Secretary that with respect to an 
     individual to whom the provider furnished home health 
     services appropriate to the individual's condition (as 
     determined by the Secretary) at a reasonable cost (as 
     determined by the Secretary), and that such reasonable cost 
     significantly exceeded such applicable per beneficiary limit 
     because of unusual variations in the type or amount of 
     medically necessary care required to treat the individual, 
     the Secretary, upon application by the provider, shall pay to 
     such provider for such individual such reasonable cost.
       ``(II) The total amount of the additional payments made to 
     home health agencies pursuant to subclause (I) in any fiscal 
     year shall not exceed an amount equal to 2 percent of the 
     amounts that would have been paid under this subparagraph in 
     such year if this clause had not been enacted.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall take effect on the date of enactment of this Act, and 
     apply with respect to each application for payment of 
     reasonable costs for outliers submitted by any home health 
     agency for cost reporting periods ending on or after October 
     1, 1999.

     SEC. 4. PROTECTION OF THE ACCESS OF MEDICARE BENEFICIARIES TO 
                   HOME HEALTH SERVICES BY ADDRESSING THE 15 
                   PERCENT CONTINGENCY REDUCTION IN INTERIM 
                   PAYMENTS FOR HOME HEALTH SERVICES.

       (a) Elimination of Contingency Reduction.--Section 4603 of 
     the Balanced Budget Act of 1997 (42 U.S.C. 1395fff note), as 
     amended by section 5101(c)(3) of the Tax and Trade Relief 
     Extension Act of 1998 (contained in division J of Public Law 
     105-277), is amended by striking subsection (e).
       (b) Effective Date.--The amendment made by subsection (a) 
     shall take effect as if included in the enactment of the 
     Balanced Budget Act of 1997 (Public Law 105-33; 111 Stat. 
     251).

     SEC. 5. PROTECTION OF THE ACCESS OF MEDICARE BENEFICIARIES TO 
                   HOME HEALTH SERVICES THROUGH A PHASE-IN OF THE 
                   15 PERCENT REDUCTION IN PROSPECTIVE PAYMENTS 
                   FOR HOME HEALTH SERVICES.

       (a) Phase-In of 15 Percent Reduction.--Section 
     1895(b)(3)(A)(ii) (42 U.S.C. 1395fff(b)), as amended by 
     section 5101(c)(1)(B) of the Tax and Trade Relief Extension 
     Act of 1998 (contained in division J of Public Law 105-277), 
     is amended--
       (1) in paragraph (3)(A)(ii), by striking ``15'' and 
     inserting ``10''; and
       (2) by adding at the end the following:
       ``(7) Special rule for payments beginning with fiscal year 
     2004.--Beginning with fiscal year 2004, payment under this 
     section shall be made as if `15' had been substituted for 
     `10' in clause (ii) of paragraph (3)(A) when computing the 
     initial basis under such paragraph.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall take effect on the date of enactment of this Act.

     SEC. 6. INCREASE IN PER VISIT COST LIMIT TO 112 PERCENT OF 
                   THE NATIONAL MEDIAN.

       Section 1861(v)(1)(L)(i) of the Social Security Act (42 
     U.S.C. 1395x(v)(1)(L)(i)), as amended by section 5101(b) of 
     the Tax and Trade Relief Extension Act of 1998 (contained in 
     division J of Public Law 105-277), is amended--
       (1) in subclause (IV), by striking ``or'';
       (2) in subclause (V)--
       (A) by inserting ``and before October 1, 1999,'' after 
     ``October 1, 1998,''; and
       (B) by striking the period and inserting ``, or''; and
       (3) by adding at the end the following:
       ``(VI) October 1, 1999, 112 percent of such median.''.

     SEC. 7. REFINEMENT OF HOME HEALTH AGENCY CONSOLIDATED 
                   BILLING.

