[Congressional Record Volume 145, Number 131 (Friday, October 1, 1999)]
[Senate]
[Pages S11761-S11774]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
MEDICARE BENEFICIARY ACCESS TO CARE ACT OF 1999
Mr. DASCHLE. Mr. President, 2 years ago, we passed the Balanced
Budget Act. It was a monumental example of what Congress can achieve
when we work together.
Not only did we end 30 years of deficit spending with the Balanced
Budget Act, we also extended the life of the Medicare Part A Trust Fund
by 13 years. And we added important new preventive benefits, including
mammograms and Pap smears, for Medicare beneficiaries.
We made many changes that achieved a lot of good.
We also know now that we made some miscalculations.
Frankly, that is to be expected. Very often, when you make a lot of
changes, you don't get everything right the first time.
But the miscalculations we made about Medicare in the Balanced Budget
Act are causing real hardships for some of our most vulnerable
citizens--hardships that cannot be justified on either financial or
medical grounds. We did not anticipate these consequences when we
passed the Balanced Budget Act. But now that we know about them, we
have a responsibility to address them.
Today I am introducing the Medicare Beneficiary Access to Care Act of
1999.
This bill is not a comprehensive Medicare reform plan. Nor is it a
wholesale revision of the Balanced Budget Act. Instead, it is a
reasonable, targeted solution to certain specific problems with
Medicare that Congress created inadvertently as part of the Balanced
Budget Act.
Before I outline the specific remedies in my bill, I want to tell you
about the real-life consequences of one of the changes we made to
Medicare under the Balanced Budget Act.
Two years ago, Congress decided to limit how much Medicare would pay
for rehabilitation therapy. The new limits are $1,500 a year per
patient for physical and speech therapy combined, and another $1,500
for occupational therapy.
For some Medicare patients who need rehabilitation therapy, the new
limits on payments are not a problem. But for Ruth Irwin, they are a
nightmare.
A while back, Mrs. Irwin had to have one of her legs amputated
because of complications of diabetes. With an incredible amount of
effort and the help of regular physical therapy, Mrs. Irwin was
learning how to walk with a prosthetic leg and two canes.
Her goal was to learn to walk with one cane, so she would have one
hand free. She was on the verge of reaching that goal--when she hit the
$1,500 physical-therapy limit. She couldn't afford to pay out-of-
pocket, so she stopped seeing her physical therapist. Her condition
deteriorated. A few months later, she tripped on a curb and broke three
ribs. Ruth Irwin is not alone.
It is estimated that 1 in 7 Medicare recipients who need physical
therapy--about 200,000 Americans--will hit the caps this year. These
are mostly patients who are recuperating from amputations, strokes, and
head trauma, and people who suffer from serious degenerative diseases
such as multiple sclerosis, Alzheimer's, and Parkinson's disease.
Mr. President, between 1990 and 1996, Medicare spending on
rehabilitation therapy grew 18 percent a year, to $1 billion. We had
good reason to try to curb that growth. But we now know, we chose the
wrong way to accomplish our goal. It's wrong to force stroke victims in
nursing homes to decide whether they want to learn how to walk or talk.
The Medicare Beneficiary Access to Care Act repeals the current,
arbitrary caps rehabilitation therapy and replaces it with limits based
on individual patients' specific needs.
It also makes a number of other, targeted adjustments.
First: It adjusts the new payment system for nursing homes and
skilled nursing facilities to better reflect the increased costs of
caring for very sick patients.
Second: It postpones additional cuts in home health care payments for
two years and addresses the more serious problems that have come to
light while the current ``interim payment system'' has been in place.
Third: It protects hospitals from crippling losses they might
otherwise suffer as the result of a new Medicare payment system for
outpatient medical services.
This protection is especially important for people who depend on
rural hospitals--like Mobridge Hospital, in Mobridge, South Dakota.
Mobridge Hospital is the only source of inpatient hospital care for 100
miles. If it were forced to drastically reduce its services, or close,
that would have a devastating impact on scores of communities. Because
they serve a population that is generally older and less wealthy than
average, America's rural hospitals operate on lower profit margins, and
they have virtually no margin for error. They need the relief that is
in this bill.
A fourth area addressed by the bill are the deep cuts made by the BBA
in payments to teaching hospitals. Major teaching hospitals represent
only 6% of all hospitals. But they account for 70% of the burn units in
America, more than half of the pediatric intensive care units, and they
provide 44% of the indigent care in this country. The bill moderates
these cuts.
When you combine other BBA cuts in payments with reductions in
payments for indirect medical education, nearly half of America's major
teaching hospitals are projected to lose money during the next few
years. We cannot sacrifice the high-quality care, teaching, and
research activities these hospitals provide. We must make this fix, and
keep these hospitals whole. This bill does it.
Fifth, Mr. President, the Medicare Beneficiary Access to Care Act
provides new protections for seniors enrolled in Medicare+Choice, when
their plan pulls out of their community.
Finally, the bill includes additional provisions to protect access to
rural hospitals, hospice care, community health centers, and rural
health clinics.
As I said, this is not a comprehensive solution to Medicare. There
are still many questions we must work together to answer. How can we
add the prescription drug plan both our parties--and the vast majority
of Americans--say we support? How can we make sure Medicare remains
solvent when the Baby Boomers retire--and beyond?
These are questions that must be answered. They are important and
must be addressed in legislation that falls outside the purview of the
bill we introduce today. But make no mistake,
[[Page S11762]]
they are high priorities, and ones which will not go away, and will be
addressed in future bills.
For now, though, there is no question that we made some
miscalculations in 1997, when we changed the way Medicare pays for
certain services. There is no question that those miscalculations are
causing real hardships today for some of America's sickest and frailest
citizens, and for the institutions that care for them. And there should
be no delay in correcting those miscalculations.
We should make these changes not just because of the human suffering
they are causing. There are compelling economic reasons to make them as
well. That is the other part of Ruth Irwin's story. As a result of her
three broken ribs, Mrs. Irwin received regular visits by a registered
nurse and a home health aide--all paid for by Medicare. She also
received physical therapy three times a week.
The bottom line: Her recovery was far longer, more painful--and more
costly--than it needed to be. We did a lot of good in 1997. We made
some tough decisions that added years of solvency to Medicare, and
enabled us to add life-saving new preventive benefits. But we also made
some miscalculations.
We didn't know at the time the harsh consequences some of these
miscalculations would have.
Now that we do, we need to correct them--the sooner, the better. So I
urge all my colleagues to support this bill and to work with us to
ensure its prompt consideration and passage.
This legislation was the result of a tremendous amount of work by a
number of our colleagues. This is clearly a team effort. I thank in
particular Senator Moynihan for his extensive efforts to help us draft
and craft this legislation. His expertise was invaluable in making very
important decisions. I thank Senators Mikulski and Durbin and Kerrey
for their commitment to solving the problem. I thank Senator Jack Reed
for his help on home health and Senators Baucus and Conrad for their
efforts on rural health. I thank especially Senator Rockefeller and the
distinguished senior Senator from Massachusetts for their commitment to
access to health care, to education, and to the array of issues they
have raised throughout the work we have done on this bill to this date.
Mr. President, I now yield the floor and again thank Senator Kennedy
and others for their efforts on the floor this morning.
I ask unanimous consent that the bill be printed in the Record.
There being no objection, the bill was ordered to be printed in the
Record.
S. 1678
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; AMENDMENTS TO SOCIAL SECURITY ACT;
TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Medicare
Beneficiary Access to Care Act of 1999''.
(b) Amendments to Social Security Act.--Except as otherwise
specifically provided, whenever in this Act an amendment is
expressed in terms of an amendment to or repeal of a section
or other provision, the reference shall be considered to be
made to that section or other provision of the Social
Security Act.
(c) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; amendments to Social Security Act; table of
contents.
TITLE I--HOSPITALS
Sec. 101. Multiyear transition to prospective payment system for
hospital outpatient department services.
Sec. 102. Limitation in reduction of payments to disproportionate share
hospitals.
Sec. 103. Changes to DSH allotments and transition rule.
Sec. 104. Revision of criteria for designation as a critical access
hospital.