       (a) In General.--Section 1842(b)(6)(F) of the Social 
     Security Act (42 U.S.C. 1395u(b)(6)(F)) is amended by 
     striking ``payment shall be made to the agency (without 
     regard to whether or not the item or service was furnished by 
     the agency, by others under arrangement with them made by the 
     agency, or when any other contracting or consulting 
     arrangement, or otherwise).'' and inserting ``(i) payment 
     shall be made to the agency (without regard to whether or not 
     the item or service was furnished by the agency, by others 
     under arrangement with them made by the agency, or when any 
     other contracting or consulting arrangement, or otherwise); 
     and (ii) in the case of an item of durable medical equipment 
     (as defined in section 1861(n)), payment for the item shall 
     be made to the agency separately from payment for other items 
     and services furnished to such an individual under such 
     plan.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to items of durable medical equipment furnished 
     on or after the date of enactment of this Act.

     SEC. 8. ELIMINATION OF TIMEKEEPING REQUIREMENTS UNDER THE 
                   PROSPECTIVE PAYMENT SYSTEM FOR HOME HEALTH 
                   AGENCIES.

       (a) In General.--Section 1895(c) of the Social Security Act 
     (42 U.S.C. 1395fff(c)) is amended--
       (1) by striking ``unless--'' and all that follows through 
     ``(1) the'' and inserting ``unless the''; and
       (2) by striking ``1835(a)(2)(A);'' and all that follows 
     through the period and inserting ``1835(a)(2)(A).''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall take effect on the date of enactment of this Act.

     SEC. 9. SENSE OF THE SENATE REGARDING THE TIMELINESS AND 
                   ACCURACY OF INTERMEDIARY COMMUNICATIONS TO HOME 
                   HEALTH AGENCIES.

       It is the sense of the Senate that the Secretary of Health 
     and Human Services should establish a nationally uniform 
     process that ensures that each fiscal intermediary (as 
     defined in section 1816(a) of the Social Security Act (42 
     U.S.C. 1395h(a))) and each carrier (as defined in section 
     1842(f) of such Act (42 U.S.C. 1395u(f))) has the training 
     and ability necessary to provide timely, accurate, and 
     consistent coverage and payment information to each home 
     health agency and to each individual eligible to have payment 
     made under the medicare program under title XVIII of such Act 
     (42 U.S.C. 1395 et seq.).

  Mr. FEINGOLD. Mr. President, I rise today to join my colleagues 
Senator Conrad and Senator Chafee to introduce the Fairness in Medicare 
Home Health Access Act of 1999 to address some serious access problems 
in the Medicare home health care program. Our bill contains provisions 
to ensure that all Medicare beneficiaries who qualify for home health 
services have real access to those services.
  Mr. President, I have been working to promote the availability of 
home care and other long-term care options for my entire public life 
because I believe strongly in the importance of enabling people to stay 
in their own homes. For seniors who are homebound and have skilled 
nursing needs, having access to home health services through the 
Medicare program is the difference between staying in their own home 
and moving into a nursing home. The availability of home health 
services is integral to preserving independence, dignity and hope for 
many beneficiaries. I feel strongly that where there is a choice, we 
should do our best to allow patients to choose home health care. I 
think seniors need and deserve that choice.
  Mr. President, as you know, and as many of our colleagues know, the 
Balanced Budget Act of 1997 contained significant changes to the way 
that Medicare pays for home health services. Perhaps the most 
significant change was a switch from cost-based reimbursement to an 
Interim Payment System, or IPS. IPS was intended as a cost-saving 
transitional payment system to tide us over until the development and 
implementation of a Prospective Payment System or PPS, for home health 
payments under Medicare. Unfortunately, the cuts went deeper than 
anyone--including CBO forecasters--anticipated, leaving many Medicare 
beneficiaries without access to the services they need.
  The IPS is based on past spending: agencies are paid the lowest of 
three measures: (1) actual costs; (2) a per visit limit of 105% of the 
national median; or (3) a per beneficiary annual limit, derived from a 
blend of 75% of an agency's costs and 25% regional costs.
  These formulas get pretty technical, Mr. President, and I won't go 
into too much detail about them. What is important is that the net 
effect of the Interim Payment System is that since IPS pays agencies 
the lowest of the three measures, agencies in areas where costs are 
historically low will be disproportionately and unfairly affected. In 
effect, they are penalized for having kept their costs low in the past.
  And, Mr. President, Wisconsin's Medicare home health spending has 
been very, very low, even before the advent of IPS. The 1999 edition of 
the Dartmouth Atlas of Health Care described the variation in Medicare 
home health reimbursements as ``extreme'': in 1996, the national 
average Medicare home health expenditure per-enrollee was $532.00, but 
the maximum and minimum ranged from a high of $3,090 in McAllen, Texas, 
to an unbelievable $81 in Appleton, Wisconsin, in my home state. Even 
the area of Wisconsin with the highest reimbursements is only at $267 
per beneficiary, about half of the national average. When you consider 
that these figures are adjusted for age, sex, race, illness and price 
of services, the variation is truly astounding. Pegging reimbursement 
to past spending, as IPS does, simply magnifies the existing payment 
inequalities.