Sec. 105. Sole community hospitals and medicare dependent hospitals.
TITLE II--GRADUATE MEDICAL EDUCATION
Sec. 201. Revision of multiyear reduction of indirect graduate medical
education payments.
Sec. 202. Acceleration of GME phase-in.
Sec. 203. Exclusion of nursing and allied health education costs in
calculating Medicare+Choice payment rate.
Sec. 204. Adjustments to limitations on number of interns and
residents.
TITLE III--HOSPICE CARE
Sec. 301. Increase in payments for hospice care.
TITLE IV--SKILLED NURSING FACILITIES
Sec. 401. Modification of case mix categories for certain conditions.
Sec. 402. Exclusion of clinical social worker services and services
performed under a contract with a rural health clinic or
Federally qualified health center from the PPS for SNFs.
Sec. 403. Exclusion of certain services from the PPS for SNFs.
Sec. 404. Exclusion of swing beds in critical access hospitals from the
PPS for SNFs.
TITLE V--OUTPATIENT REHABILITATION SERVICES
Sec. 501. Modification of financial limitation on rehabilitation
services.
TITLE VI--PHYSICIANS' SERVICES
Sec. 601. Technical amendment to update adjustment factor and physician
sustainable growth rate.
Sec. 602. Publication of estimate of conversion factor and MedPAC
review.
TITLE VII--HOME HEALTH
Sec. 701. Delay in the 15 percent reduction in payments under the PPS
for home health services.
Sec. 702. Increase in per visit limit.
Sec. 703. Treatment of Outliers.
Sec. 704. Elimination of 15-minute billing requirement.
Sec. 705. Recoupment of overpayments.
Sec. 706. Refinement of home health agency consolidated billing.
TITLE VIII--MEDICARE+CHOICE
Sec. 801. Delay in ACR deadline under the Medicare+Choice program.
Sec. 802. Change in time period for exclusion of Medicare+Choice
organizations that have had a contract terminated.
Sec. 803. Enrollment of medicare beneficiaries in alternative
Medicare+Choice plans and medigap coverage in case of
involuntary termination of Medicare+Choice enrollment.
Sec. 804. Applying medigap and Medicare+Choice protections to disabled
and ESRD medicare beneficiaries.
Sec. 805. Extended Medicare+Choice disenrollment window for certain
involuntarily terminated enrollees.
Sec. 806. Nonpreemption of State prescription drug coverage mandates in
case of approved State medigap waivers.
Sec. 807. Modification of payment rules for certain frail elderly
medicare beneficiaries.
Sec. 808. Extension of medicare community nursing organization
demonstration projects.
TITLE IX--CLINICS
Sec. 901. New prospective payment system for Federally-qualified health
centers and rural health clinics under the medicaid
program.
TITLE I--HOSPITALS
SEC. 101. MULTIYEAR TRANSITION TO PROSPECTIVE PAYMENT SYSTEM
FOR HOSPITAL OUTPATIENT DEPARTMENT SERVICES.
(a) In General.--Section 1833(t) (42 U.S.C. 1395(t)) is
amended by adding at the end the following:
``(10) Multiyear transition.--
``(A) In general.--In the case of covered OPD services
furnished by a hospital during a transition year, the
Secretary shall increase the payments for such services under
the prospective payment system established under this
subsection by the amount (if any) that the Secretary
determines is necessary to ensure that the payment to cost
ratio of the hospital for the transition year equals the
applicable percentage of the payment to cost ratio of the
hospital for 1996.
``(B) Payment to cost ratio.--
``(i) In general.--The payment to cost ratio of a hospital
for any year is the ratio which--
``(I) the hospital's reimbursement under this part for
covered OPD services furnished during the year, including
through cost-sharing described in subparagraph (D)(ii), bears
to
``(II) the cost of such services.
``(ii) Calculation of 1996 payment to cost ratio.--The
Secretary shall determine each hospital's payment to cost
ratio for 1996 as if the amendments to this title by the
provisions of section 4521 of the Balanced Budget Act of 1997
were in effect in 1996.
``(iii) Transition years.--The Secretary shall estimate
each payment to cost ratio of a hospital for any transition
year before the beginning of such year.
``(C) Interim payments.--
``(i) In general.--The Secretary shall make interim
payments to a hospital during any transition year for which
the Secretary estimates a payment is required under
subparagraph (A).
``(ii) Adjustments.--If the Secretary makes payments under
clause (i) for any transition year, the Secretary shall make
retrospective adjustments to each hospital based on its
settled cost report so that the amount of any additional
payment to a hospital for such year equals the amount
described in subparagraph (A).
[[Page S11763]]
``(D) Definitions.--In this paragraph:
``(i) Applicable percentage.--The term `applicable
percentage' means, with respect to covered OPD services
furnished during--
``(I) the first full year (and any portion of the
immediately preceding year) for which the prospective payment
system under this subsection is in effect, 95 percent;
``(II) the second full calendar year for which such system
is in effect, 90 percent; and
``(III) the third full calendar year for which such system
is in effect, 85 percent.
``(ii) Cost-sharing.--The term `cost-sharing' includes--
``(I) copayment amounts described in paragraph (5);
``(II) coinsurance described in section 1866(a)(2)(A)(ii);
and
``(III) the deductible described under section 1833(b).
``(iii) Transition year.--The term `transition year' means
any year (or portion thereof) described in clause (i).
``(E) Effect on copayments.--Nothing in this paragraph
shall be construed as affecting the unadjusted copayment
amount described in paragraph (3)(B).
``(F) Application without regard to budget neutrality.--The
transitional payments made under this paragraph--
``(i) shall not be considered an adjustment under paragraph
(2)(E); and
``(ii) shall not be implemented in a budget neutral
manner.''.
(b) Special Rule for Rural and Cancer Hospitals.--Section
1833(t) (42 U.S.C. 1395(t)), as amended by subsection (a), is
amended by adding at the end the following:
``(11) Special rule for rural and cancer hospitals.--
``(A) In general.--For each year (or portion thereof),
beginning in 2000, in the case of covered OPD services
furnished by a medicare-dependent, small rural hospital (as
defined in section 1886(d)(5)(G)(iv)), a sole community
hospital (as defined in section 1886(d)(5)(D)(iii)), or in a
hospital described in section 1886(d)(1)(B)(v), the Secretary
shall increase the payments for such services under the
prospective payment system established under this subsection
by the amount (if any) that the Secretary determines is
necessary to ensure that the payment to cost ratio of the
hospital (as determined pursuant to paragraph (10)(B)) for
the year equals the payment to cost ratio of the hospital for
1996 (as calculated under clause (ii) of such paragraph).
``(B) Interim payments.--
``(i) In general.--The Secretary shall make interim
payments to a hospital during any year for which the
Secretary estimates a payment is required under subparagraph
(A).
``(ii) Adjustments.--If the Secretary makes payments under
clause (i) for any year, the Secretary shall make
retrospective adjustments to each hospital based on its
settled cost report so that the amount of any additional
payment to a hospital for such year equals the amount
described in subparagraph (A).
``(C) Effect on copayments.--Nothing in this paragraph
shall be construed as affecting the unadjusted copayment
amount described in paragraph (3)(B).
``(D) Application without regard to budget neutrality.--The
payments made under this paragraph--
``(i) shall not be considered an adjustment under paragraph
(2)(E); and
``(ii) shall not be implemented in a budget neutral
manner.''.
(c) Effective Date.--The amendments made by this section
shall take effect as if included in the amendments made by
section 4523 of the Balanced Budget Act of 1997 (Public Law
105-33; 111 Stat. 445).
SEC. 102. LIMITATION IN REDUCTION OF PAYMENTS TO
DISPROPORTIONATE SHARE HOSPITALS.
(a) In General.--Section 1886(d)(5)(F)(ix) (42 U.S.C.
1395ww(d)(5)(F)(ix)) is amended--
(1) in subclause (II)--
(A) by striking ``fiscal year 1999,'' and inserting ``each
of fiscal years 1999, 2000, 2001, and 2002,''; and
(B) by inserting ``and'' after the semicolon;
(2) by striking subclauses (III), (IV), and (V); and
(3) by redesignating subclause (VI) as subclause (III).