  Mr. President, in Wisconsin, 29 Medicare home health providers have 
shut down since the implementation of IPS. Still more have shrunken 
their service areas, stopped accepting Medicare, or cannot accept 
assignment for high cost patients because the payments are simply too 
low.
  So, what do these changes mean for Medicare beneficiaries? Well, 
quite

[[Page S10732]]

frankly, in many parts of Wisconsin, the changes mean the beneficiaries 
in certain areas or with certain diagnoses simply don't have access to 
home health care. The IPS has created disincentives to treat patients 
with expensive medical diagnoses. Few agencies, if any, can afford to 
care for them.
  Mr. President, I think that a letter I received from my constituents 
at the Douglas County Health Department does a great job of 
illustrating just how bad the access problem is, particularly in rural 
areas. The Douglas County Health Department operates a home health 
program in Superior, Wisconsin, in the northwestern corner of my state. 
According to their letter, as a result of IPS, the program will lose 
approximately $590,000. Let me read my colleagues a passage from their 
letter: ``The Douglas County Home Care [program] serves . . . about 400 
residents a year, [of which] 82% [are] Medicare covered . . . 33% of 
our patients live in rural areas not covered by other home care 
providers. There are four other providers in our area. All have 
discontinued taking Medicare patients and/or have stopped serving rural 
patients due to the high cost and low reimbursement.''
  The legislation we are introducing today contains several important 
provisions to enable elderly and disabled homebound individuals to 
remain in their homes. The bill ensures by statute that by 15% across-
the-board cut for all home health providers cannot happen during the 
Interim Payment System and that it will only be 10% for the first three 
years of PPS. The bill also makes special provisions for medically 
complex patients who have more expensive health care needs, and raises 
the per visit limits to enable home care agencies to continue serving 
patients in rural areas, where travel times are longer. I think these 
two provisions are particularly significant because the present IPS 
does not adequately account for the care needs of homebound individuals 
in rural areas, and the absence of home care options essentially forces 
these individuals into nursing homes or hospitals.
  The bill provides some administrative relief from the 15 minute 
increment reporting rule and asks HCFA to reexamine whether the cost 
associated with the collection of data is worthwhile in terms of what 
those data may yield. Finally, the bill expresses the sense of the 
Senate that HCFA should ensure that fiscal intermediaries receive and 
convey accurate and consistent information to agencies.
  These provisions all need to be in place in order to ensure that we 
do not punish the most efficient and well-performing agencies as we 
seek to streamline and modernize the program.
  Like many of my colleagues, I voted in favor of BBA '97 because I 
believed it contained meaningful provisions to balance the budget. I 
want to emphasize that the goal was to balance the budget--it was not 
to punish home health agencies, and certainly not to deny Medicare 
beneficiaries access to the home health services they need.

  I believe we ought to take a serious look at what refinements and 
fine tuning need to occur to ensure that our homebound elderly and 
disabled constituents--among the frailest and most vulnerable of our 
people we serve--can receive the services they need.
  Without that fine-tuning, I am quite certain that more home health 
agencies in Wisconsin and in other areas across our country will close, 
leaving some of our frailest Medicare beneficiaries without the choice 
to receive care at home. Again, I think Seniors need and deserve that 
choice, and I hope my colleagues will join us in supporting this 
legislation.
  Mr. CHAFEE. Mr. President. I am pleased to join my colleagues, 
Senators Conrad and Feingold, in introducing the Fairness in Medicare 
Home Health Access Act of 1999. This legislation is an important step 
towards ensuring that our seniors retain access to medically necessary 
home health care services.
  The Fairness in Medicare Home Health Access Act contains several 
critical provisions, carefully designed to achieve the twin goals of 
controlling Medicare spending (thereby preserving and protecting the 
program for future beneficiaries), and ensuring that current 
beneficiaries continue to have access to crucial home health services.
  These provisions will allow the home health agencies in my state of 
Rhode Island, as well as agencies across the country, to continue 
delivering high quality, cost-effective care to our most frail seniors.
  Why are these provisions necessary? The Balanced Budget Act of 1997 
(BBA) included many important reforms to the Medicare program. As a 
result of these provisions, the program has been strengthened, and 
solvency of the trust fund extended. However, it now appears that the 
reductions in home health payments may be limiting access to our 
Medicare beneficiaries.
  In Rhode Island the number of beneficiaries served by Medicare home 
health providers has decreased by 22 percent, services provided to 
beneficiaries have decreased by 49 percent, and total payments to home 
health agencies have decreased by 47 percent. Agencies have had to lay 
off workers and some have even been forced to close.
  On October 1st, 2000, an additional 15 percent reduction in Medicare 
reimbursements is scheduled to take effect. I am concerned that a cut 
of that level could jeopardize or restrict access to care. At the same 
time, we must be mindful of the precarious financial situation of the 
Medicare program, and the limited resources available. The President 
has proposed restoring $7.5 billion over the next decade to those 
programs under Medicare which have been especially hard hit by the cost 
control measures included in the BBA. In his proposal, these funds 
would be available for changes to home health policies, as well as 
other components of the Medicare program which have been adversely 
impacted by those new policies.

  Therefore, while some of my colleagues have called for a repeal of 
the scheduled 15 percent reduction, given resource constraints, I 
simply do not believe that will be possible. To repeal that provision 
outright would cost $17.5 billion over the 10-year budget period. This 
restoration alone would greatly exceed the $7.5 billion the President 
has recommended to soften the impact of the BBA. Even in Congress, the 
most I've heard discussed in the way of ``BBA add-backs'' is in the 
range of $15 billion. Thus, while in an ideal world some may wish to 
spend $17.5 billion on this provision, it is clearly not possible.
  I believe it is critical to address the very real problems facing 
home health beneficiaries and agencies, but I also believe we must be 
realistic in our goals and expectations, and make carefully targeted 
adjustments to the BBA policies. For that reason I am pleased to join 
with Senators Conrad and Feingold in calling for a scaling-back of the 
scheduled reduction in home health reimbursements. Our bill would 
provide much-needed relief by gradually phasing-in the 15 percent 
reduction; for the first three years, the reduction would be limited to 
10 percent. Furthermore, beneficiary access will be protected by tying 
the reduction to implementation of the prospective payment system 
(PPS). Although I am confident the prospective payment system will be 
implemented by October 1, 2000 as required under the BBA, in the event 
the deadline is not met, our provision would ensure that no further 
reductions occur until the PPS is fully implemented.
  In addition, the Conrad-Feingold-Chafee bill includes several other 
important provisions:
  An ``outlier policy'' to ensure that patients with higher than 
average medical costs do not face access barriers as a result of their 
intensive medical needs;
  An increase in the interim payment system per visit cost limit to 112 
percent of the national median;
  A refinement to the consolidated billing policy by allowing durable 
medical equipment suppliers to continue delivering services to 
beneficiaries regardless of their home health status; and
  Elimination of the 15-minute incremental reporting requirement.
  The Medicare home health benefit provides vital services to our most 
vulnerable citizens. Patients receiving these services have lower 
incomes, are older, and have more serious functional impairments than 
the general Medicare population. The availability of home health 
services averts the need for even more costly institutional living 
arrangements for the elderly and