(b) Effective Date.--The amendments made by subsection (a)
shall take effect as if included in the amendments made by
section 4403 of the Balanced Budget Act of 1997 (Public Law
105-33; 111 Stat. 398).
SEC. 103. CHANGES TO DSH ALLOTMENTS AND TRANSITION RULE.
(a) Change in Disproportionate Share Hospital Allotments.--
Section 1923(f)(2) (42 U.S.C. 1396r-4(f)(2)) is amended, in
the table contained in such section and in the DSH Allotments
for fiscal years 2000, 2001, and 2002--
(1) for Minnesota, by striking ``16'' and inserting ``33'';
(2) for New Mexico, by striking ``5'' and inserting ``9'';
and
(3) for Wyoming, by striking ``0'' and inserting ``0.1''.
(b) Making Medicaid DSH Transition Rule Permanent.--Section
4721(e) of the Balanced Budget Act of 1997 is amended--
(1) in the matter before paragraph (1), by striking
``1923(g)(2)(A)'' and ``1396r-4(g)(2)(A)'' and inserting
``1923(g)(2)'' and ``1396r-4(g)(2)'', respectively;
(2) in paragraphs (1) and (2)--
(A) by striking ``, and before July 1, 1999''; and
(B) by striking ``in such section'' and inserting ``in
subparagraph (A) of such section''; and
(3) by striking ``and'' at the end of paragraph (1), by
striking the period at the end of paragraph (2) and inserting
``; and'', and by adding at the end the following:
``(3) effective for State fiscal years that begin on or
after July 1, 1999, `or (b)(1)(B)' were inserted in
1923(g)(2)(B)(ii)(I) after `(b)(1)(A)'.''.
(c) Effective Date.--The amendments made by this section
shall take effect as if included in the enactment of the
Balanced Budget Act of 1997 (Public Law 105-33; 111 Stat.
251).
SEC. 104. REVISION OF CRITERIA FOR DESIGNATION AS A CRITICAL
ACCESS HOSPITAL.
(a) Criteria for Designation.--Section 1820(c)(2)(B)(iii)
(42 U.S.C. 1395i-4(c)(2)(B)(iii)) is amended by striking ``to
exceed 96 hours'' and all that follows before the semicolon
and inserting ``to exceed, on average, 96 hours per
patient''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect 60 days after the date of enactment of this
Act.
SEC. 105. SOLE COMMUNITY HOSPITALS AND MEDICARE DEPENDENT
HOSPITALS.
(a) In General.--Section 1886(b)(3)(B)(iv) (42 U.S.C.
1395ww(b)(3)(B)(iv)) is amended--
(1) in subclause (III), by striking ``and'' at the end;
(2) in subclause (IV)--
(A) by striking ``fiscal year 1996 and each subsequent
fiscal year'' and inserting ``fiscal years 1996 through
1999''; and
(B) by striking the period at the end and inserting ``,
and''; and
(3) by adding at the end the following:
``(V) for fiscal year 2000 and each subsequent fiscal year,
the market basket percentage increase.''.
(b) Effective Date.--The amendments made by subsection (a)
shall take effect on the date of enactment of this Act.
TITLE II--GRADUATE MEDICAL EDUCATION
SEC. 201. REVISION OF MULTIYEAR REDUCTION OF INDIRECT
GRADUATE MEDICAL EDUCATION PAYMENTS.
(a) In General.--Section 1886(d)(5)(B)(ii) (42 U.S.C.
1395ww(d)(5)(B)(ii)) is amended by striking subclauses (III),
(IV), and (V) and inserting the following:
``(III) during each of fiscal years 1999, 2000, and 2001,
`c' is equal to 1.6; and
``(IV) on or after October 1, 2001, `c' is equal to
1.35.''.
(b) Effective Date.--The amendments made by subsection (a)
shall take effect as if included in section 4621 of the
Balanced Budget Act of 1997 (Public Law 105-33; 111 Stat.
475).
SEC. 202. ACCELERATION OF GME PHASE-IN.
(a) Acceleration of Payment to Hospitals of Indirect and
Direct Medical Education Costs for Medicare+Choice
Enrollees.--
(1) In general.--Section 1886(h)(3)(D)(ii) (42 U.S.C.
1395ww(h)(3)(D)(ii)) is amended by striking subclauses (IV)
and (V) and inserting the following:
``(IV) 100 percent in 2001 and subsequent years.''.
(2) Acceleration of carve-out.--Section 1853(c)(3)(B)(ii)
(42 U.S.C. 1395w-23(c)(3)(B)(ii)) is amended--
(A) in subclause (III), by inserting ``and'' at the end;
(B) by striking subclause (IV); and
(C) by redesignating subclause (V) as subclause (IV).
(b) Effective Date.--The amendments 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. 203. EXCLUSION OF NURSING AND ALLIED HEALTH EDUCATION
COSTS IN CALCULATING MEDICARE+CHOICE PAYMENT
RATE.
(a) Excluding Costs in Calculating Payment Rate.--
(1) In general.--Section 1853(c)(3)(C)(i) (42 U.S.C. 1395w-
23(c)(3)(C)(i)) is amended--
(A) in subclause (I), by striking ``and'' at the end;
(B) in subclause (II), by striking the period at the end
and inserting ``, and''; and
(C) by adding at the end the following:
``(III) for costs attributable to approved nursing and
allied health education programs under section 1861(v).''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply in determining the annual per capita rate of
payment for years beginning with 2001.
(b) Payment to Hospitals of Nursing and Allied Health
Education Program Costs for Medicare+Choice Enrollees.--
Section 1861(v)(1) (42 U.S.C. 1395x(v)(1)) is amended by
adding at the end the following:
``(V)(i) In determining the amount of payment to a hospital
for portions of cost reporting periods occurring on or after
January 1, 2001, with respect to the reasonable costs for
approved nursing and allied health education programs,
individuals who are enrolled with a Medicare+Choice
organization under part C shall be treated as if they were
not so enrolled.
``(ii) The Secretary shall establish rules for applying
clause (i) to a hospital reimbursed under a reimbursement
system authorized under section 1814(b)(3) in the same manner
as it would apply to the hospital if it were not reimbursed
under such section.''.
SEC. 204. ADJUSTMENTS TO LIMITATIONS ON NUMBER OF INTERNS AND
RESIDENTS.
(a) Indirect Graduate Medical Education Adjustment.--
Section 1886(d)(5)(B)(v) (42 U.S.C. 1395ww(d)(5)(B)(v)) is
amended--
[[Page S11764]]
(1) by striking ``(v) In determining'' and inserting
``(v)(I) Subject to subclause (II), in determining'';
(2) by striking ``in the hospital with respect to the
hospital's most recent cost reporting period ending on or
before December 31, 1996'' and inserting ``who were appointed
by the hospital's approved medical residency training
programs for the hospital's most recent cost reporting period
ending on or before December 31, 1996''; and
(3) by adding at the end the following:
``(II) Beginning on or after January 1, 1997, in the case
of a hospital that sponsors only 1 allopathic or osteopathic
residency program, the limit determined for such hospital
under subclause (I) may, at the hospital's discretion, be
increased by 1 for each calendar year but shall not exceed a
total of 3 more than the limit determined for the hospital
under subclause (I).''.
(b) Direct Graduate Medical Education Adjustment.--
(1) Limitation on number of residents.--Section
1886(h)(4)(F) (42 U.S.C. 1395ww(h)(4)(F)) is amended by
inserting ``who were appointed by the hospital's approved
medical residency training programs'' after ``may not exceed
the number of such full-time equivalent residents''.
(2) Funding for programs.--Section 1886(h)(4)(H)(i) (42
U.S.C. 1395ww(h)(4)(H)(i)) is amended in the second sentence,
by inserting ``, including facilities that are not located in
an underserved rural area but have established separately
accredited rural training tracks'' before the period.
(c) GME Payments for Certain Interns and Residents.--
(1) Indirect and direct medical education.--Each limitation
regarding the number of residents or interns for which
payment may be made under section 1886 of the Social Security
Act (42 U.S.C. 1395ww) is increased by the number of
applicable residents (as defined in paragraph (2)).