[[Page S10733]]

disabled who rely upon these services. It is these patients who are 
harmed when home health agencies are forced to close their doors or cut 
back on services.
  It is my hope that we will pass this legislation and therefore 
protect the beneficiaries who need our help the most. In that regard, I 
will work for its incorporation into any Medicare legislation the 
Senate Finance Committee, of which I am a member, may consider in the 
future. I urge my colleagues to support this measure.
                                 ______
                                 
      By Mr. FRIST:
  S. 1575. A bill to change the competition requirements with respect 
to the purchase of the products of the Federal Prison Industries by the 
Secretary of Defense; to the Committee on the Judiciary.


                    victims restitution fairness act

 Mr. FRIST. Mr. President, I ask that the text of the bill be 
printed in the Record.
  The bill follows:

                                S. 1575

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Victims Restitution Fairness 
     Act''.

     SEC. 2. APPLICABILITY OF COMPETITION REQUIREMENTS TO 
                   PURCHASES FROM A REQUIRED SOURCE.

       (a) Conditions for Competition.--Chapter 141 of title 10, 
     United States Code, is amended by adding at the end the 
     following:

     ``Sec. 2410n. Products of Federal Prison Industries: 
       procedural requirements

       ``(a) Market Research.--Before purchasing a product listed 
     in the latest edition of the Federal Prison Industries 
     catalog under section 4124(d) of title 18, the Secretary of 
     Defense shall conduct market research to determine whether 
     the Federal Prison Industries product is comparable in price, 
     quality, and time of delivery to products available from the 
     private sector.
       ``(b) Limited Competition Requirement.--If the Secretary 
     determines that a Federal Prison Industries product is not 
     comparable in price, quality, and time of delivery to 
     products available from the private sector, the Secretary 
     shall use competitive procedures for the procurement of the 
     product. In conducting such a competition, the Secretary 
     shall consider a timely offer from Federal Prison Industries 
     for award in accordance with the specifications and 
     evaluation factors specified in the solicitation.
       ``(c) Exemptions.--Notwithstanding any other provision of 
     law, the Secretary shall not be required--
       (1) to purchase from Federal Prison Industries any product 
     that is--
       (A) integral to, or embedded in, a product that is not 
     available from Federal Prison Industries; or
       (B) a national security system; or
       (2) to make a purchase from Federal Prison Industries in a 
     total amount that is less than the micropurchase threshold, 
     as defined in section 32(f) of the Office of Federal 
     Procurement Policy Act (41 U.S.C. 428(f)).
       ``(d) National Security System Defined.--In this section, 
     the term `national security system' means any 
     telecommunications or information system operated by the 
     United States Government, the function, operation, or use of 
     which--
       ``(1) involves intelligence activities;
       ``(2) involves cryptologic activities related to national 
     security;
       ``(3) involves command and control of military forces;
       ``(4) involves equipment that is an integral part of a 
     weapon or a weapon system; or
       ``(5) is critical to the direct fulfillment of military or 
     intelligence missions, except for a system that is to be used 
     for routine administrative and business applications 
     (including payroll, finance, logistics, and personnel 
     management applications).''.
       (b) Clerical Amendment.--The table of sections at the 
     beginning of such chapter is amended by adding at the end the 
     following:

``2410n. Products of Federal Prison Industries: procedural 
              requirements.''.
       (c) Authorization of Appropriations.--There are authorized 
     to be appropriated from the Judgment Fund as established 
     under section 1304 of title 31, United States Code, such sums 
     as are necessary to offset any losses resulting in the Crime 
     Victims Fund as a result of the enactment of section 2410n of 
     title 10, United States Code, added by subsection 
     (a).
                                 ______
                                 
      By Ms. COLLINS:
  S. 1576. A bill to establish a commission to study the impact of 
deregulation of the airline industry on small town America; to the 
Committee on Commerce, Science, and Transportation.


                 airline deregulation study commission

  Ms. COLLINS. Mr. President, I rise today to introduce legislation 
that would establish a commission to study the impact of deregulation 
of the airline industry on small-town America. For too long, we have 
allowed small and medium-sized communities from Bangor, Maine to 
Billings, Montana to Bristol, Tennessee to weather the effects of 
airline deregulation without adequately assessing how deregulation has 
affected their economic development, the quality and availability of 
air transportation for their residents, and the long-term viability of 
their local airports. It is time to evaluate the effects of airline 
deregulation in a new, meaningful way.
  The 1978 deregulation of the airline industry has dramatically shaped 
the modern airline industry and the way Americans travel. The purpose 
of deregulation was to harness the market in order to foster 
competition that would improve service and lower costs for consumers. 
According to some measures, this market experiment has been a success. 
According to the U.S. Department of Transportation, since the advent of 
deregulation, the average airfare in major hubs has been reduced by 35 
percent. Economists at George Mason University and the Brookings 
Institution estimate that the increased competition resulting from 
deregulation saves consumers billions of dollars.
  Similarly, other studies conducted by the General Accounting Office 
have shown that deregulation has ushered in an overall decline in 
airfares and an improvement in the quality of air service--although 
many of us who fly frequently would take strong issue with the finding 
of improved quality.
  For many large cities, this is as far as the story needs be told. But 
for many smaller and medium-sized communities, several chapters remain. 
The rest of the story tells us that deregulation's benefits are not 
evenly distributed throughout U.S. markets. Although a March 1999 GAO 
report found that, on average, airfares declined about 21 percent from 
1990 to the second quarter of 1998, it also found that airports serving 
small communities have experienced the lowest average decline in 
airfare. Similarly, the Department of Transportation has found that the 
competition encouraged by deregulation has not made its way to all 
parts of our great nation. Indeed, the number of cities served by more 
than two airlines has fallen 41 percent since 1989.
  In short, there are signs that the airline deregulation story is not 
good for smaller and medium-sized communities--like Presque Isle and 
Bangor in my state. There are important areas of inquiry that, I 
believe, no one has yet explored, and that is why I am introducing this 
bill today.
  We need to know more about how airline deregulation has affected 
smaller and medium-sized communities, and we need to focus on the 
relationship between access to affordable, quality airline service and 
the economic development of America's smaller communities. As many 
communities continue to struggle to attract businesses, it is not 
enough for us report that airfares, in the aggregate, have decreased in 
constant dollars. Nor is it sufficient to select certain proxies for 
quality air travel and to conclude that quality has improved. Just as 
not all communities have benefitted equally from our recent prosperity, 
not all can say that deregulation has enhanced their air 
transportation. We need to evaluate how airline deregulation has 
affected these communities' ability to compete for business 
development, job creation, and economic expansion. In the process, we 
need to differentiate between business and leisure travel, as each 
serves a very different set of needs in our communities. And we much 
ask communities how they measure quality service, instead of making 
assumptions that may or may not apply to a given area.

  What I am proposing is a thorough evaluation of the effects of 
airline deregulation on communities--an evaluation that has not yet 
been done, but would happen under the bill I introduce today.
  Mr. President, during the past 20 years, air travel has become 
increasingly linked to business development. Successful businesses 
expect and need to be able to travel quickly over long distances. It is 
expected that a region being considered for business location or 
expansion should be reachable, conveniently, via airplane. Those areas 
without air access, or with access that is restricted by prohibitive 
costs of travel, infrequent flights, or small,

[[Page S10734]]