(2) Applicable resident defined.--In this subsection, the
term ``applicable resident'' means a resident or intern
that--
(A) participated in graduate medical education at a
facility of the Department of Veterans Affairs;
(B) was subsequently transferred on or after January 1,
1997, and before July 31, 1998, to a hospital and the
hospital was not a Department of Veterans Affairs facility;
and
(C) was transferred because the approved medical residency
program in which the resident or intern participated would
lose accreditation by the Accreditation Council on Graduate
Medical Education if such program continued to train
residents at the Department of Veterans Affairs facility.
(d) Effective Date.--This section shall take effect as if
included in the enactment of the Balanced Budget Act of 1997
(Public Law 105-33; 111 Stat. 251).
TITLE III--HOSPICE CARE
SEC. 301. INCREASE IN PAYMENTS FOR HOSPICE CARE.
(a) In General.--Section 1814(i)(1)(C)(ii)(VI) (42 U.S.C.
1395f(i)(1)(C)(ii)(VI)) is amended by striking ``through
2002'' and inserting ``and 1999''.
(b) Effective Date.--The amendments made by this section
shall take effect as if included in the amendments made by
section 4441 of the Balanced Budget Act of 1997 (Public Law
105-33; 111 Stat. 422).
TITLE IV--SKILLED NURSING FACILITIES
SEC. 401. MODIFICATION OF CASE MIX CATEGORIES FOR CERTAIN
CONDITIONS.
(a) In General.--For purposes of applying any formula under
paragraph (1) of section 1888(e) of the Social Security Act
(42 U.S.C. 1395yy(e)), for services provided on or after
April 1, 2000, and before the earlier of October 1, 2001, or
the date described in subsection (d), the Secretary of Health
and Human Services shall increase the adjusted Federal per
diem rate otherwise determined under paragraph (4) of such
section for services provided to any individual during the
period in which such individual is in a RUG III category by
the applicable payment add-on as determined in accordance
with the following table:
RUG III category Applicable payment add-on
RUB.......................................................$23.06 ....
RVC.......................................................$76.25 ....
RVB.......................................................$30.36 ....
RHC.......................................................$54.07 ....
RHB.......................................................$27.28 ....
RMC.......................................................$69.98 ....
RMB.......................................................$30.09 ....
SE3.......................................................$98.41 ....
SE2.......................................................$89.05 ....
SSC.......................................................$46.80 ....
SSB.......................................................$55.56 ....
SSA.......................................................$59.94.....
(b) Update.--The Secretary shall update the applicable
payment add-on under subsection (a) for fiscal year 2001 by
the skilled nursing facility market basket percentage change
(as defined under section 1888(e)(5)(B) of the Social
Security Act (42 U.S.C. 1395yy(e)(5)(B))) applicable to such
fiscal year.
(c) Rule of Construction.--Nothing in this section shall be
construed as permitting the Secretary of Health and Human
Services to include any applicable payment add-on determined
under subsection (a) in updating the Federal per diem rate
under section 1888(e)(4) of the Social Security Act (42
U.S.C. 1395yy(e)(4)).
(d) Date Described.--The date described in this subsection
is the date that the Secretary of Health and Human Services--
(1) refines the case mix classification system under
section 1888(e)(4)(G)(i) of the Social Security Act (42
U.S.C. 1395yy(e)(4)(G)(i)) to better account for medically
complex patients; and
(2) implements such refined system.
SEC. 402. EXCLUSION OF CLINICAL SOCIAL WORKER SERVICES AND
SERVICES PERFORMED UNDER A CONTRACT WITH A
RURAL HEALTH CLINIC OR FEDERALLY QUALIFIED
HEALTH CENTER FROM THE PPS FOR SNFS.
(a) In General.--Section 1888(e)(2)(A)(ii) (42 U.S.C.
1395yy(e)(2)(A)(ii)) is amended--
(1) in the first sentence, by inserting ``clinical social
worker services,'' after ``qualified psychologist
services,''; and
(2) by inserting after the first sentence the following:
``Services described in this clause also include services
that are provided by a physician, a physician assistant, a
nurse practitioner, a qualified psychologist, or a clinical
social worker who is employed, or otherwise under contract,
with a rural health clinic or a Federally qualified health
center.''.
(b) Conforming Amendment.--Section 1861(hh)(2) (42 U.S.C.
1395x(hh)(2)) is amended by striking ``and other than
services furnished to an inpatient of a skilled nursing
facility which the facility is required to provide as a
requirement for participation''.
(c) Effective Date.--The amendments made by this section
shall apply to services provided on or after the date which
is 60 days after the date of enactment of this Act.
SEC. 403. EXCLUSION OF CERTAIN SERVICES FROM THE PPS FOR
SNFS.
(a) In General.--Section 1888(e)(2)(A)(ii) (42 U.S.C.
1395yy(e)(2)(A)(ii)), as amended by section 402, is amended--
(1) in the first sentence, by inserting ``ambulance
services, services identified by HCPCS code in Program
Memorandum Transmittal No. A-98-37 issued in November 1998
(but without regard to the setting in which such services are
furnished),'' after ``subparagraphs (F) and (O) of section
1861(s)(2),''; and
(2) by inserting after the second sentence the following:
``In addition to the services described in the previous
sentences, services described in this clause include
chemotherapy items (identified as of July 1, 1999, by HCPCS
codes J9000-J9020, J9040-J9151, J9170-J9185, J9200-J9201,
J9206-J9208, J9211, J9230-J9245, and J9265-J9600),
chemotherapy administration services (identified as of July
1, 1999, by HCPCS codes 36260-36262, 36489, 36530-36535,
36640, 36823, and 96405-96542), radioisotope services
(identified as of July 1, 1999, by HCPCS codes 79030-79440),
and customized prosthetic devices (identified as of July 1,
1999, by HCPCS codes L5050-L5340, L5500-L5610, L5613-L5986,
L5988, L6050-L6370, L6400-L6880, L6920-L7274, and L7362-
L7366).''.
(b) Effective Date.--The amendments made by this section
shall apply to services furnished on or after the date which
is 60 days after the date of enactment of this Act.
SEC. 404. EXCLUSION OF SWING BEDS IN CRITICAL ACCESS
HOSPITALS FROM THE PPS FOR SNFS.
(a) In General.--Section 1888(e)(7) of the Social Security
Act (42 U.S.C. 1395yy(e)(7)) is amended--
(1) in the heading, by striking ``Transition'' and
inserting ``Special Rules'';
(2) in subparagraph (A), by striking ``In general.--The''
and inserting ``Transition.--Except as provided in
subparagraph (C), the''; and
(3) by adding at the end the following:
``(C) Exemption of swing beds in critical access hospitals
from PPS.--The prospective payment system under this
subsection shall not apply (and section 1834(g) shall apply)
to services provided by a critical access hospital under an
agreement described in subparagraph (B).''.
(b) Effective Date.--The amendments made by this section
shall apply to services provided on or after October 1, 1999.
TITLE V--OUTPATIENT REHABILITATION SERVICES
SEC. 501. MODIFICATION OF FINANCIAL LIMITATION ON
REHABILITATION SERVICES.
(a) 3-Year Repeal.--Section 1833(g) (42 U.S.C. 1395l(g)) is
amended by adding at the end the following:
``(4) Subject to paragraph (6), the provisions of
paragraphs (1) through (3) shall not apply to outpatient
physical therapy services, outpatient occupational therapy
services, and outpatient speech-language pathology services
covered under this title and furnished on or after January 1,
2000.
``(5)(A) Notwithstanding the preceding provisions of this
subsection and subject to subparagraph (B), with respect to
services described in paragraph (4) that are furnished on or
after January 1, 2003, the Secretary shall implement, by not
later than January 1, 2003, a payment system for such
services that takes into account the needs of beneficiaries
under this title for differing amounts of therapy based on
factors such as diagnosis, functional status, and prior use
of services.
``(B) The payment system established under subparagraph (A)
shall be designed so that the system shall not result in any
increase or decrease in the expenditures under this title on
a fiscal year basis, determined as if paragraph (4) had not
been enacted.