slower planes are at a distinct disadvantage compared to those areas 
that enjoy accessible, convenient, and economical air service.
  This country's air infrastructure has grown to the point where it now 
rivals our ground transportation infrastructure in its importance to 
the economic viability of communities. It has long been accepted that 
building a highway creates an almost instant corridor of economic 
activity of businesses eager to cut shipping and transportation costs 
by locating close to the stream of commerce. Like a community located 
on an interstate versus one only reachable by back roads, a community 
with a mid-size or small airport underserved by air carriers operates 
at a distinct disadvantage to one located near a large airport.
  Bob Ziegelaar, Director of the Bangor, Maine International Airport, 
perhaps put it best. He tells me, ``Communities like Bangor are at risk 
of being left with service levels below what the market warrants both 
in terms of capacity and quality. The follow-on consequences is a 
decreasing capacity to attract economic growth.''
  This issue is of critical importance and has not received the 
attention it deserves. The legislation I have introduced will result in 
a comprehensive examination of how this complicated issue affects the 
economy of small town America. It would establish a commission of 15 
members from all areas of the country, including at least five members 
from rural areas, to study and report on the effects of airline 
deregulation. The Commission will examine a vital component of the 
deregulated airline industry--the effects on economic development and 
job creation, particularly in areas that are underserved by air 
carriers.
  The Commission will also explore the broader effects of deregulation 
on affordability, accessibility, availability, and the quality of air 
transportation, nationally and in small-sized and medium-sized 
communities. It will explore deregulation's impact on the economical 
viability of smaller airports and the long-term configuration of the 
U.S. passenger air transportation system.
  Mr. President, sometimes the best use we can make of the Senate's 
legislative powers is to study the results of our previous actions. In 
passing airline deregulation, Congress unleashed the power of 
competition with many positive benefits for consumers who live in large 
cities. It is now time to evaluate the impact on residents living in 
small-town America.
  I urge my colleagues to join me in passing this important measure.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 1576

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. AIRLINE DEREGULATION STUDY COMMISSION.

       (a) Establishment of Commission.--
       (1) Establishment.--There is established a commission to be 
     known as the Airline Deregulation Study Commission (in this 
     section referred to as the ``Commission'').
       (2) Membership.--
       (A) Composition.--Subject to subparagraph (B), the 
     Commission shall be composed of 15 members of whom--
       (i) 5 shall be appointed by the President;
       (ii) 5 shall be appointed by the President pro tempore of 
     the Senate, upon the recommendation of the Majority and 
     Minority leaders of the Senate; and
       (iii) 5 shall be appointed by the Speaker of the House of 
     Representatives, in consultation with the Minority leader of 
     the House of Representatives.
       (B) Members from rural areas.--
       (i) Requirement.--Of the individuals appointed to the 
     Commission under subparagraph (A)--

       (I) one of the individuals appointed under clause (i) of 
     that subparagraph shall be an individual who resides in a 
     rural area; and
       (II) two of the individuals appointed under each of clauses 
     (ii) and (iii) of that subparagraph shall be individuals who 
     reside in a rural area.