``(6) If the Secretary for any reason does not implement
the payment system described in paragraph (5) on or before
January 1, 2003, paragraph (4) shall not apply with respect
to services described in such paragraph
[[Page S11765]]
that are furnished on or after such date and before the date
on which the Secretary implements such payment system.''.
(b) Effective Date.--The amendment made by this section
shall take effect as if included in the enactment of the
Balanced Budget Act of 1997 (Public Law 105-33; 111 Stat.
251).
TITLE VI--PHYSICIANS' SERVICES
SEC. 601. TECHNICAL AMENDMENT TO UPDATE ADJUSTMENT FACTOR AND
PHYSICIAN SUSTAINABLE GROWTH RATE.
(a) Update Adjustment Factor.--
(1) Change to calendar year basis.--Section 1848(d) (42
U.S.C. 1395w-4(d)) is amended--
(A) in paragraph (1), by striking subparagraph (E) and
inserting the following:
``(E) Publication.--The Secretary shall publish in the
Federal Register--
``(i) not later than November 1 of each year (beginning
with 1999), the conversion factor that will apply to
physicians' services for the succeeding year and the update
determined under paragraph (3) for such year; and
``(ii) not later than November 1 of 1999--
``(I) the special update for the year 2000 under paragraph
(3)(E)(i); and
``(II) the estimated special adjustments for years 2001
through 2006 under paragraph (3)(E)(ii).''; and
(B) in paragraph (3)(C)--
(i) in the matter preceding clause (i), by striking ``the
12-month period ending with March 31 of'';
(ii) in clause (i)--
(I) by striking ``1997'' and inserting ``1996,''; and
(II) by striking ``such 12-month period'' and inserting
``1996''; and
(iii) in clause (ii)--
(I) by inserting a comma after ``subsequent year''; and
(II) by striking ``fiscal year which begins during such 12-
month period'' and inserting ``year involved''.
(2) Formula for determining the update adjustment factor.--
Section 1848(d)(3) (42 U.S.C. 1395w-4(d)(3)) is amended--
(A) in subparagraph (A)--
(i) in clause (ii), by striking ``(divided by 100),'' and
inserting a period; and
(ii) by striking the matter following clause (ii);
(B) in subparagraph (B)--
(i) in the matter preceding clause (i), by inserting ``the
sum of'' after ``Secretary) to''; and
(ii) by striking clauses (i) and (ii) and inserting the
following:
``(i) the figure arrived at by--
``(I) determining the difference between the allowed
expenditures for physicians' services for the prior year (as
determined under subparagraph (C)) and the actual
expenditures for such services for that year;
``(II) dividing that difference by the actual expenditures
for such services in that year; and
``(III) multiplying that quotient by 0.75; and
``(ii) the figure arrived at by--
``(I) determining the difference between the allowed
expenditures for physicians' services (as determined under
subparagraph (C)) from 1996 through the prior year and the
actual expenditures for such services during that period,
corrected with the best available data;
``(II) dividing that difference by actual expenditures for
such services for the prior year as increased by the
sustainable growth rate under subsection (f) for the year
whose update adjustment factor is to be determined; and
``(III) multiplying that quotient by 0.33.''; and
(C) by amending subparagraph (D) to read as follows:
``(D) Restriction on update adjustment factor.--The update
adjustment factor determined under subparagraph (B) for a
year may not be less than negative 0.07 or greater than
0.03.''.
(3) Special provisions.--Section 1848(d)(3) (42 U.S.C.
1395w-4(d)(3)) is amended--
(A) in subparagraph (A), in the matter preceding clause
(i), by striking ``subparagraph (D)'' and inserting
``subparagraphs (D) and (E)''; and
(B) by adding at the end the following:
``(E) Special update and adjustments.--
``(i) Year 2000.--For the year 2000, the update under this
paragraph shall be the percentage that the Secretary
estimates will, without regard to any otherwise applicable
restriction, result in expenditures equal to the expenditures
that would have occurred in that year in the absence of the
amendments made by section 601 of the Medicare Beneficiary
Access to Care Act of 1999.
``(ii) Years 2001-2006.--For each of the years 2001 through
2006, the Secretary shall make that adjustment to the update
for that year which the Secretary estimates will, without
regard to any otherwise applicable restriction, result in
expenditures equal to the expenditures that would have
occurred for that year in the absence of the amendments made
by section 601 of the Medicare Beneficiary Access to Care Act
of 1999.''.
(b) Sustainable Growth Rate.--Section 1848(f) (42 U.S.C.
1395w-4(f)) is amended--
(1) by striking paragraph (1) and inserting the following:
``(1) Publication.--Not later than November 1 of each year
(beginning with 1999), the Secretary shall publish in the
Federal Register the sustainable growth rate as determined
under this subsection for the succeeding year, the current
year, and each of the preceding 2 years.''; and
(2) in paragraph (2)--
(A) by striking ``fiscal'' each place it appears; and
(B) in the matter preceding subparagraph (A), by striking
``year 1998'' and inserting ``1997''.
(c) Data To Be Used in Determining the Sustainable Growth
Rate.--Section 1848(f) (42 U.S.C. 1395w-4(f)) is amended--
(1) by redesignating paragraph (3) as paragraph (4); and
(2) by inserting after paragraph (2) the following:
``(3) Methodology.--For purposes of determining the update
adjustment factor under subsection (d)(3)(B) and the allowed
expenditures under subsection (d)(3)(C) for a year, the
sustainable growth rate for each year taken into
consideration in the determination under paragraph (2) shall
be determined as follows:
``(A) For purposes of such calculations for the year 2000,
the sustainable growth rate shall be determined on the basis
of the best data available to the Secretary as of September
1, 1999.
``(B) For purposes of such calculations for each year after
the year 2000--
``(i) the sustainable growth rate for such year and each of
the 2 preceding years shall be determined on the basis of the
best data available to the Secretary as of September 1 of
such year; and
``(ii) the sustainable growth rate for each year preceding
the years specified in clause (i) shall be the rate used for
such year in such calculation for the immediately preceding
year.''.
(d) Effective Date.--
(1) In general.--Subject to paragraph (2), the amendments
made by this section shall take effect as if included in the
enactment of the Balanced Budget Act of 1997 (Public Law 105-
33; 111 Stat. 251).
(2) No effect on updates for 1998 and 1999.--The amendments
made by this section shall have no effect on the updates
established by the Secretary for 1998 and 1999, and such
established updates may not be changed.
SEC. 602. PUBLICATION OF ESTIMATE OF CONVERSION FACTOR AND
MEDPAC REVIEW.
(a) Publication.--Not later than April 15 of each year
(beginning in 2000), the Secretary of Health and Human
Services (in this section referred to as the ``Secretary'')
shall publish in the Federal Register--
(1) an estimate of the single conversion factor to be used
in the next calendar year for reimbursement of physicians
services under section 1848 of the Social Security Act (42
U.S.C. 1395w-4); and
(2) the data on which such estimate is based.
(b) MedPAC Review and Report.--
(1) Review.--The Medicare Payment Advisory Commission (in
this section referred to as ``MedPAC'') shall annually review
the estimates and data published by the Secretary pursuant to
subsection (a).
(2) Report.--Not later than June 30 of each year (beginning
in 2000), MedPAC shall submit a report to the Secretary and
to the committees of jurisdiction in Congress on the review
conducted pursuant to paragraph (1), together with any
recommendations as determined appropriate by MedPAC.
TITLE VII--HOME HEALTH
SEC. 701. DELAY IN THE 15 PERCENT REDUCTION IN PAYMENTS UNDER
THE PPS FOR HOME HEALTH SERVICES.
(a) Contingency Reduction.--Section 4603(e) 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 ``September 30, 2000'' and inserting
``September 30, 2002''.
(b) Prospective Payment System.--Section 1895(b)(3)(A) (42
U.S.C. 1395fff(b)(3)(A)), 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 by striking
clause (i) and inserting the following:
``(i) In general.--Under such system the Secretary shall
provide for computation of a standard prospective payment
amount (or amounts). Such amount (or amounts) shall initially
be based on the most current audited cost report data
available to the Secretary and shall be computed in a manner
so that the total amounts payable under the system--
``(I) for fiscal year 2001, shall be equal to the total
amount that would have been made if the system had not been
in effect;
``(II) for fiscal year 2002, shall be equal to the amount
determined under subclause (I), updated under subparagraph
(B); and
``(III) for fiscal year 2003, shall be equal to the total
amount that would have been made for fiscal year 2001 if the
system had not been in effect but if the reduction in limits
described in clause (ii) had been in effect, and updated
under subparagraph (B) for fiscal years 2001 and 2002.
Each such amount shall be standardized in a manner that
eliminates the effect of variations in relative case mix and
wage levels among different home health agencies in a budget
neutral manner consistent with the case mix and wage level
adjustments provided under paragraph (4)(A). Under the
system, the Secretary may recognize regional differences or
differences based upon whether or not the services or agency
are in an urbanized area.''.
[[Page S11766]]
SEC. 702. INCREASE IN PER VISIT LIMIT.
(a) Interim Payment System.--Section 1861(v)(1)(L)(i) (42
U.S.C. 1395x(v)(1)(L)(i)), as amended by section 701(b), 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.''.
(b) Ensuring the Increase in Per Visit Limit Has No Effect
on the Prospective Payment System.--The second sentence of
section 1895(b)(3)(A)(i) (42 U.S.C. 1395fff(b)(3)(A)(i)), 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) and section 701(b), is amended--
(1) in subclause (I), by inserting ``but if the reference
in section 1861(v)(1)(L)(i)(VI) to 112 percent were a
reference to 106 percent'' after ``if the system had not been
in effect''; and
(2) in subclause (III), by inserting ``and if the reference
in section 1861(v)(1)(L)(i)(VI) to 112 percent were a
reference to 106 percent'' after ``clause (ii) had been in
effect''.
SEC. 703. TREATMENT OF OUTLIERS.
(a) Waiver of Per Beneficiary Limits for Outliers.--Section
1861(v)(1)(L) (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 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 amendments made by subsection (a)
shall take effect on the date of enactment of this Act, and
shall apply 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. 704. ELIMINATION OF 15-MINUTE BILLING REQUIREMENT.
(a) In General.--Section 1895(c) (42 U.S.C. 1395fff(c)) is
amended to read as follows:
``(c) Requirements for Payment Information.--With respect
to home health services furnished on or after October 1,
1998, no claim for such a service may be paid under this
title unless the claim has the unique identifier (provided
under section 1842(r)) for the physician who prescribed the
services or made the certification described in section
1814(a)(2) or 1835(a)(2)(A).''
(b) Effective Date.--The amendment made by subsection (a)
shall apply to claims submitted on or after the date which is
60 days after the date of enactment of this section.
SEC. 705. RECOUPMENT OF OVERPAYMENTS.
(a) 36-Month Repayment Period.--In the case of an
overpayment by the Secretary of Health and Human Services to
a home health agency for home health services furnished
during a cost reporting period beginning on or after October
1, 1997, as a result of payment limitations provided for
under clause (v), (vi), or (viii) of section 1861(v)(1)(L) of
the Social Security Act (42 U.S.C. 1395x(v)(1)(L)), the home
health agency may elect to repay the amount of such
overpayment ratably over a 36-month period beginning on the
date of notification of such overpayment.
(b) No Interest on Overpayment Amounts.--In the case of an
agency that makes an election under subsection (a), no
interest shall accrue on the outstanding balance of the
amount of overpayment during such 36-month period.
(c) Termination.--No election under subsection (a) may be
made for cost reporting periods, or portions of cost
reporting periods, beginning on or after the date of the
implementation of the prospective payment system for home
health services under section 1895 of the Social Security Act
(42 U.S.C. 1395fff).
(d) Effective Date.--The provisions of subsection (a) shall
apply to debts that are outstanding as of the date of
enactment of this Act.
SEC. 706. REFINEMENT OF HOME HEALTH AGENCY CONSOLIDATED
BILLING.
(a) In General.--Section 1842(b)(6)(F) (42 U.S.C.
1395u(b)(6)(F)) is amended by inserting ``(including medical
supplies described in section 1861(m)(5), but excluding
durable medical equipment described in such section)'' after
``home health services''.
(b) Conforming Amendment.--Section 1862(a)(21) (42 U.S.C.
1395y(a)(21)) is amended by inserting ``(including medical
supplies described in section 1861(m)(5), but excluding
durable medical equipment described in such section)'' after
``home health services''.
(c) Effective Date.--The amendments made by this section
shall take effect as if included in the amendments made by
section 4603 of the Balanced Budget Act of 1997 (Public Law
105-33; 111 Stat. 467).
TITLE VIII--MEDICARE+CHOICE
SEC. 801. DELAY IN ACR DEADLINE UNDER THE MEDICARE+CHOICE
PROGRAM.
(a) Delay in Deadline for Submission of Adjusted Community
Rates and Related Information.--Section 1854(a)(1) (42 U.S.C.
1395w-24(a)(1)) is amended by striking ``May 1'' and
inserting ``July 1''.
(b) Adjustment in Information Disclosure Provisions.--
Section 1851(d)(2)(A)(ii) (42 U.S.C. 1395w-21(d)(2)(A)(ii))
is amended in the first sentence by inserting ``, to the
extent such information is available at the time of
preparation of the material for mailing'' before the period.
(c) Effective Date.--The amendments made by this section
shall take effect on the date of enactment of this Act.
SEC. 802. CHANGE IN TIME PERIOD FOR EXCLUSION OF
MEDICARE+CHOICE ORGANIZATIONS THAT HAVE HAD A
CONTRACT TERMINATED.
(a) In General.--Section 1857(c)(4) (42 U.S.C. 1395w-
27(c)(4)) is amended by striking ``5-year period'' and
inserting ``3-year period''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to contract years beginning on or after January
1, 1999.
SEC. 803. ENROLLMENT OF MEDICARE BENEFICIARIES IN ALTERNATIVE
MEDICARE+CHOICE PLANS AND MEDIGAP COVERAGE IN
CASE OF INVOLUNTARY TERMINATION OF
MEDICARE+CHOICE ENROLLMENT.
(a) Permitting Enrollment in Alternative Plans Upon Receipt
of Notice of Medicare+Choice Plan Termination.--
(1) Medicare+choice plans.--Section 1851(e)(4) (42 U.S.C.
1395w-21(e)(4)) is amended by striking subparagraph (A) and
inserting the following:
``(A)(i) the certification of the organization or plan
under this part has been terminated, or the organization or
plan has notified the individual of an impending termination
of such certification; or
``(ii) the organization has terminated or otherwise
discontinued providing the plan in the area in which the
individual resides, or has notified the individual of an
impending termination or discontinuation of such plan;''.
(2) Medigap plans.--
(A) In general.--Section 1882(s)(3)(A) (42 U.S.C.
1395ss(s)(3)(A)) is amended in the matter following clause
(iii)--
(i) by inserting ``(92 days in the case of a termination or
discontinuation of coverage under the types of circumstances
described in section 1851(e)(4)(A))'' after ``63 days'';
(ii) by inserting ``(or, if elected by the individual, the
date of notification of the individual by the plan or
organization of the impending termination or discontinuance
of the plan in the area in which the individual resides)''
after ``the date of the termination of enrollment described
in such subparagraph''; and
(iii) by inserting ``(or date of such notification)'' after
``the date of termination or disenrollment''.
(B) Effective date.--The amendments made by this paragraph
shall apply to notices of intended termination made by group
health plans and Medicare+Choice organizations after the date
of enactment of this Act.
(b) Guaranteed Access for Certain Medicare Beneficiaries to
Medigap Policies in Case of Involuntary Termination of
Coverage Under a Medicare+Choice Plan.--
(1) In general.--Section 1882(s)(3)(C)(iii) (42 U.S.C.
1395ss(s)(3)(C)(iii)) is amended by inserting ``or an
individual described in clause (ii) or (iii) of subparagraph
(B) in the case of circumstances described in section
1851(e)(4)(A)'' after ``subparagraph (B)(vi)''.
(2) Effective date.--
(A) In general.--Subject to subparagraph (B), the amendment
made by paragraph (1) shall apply to terminations of coverage
effected on or after the date of enactment of this Act.