       (ii) Geographic distribution.--The appointment of 
     individuals under subparagraph (A) pursuant to the 
     requirement in clause (i) of this subparagraph shall, to the 
     maximum extent practicable, be made so as to ensure that a 
     variety of geographic areas of the country are represented in 
     the membership of the Commission.
       (C) Date.--The appointments of the members of the 
     Commission shall be made not later than 60 days after the 
     date of the enactment of this Act.
       (3) Period of appointment; vacancies.--Members shall be 
     appointed for the life of the Commission. Any vacancy in the 
     Commission shall not affect its powers, but shall be filled 
     in the same manner as the original appointment.
       (4) Initial meeting.--Not later than 30 days after the date 
     on which all members of the Commission have been appointed, 
     the Commission shall hold its first meeting.
       (5) Meetings.--The Commission shall meet at the call of the 
     Chairperson.
       (6) Quorum.--A majority of the members of the Commission 
     shall constitute a quorum, but a lesser number of members may 
     hold hearings.
       (7) Chairperson.--The Commission shall select a Chairman 
     and Vice Chairperson from among its members.
       (b) Duties of the Commission.--
       (1) Study.--
       (A) Definitions.--In this subsection, the terms ``air 
     carrier'' and ``air transportation'' have the meanings given 
     those terms in section 40102(a) of title 49, United States 
     Code.
       (B) Contents.--The Commission shall conduct a thorough 
     study of the impacts of deregulation of the airline industry 
     of the United States on--
       (i) the affordability, accessibility, availability, and 
     quality of air transportation, particularly in small-sized 
     and medium-sized communities;
       (ii) economic development and job creation, particularly in 
     areas that are underserved by air carriers;
       (iii) the economic viability of small-sized airports; and
       (iv) the long-term configuration of the United States 
     passenger air transportation system.
       (C) Measurement factors.--In carrying out the study under 
     this subsection, the Commission shall develop measurement 
     factors to analyze the quality of passenger air 
     transportation service provided by air carriers by 
     identifying the factors that are generally associated with 
     quality passenger air transportation service.
       (D) Business and leisure travel.--In conducting 
     measurements for an analysis of the affordability of air 
     travel, to the extent practicable, the Commission shall 
     provide for appropriate control groups and comparisons with 
     respect to business and leisure travel.
       (2) Report.--Not later than 1 year after the date of the 
     enactment of this Act, the Commission shall submit an interim 
     report to the President and Congress, and not later than 18 
     months after the date of the enactment of this Act, the 
     Commission shall submit a report to the President and the 
     Congress. Each such report shall contain a detailed statement 
     of the findings and conclusions of the Commission, together 
     with its recommendations for such legislation and 
     administrative actions as it considers appropriate.
       (c) Powers of the Commission.--
       (1) Hearings.--The Commission may hold such hearings, sit 
     and act at such times and places, take such testimony, and 
     receive such evidence as the Commission considers advisable 
     to carry out the duties of the Commission under this section.
       (2) Information from federal agencies.--The Commission may 
     secure directly from any Federal department or agency such 
     information as the Commission considers necessary to carry 
     out the duties of the Commission under this section. Upon 
     request of the Chairperson of the Commission, the head of 
     such department or agency shall furnish such information to 
     the Commission.
       (3) Postal services.--The Commission may use the United 
     States mails in the same manner and under the same conditions 
     as other departments and agencies of the Federal Government.
       (4) Gifts.--The Commission may accept, use, and dispose of 
     gifts or donations of services or property.
       (d) Commission Personnel Matters.--
       (1) Travel expenses.--The members of the Commission shall 
     be allowed travel expenses, including per diem in lieu of 
     subsistence, at rates authorized for employees of agencies 
     under subchapter I of chapter 57 of title 5, United States 
     Code, while away from their homes or regular places of 
     business in the performance of services for the Commission.
       (2) Staff.--
       (A) In general.--The Chairperson of the Commission may, 
     without regard to the civil service laws and regulations, 
     appoint and terminate an executive director and such other 
     additional personnel as may be necessary to enable the 
     Commission to perform its duties. The employment of an 
     executive director shall be subject to confirmation by the 
     Commission.
       (B) Compensation.--The Chairperson of the Commission may 
     fix the compensation of the executive director and other 
     personnel without regard to the provisions of chapter 51 and 
     subchapter III of chapter 53 of title 5, United States Code, 
     relating to classification of positions and General Schedule 
     pay rates, except that the rate of pay for the executive 
     director and other personnel may not exceed the rate payable 
     for level V of the Executive Schedule under section 5316 of 
     such title.
       (3) Detail of government employees.--Any Federal Government 
     employee may be detailed to the Commission without 
     reimbursement, and such detail shall be without interruption 
     or loss of civil service status or privilege.

[[Page S10735]]

       (4) Procurement of temporary and intermittent services.--
     The Chairperson of the Commission may procure temporary and 
     intermittent services under section 3109(b) of title 5, 
     United States Code, at rates for individuals which do not 
     exceed the daily equivalent of the annual rate of basic pay 
     prescribed for level V of the Executive Schedule under 
     section 5316 of such title.
       (e) Termination of Commission.--The Commission shall 
     terminate 90 days after the date on which the Commission 
     submits its report under subsection (b).
       (f) Authorization of Appropriations.--
       (1) In general.--There is authorized to be appropriated 
     $1,500,000 for fiscal year 2000 to the Commission to carry 
     out this section.
       (2) Availability.--Any sums appropriated pursuant to the 
     authorization of appropriations in paragraph (1) shall remain 
     available until expended.

                          ____________________