(B) Transitional medigap open enrollment period for certain
individuals affected by plan withdrawals.--In the case of an
individual described in clause (ii) or (iii) of subparagraph
(B) of section 1882(s)(3) of the Social Security Act in the
case of circumstances described in section 1851(e)(4)(A) of
such Act (relating to discontinuation of a plan or
organization entirely or in an area), if the termination or
discontinuation of coverage occurred after December 31, 1998,
and before the date of enactment of this Act, the provisions
of subparagraph (A) of section 1882(s)(3) such Act (in the
matter up to and including clause (iii) thereof) shall apply
to such an individual who seeks enrollment under a medicare
supplemental policy during the 92-day period beginning with
the first month that begins more than 30 days after the date
of enactment of this Act in the same manner as such
provisions apply to an individual described in the matter
following such clause (iii).
[[Page S11767]]
SEC. 804. APPLYING MEDIGAP AND MEDICARE+CHOICE PROTECTIONS TO
DISABLED AND ESRD MEDICARE BENEFICIARIES.
(a) Assuring Availability of Medigap Coverage.--
(1) In general.--Section 1882(s) (42 U.S.C. 1395ss(s)) is
amended--
(A) in paragraph (2)(A), by striking ``is 65 years of age
or older and is'' and inserting ``is first'';
(B) in paragraph (2)(D), by striking ``who is 65 years of
age or older as of the date of issuance and''; and
(C) in paragraph (3)(B)(vi), by striking ``at age 65''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply to terminations of coverage effected on or after
the date of enactment of this Act, regardless of when the
individuals become eligible for benefits under part A or B of
title XVIII of the Social Security Act.
(b) Permitting ESRD Beneficiaries To Elect Another
Medicare+Choice Plan in Case of Plan Discontinuance.--
(1) In general.--Section 1851(a)(3)(B) (42 U.S.C. 1395w-
21(a)(3)(B)) is amended by striking ``except that'' and all
that follows and inserting the following: ``except that--
``(i) an individual who develops end-stage renal disease
while enrolled in a Medicare+Choice plan may continue to be
enrolled in that plan; and
``(ii) in the case of such an individual who is enrolled in
a Medicare+Choice plan under clause (i) (or subsequently
under this clause), if the enrollment is discontinued under
section 1851(e)(4)(A) the individual will be treated as a
`Medicare+Choice eligible individual' for purposes of
electing to continue enrollment in another Medicare+Choice
plan.''.
(2) Effective date.--
(A) The amendment made by paragraph (1) shall apply to
terminations and discontinuations occurring on or after the
date of enactment of this Act.
(B) Clause (ii) of section 1851(a)(3)(B) of the Social
Security Act (as inserted by such amendment) also shall apply
to individuals whose enrollment in a Medicare+Choice plan was
terminated or discontinued after December 31, 1998, and
before the date of enactment of this Act. In applying this
subparagraph, such an individual shall be treated, for
purposes of part C of title XVIII of the Social Security Act,
as having discontinued enrollment in such a plan as of the
date of enactment of this Act.
SEC. 805. EXTENDED MEDICARE+CHOICE DISENROLLMENT WINDOW FOR
CERTAIN INVOLUNTARILY TERMINATED ENROLLEES.
(a) Previous Medigap Enrollees.--Section
1882(s)(3)(B)(v)(III) (42 U.S.C. 1395ss(s)(3)(B)(v)(III)) is
amended--
(1) by inserting ``(aa)'' after ``(III)'';
(2) by striking the period and inserting ``, or''; and
(3) by adding at the end the following:
``(bb) during the 12-month period described in item (aa),
is disenrolled under the circumstances described in section
1851(e)(4)(A) from the organization described in subclause
(II); enrolls, without an intervening enrollment, with
another such organization; and subsequently disenrolls during
such period (during which the enrollee is permitted to
disenroll under section 1851(e)).''.
(b) Initial Medigap Enrollees.--Section 1882(s)(3)(B)(vi)
(42 U.S.C. 1395ss(s)(3)(B)(vi)), as amended by section
804(a)(1)(C), is amended--
(1) by striking ``benefits under part A, enrolls'' and
inserting ``benefits under part A--
``(I) enrolls'';
(2) by striking the period and inserting ``, or''; and
(3) by adding at the end the following:
``(II)(aa) enrolls in a Medicare+Choice plan under part C,
which enrollment is terminated or discontinued under the
circumstances described in section 1851(e)(4)(A), and
``(bb) subsequently enrolls, without an intervening
enrollment, in another Medicare+Choice plan, and disenrolls
from such plan by not later than 12 months after the
effective date of the enrollment in the Medicare+Choice plan
described in item (aa).''.
(c) Effective Date.--The amendments made by this section
shall apply to terminations and discontinuations occurring on
or after the date of enactment of this Act.
SEC. 806. NONPREEMPTION OF STATE PRESCRIPTION DRUG COVERAGE
MANDATES IN CASE OF APPROVED STATE MEDIGAP
WAIVERS.
(a) In General.--Section 1856(b)(3) (42 U.S.C. 1395w-
26(b)(3)) is amended--
(1) in subparagraph (A), by striking ``The standards'' and
inserting ``Subject to subparagraph (C), the standards''; and
(2) by adding at the end the following:
``(C) Continuation of state prescription drug laws.--
Subparagraph (A) shall not supersede any State law that
requires the comprehensive coverage of prescription drugs or
any regulation that carries out such a law, if--
``(i) the State has a waiver in effect under section
1882(p)(6)(A) with respect to requiring such coverage under
medicare supplemental policies; or
``(ii) the Secretary provides for a waiver for the State to
impose such a requirement under section 1882(p)(6)(B).''.
(b) Medigap Waiver.--Section 1882(p)(6) (42 U.S.C.
1395ss(p)(6)) is amended--
(1) by inserting ``(A)'' after ``(6)''; and
(2) by adding at the end the following:
``(B) The Secretary also may waive the application of the
standards described in paragraph (1)(A)(i) so that a State
may include comprehensive prescription drug coverage among
the benefits required for all medicare supplemental
policies.''.
(c) Effective Date.--The amendments made by this section
shall take effect on the date of enactment of this Act.
SEC. 807. MODIFICATION OF PAYMENT RULES FOR CERTAIN FRAIL
ELDERLY MEDICARE BENEFICIARIES.
(a) Modification of Payment Rules.--Section 1853 (42 U.S.C.
1395w-23) is amended--
(1) in subsection (a)--
(A) in paragraph (1)(A), by striking ``subsections (e) and
(f)'' and inserting ``subsections (e) through (i)'';
(B) in paragraph (3)(D), by inserting ``and paragraph (4)''
after ``section 1859(e)(4)''; and
(C) by adding at the end the following:
``(4) Exemption from risk-adjustment system for frail
elderly beneficiaries enrolled in specialized programs for
the frail elderly.--
``(A) In general.--During the period described in
subparagraph (B), the risk-adjustment described in paragraph
(3) shall not apply to a frail elderly Medicare+Choice
beneficiary (as defined in subsection (i)(3)) who is enrolled
in a Medicare+Choice plan under a specialized program for the
frail elderly (as defined in subsection (i)(2)).
``(B) Period of application.--The period described in this
subparagraph begins with January 2000, and ends with the
first month for which the Secretary certifies to Congress
that a comprehensive risk adjustment methodology under
paragraph (3)(C) (that takes into account the types of
factors described in subsection (i)(1)) is being fully
implemented.''; and
(2) by adding at the end the following:
``(i) Special Rules for Frail Elderly Enrolled in
Specialized Programs for the Frail Elderly.--
``(1) Development and implementation of new payment
system.--The Secretary shall develop and implement (as soon
as possible after the date of enactment of this subsection),
during the period described in subsection (a)(4)(B), a
payment methodology for frail elderly Medicare+Choice
beneficiaries enrolled in a Medicare+Choice plan under a
specialized program for the frail elderly (as defined in
paragraph (2)(A)). Such methodology shall account for the
prevalence, mix, and severity of chronic conditions among
such beneficiaries and shall include medical diagnostic
factors from all provider settings (including hospital and
nursing facility settings). It shall include functional
indicators of health status and such other factors as may be
necessary to achieve appropriate payments for plans serving
such beneficiaries.
``(2) Specialized program for the frail elderly
described.--
``(A) In general.--For purposes of this part, the term
`specialized program for the frail elderly' means a program
which the Secretary determines--
``(i) is offered under this part as a distinct part of a
Medicare+Choice plan;
``(ii) primarily enrolls frail elderly Medicare+Choice
beneficiaries; and
``(iii) has a clinical delivery system that is specifically
designed to serve the special needs of such beneficiaries and
to coordinate short-term and long-term care for such
beneficiaries through the use of a team described in
subparagraph (B) and through the provision of primary care
services to such beneficiaries by means of such a team at the
nursing facility involved.
``(B) Specialized team.--A team described in this
subparagraph--
``(i) includes--
``(I) a physician; and
``(II) a nurse practitioner or geriatric care manager, or
both; and
``(ii) has as members individuals who have special training
and specialize in the care and management of the frail
elderly beneficiaries.
``(3) Frail elderly medicare+choice beneficiary
described.--For purposes of this part, the term `frail
elderly Medicare+Choice beneficiary' means a Medicare+Choice
eligible individual who--
``(A) is residing in a skilled nursing facility or a
nursing facility (as defined for purposes of title XIX) for
an indefinite period and without any intention of residing
outside the facility; and
``(B) has a severity of condition that makes the individual
frail (as determined under guidelines approved by the
Secretary).''.
(b) Continuous Open Enrollment for Certain Frail Elderly
Medicare Beneficiaries.--
(1) In general.--Section 1851(e) (42 U.S.C. 1395w-21(e)) is
amended by adding at the end the following:
``(7) Special rules for frail elderly medicare+choice
beneficiaries enrolling in specialized programs for the frail
elderly.--There shall be a continuous open enrollment period
for any frail elderly Medicare+Choice beneficiary (as defined
in section 1853(i)(3)) who is seeking to enroll in a
Medicare+Choice plan under a specialized program for the
frail elderly (as defined in section 1853(i)(2)).''.
(2) Conforming Amendments.--
(A) Open enrollment periods.--Section 1851(e)(6) (42 U.S.C.
1395w-21(e)(6)) is amended--
(i) in subparagraph (A), by striking ``and'' at the end;
[[Page S11768]]
(ii) by redesignating subparagraph (B) as subparagraph (C);
and
(iii) by inserting after subparagraph (A) the following:
``(B) that is offering a specialized program for the frail
elderly (as defined in section 1853(i)(2)), shall accept
elections at any time for purposes of enrolling frail elderly
Medicare+Choice beneficiaries (as defined in section
1853(i)(3)) in such program; and''.
(B) Effectiveness of elections.--Section 1851(f)(4) (42
U.S.C. 1395w-21(f)(4)) is amended by striking ``subsection
(e)(4)'' and inserting ``paragraph (4) or (7) of subsection
(e)''.
(c) Development of Quality Measurement Program for
Specialized Programs for the Frail Elderly.--Section 1852(e)
(42 U.S.C. 1395w-22(e)) is amended by adding at the end the
following:
``(5) Quality measurement program for specialized programs
for the frail elderly as part of medicare+choice plans.--The
Secretary shall develop and implement a program to measure
the quality of care provided in specialized programs for the
frail elderly (as defined in section 1853(i)(2)) in order to
reflect the unique health aspects and needs of frail elderly
Medicare+Choice beneficiaries (as defined in section
1853(i)(3)). Such quality measurements may include indicators
of the prevalence of pressure sores, reduction of iatrogenic
disease, use of urinary catheters, use of antianxiety
medications, use of advance directives, incidence of
pneumonia, and incidence of congestive heart failure.''.
(d) Effective Dates.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall take effect on the date
of enactment of this Act.
(2) Development of quality measurement program for
specialized programs for the frail elderly.--The Secretary of
Health and Human Services shall first provide for the
implementation of the quality measurement program for
specialized programs for the frail elderly under the
amendment made by subsection (c) by not later than July 1,
2000.
SEC. 808. EXTENSION OF MEDICARE COMMUNITY NURSING
ORGANIZATION DEMONSTRATION PROJECTS.
Notwithstanding any other provision of law and in addition
to the extension provided under section 4019 of the Balanced
Budget Act of 1997 (Public Law 105-33; 111 Stat. 347),
demonstration projects conducted under section 4079 of the
Omnibus Budget Reconciliation Act of 1987 (Public Law 100-
203; 101 Stat. 1330-121) shall be conducted for an additional
period of 3 years, and the deadline for any report required
relating to the results of such projects shall be not later
than 6 months before the end of such additional period.
TITLE IX--CLINICS
SEC. 901. NEW PROSPECTIVE PAYMENT SYSTEM FOR FEDERALLY-
QUALIFIED HEALTH CENTERS AND RURAL HEALTH
CLINICS UNDER THE MEDICAID PROGRAM.
(a) In General.--Section 1902(a)(13) (42 U.S.C.
1396a(a)(13)) is amended--
(1) in subparagraph (A), by adding ``and'' at the end;
(2) in subparagraph (B), by striking ``and'' at the end;
and
(3) by striking subparagraph (C).
(b) New Prospective Payment System.--Section 1902 (42
U.S.C. 1396a) is amended by adding at the end the following:
``(aa) Payment for Services Provided by Federally-Qualified
Health Centers and Rural Health Clinics.--
``(1) In general.--Beginning with fiscal year 2000 and each
succeeding fiscal year, the State plan shall provide for
payment for services described in section 1905(a)(2)(C)
furnished by a Federally-qualified health center and services
described in section 1905(a)(2)(B) furnished by a rural
health clinic in accordance with the provisions of this
subsection.
``(2) Fiscal year 2000.--For fiscal year 2000, the State
plan shall provide for payment for such services in an amount
(calculated on a per visit basis) that is equal to 100
percent of the costs of the center or clinic of furnishing
such services during fiscal year 1999 which are reasonable
and related to the cost of furnishing such services, or based
on such other tests of reasonableness as the Secretary
prescribes in regulations under section 1833(a)(3), or in the
case of services to which such regulations do not apply, the
same methodology used under section 1833(a)(3), adjusted to
take into account any increase in the scope of such services
furnished by the center or clinic during fiscal year 2000.
``(3) Fiscal year 2001 and succeeding years.--For fiscal
year 2001 and each succeeding fiscal year, the State plan
shall provide for payment for such services in an amount
(calculated on a per visit basis) that is equal to the amount
calculated for such services under this subsection for the
preceding fiscal year--
``(A) increased by the percentage increase in the MEI
(medicare economic index) (as defined in section 1842(i)(3))
applicable to primary care services (as defined in section
1842(i)(4)) for that fiscal year; and
``(B) adjusted to take into account any increase in the
scope of such services furnished by the center or clinic
during that fiscal year.
``(4) Establishment of initial year payment amount for new
centers or clinics.--In any case in which an entity first
qualifies as a Federally-qualified health center or rural
health clinic after October 1, 2000, the State plan shall
provide for payment for services described in section
1905(a)(2)(C) furnished by the center or services described
in section 1905(a)(2)(B) furnished by the clinic in the first
fiscal year in which the center or clinic qualifies in an
amount (calculated on a per visit basis) that is equal to 100
percent of the costs of furnishing such services during such
fiscal year in accordance with the regulations and
methodology referred to in paragraph (2). For each fiscal
year following the fiscal year in which the entity first
qualifies as a Federally-qualified health center or rural
health clinic, the State plan shall provide for the payment
amount to be calculated in accordance with paragraph (3) of
this subsection.
``(5) Administration in the case of managed care.--In the
case of services furnished by a Federally-qualified health
center or rural health clinic pursuant to a contract between
the center or clinic and a managed care entity (as defined in
section 1932(a)(1)(B)), the State plan shall provide for
payment to the center or clinic (at least quarterly) by the
State of a supplemental payment equal to the amount (if any)
by which the amount determined under paragraphs (2), (3), and
(4) of this subsection exceeds the amount of the payments
provided under the contract.
``(6) Alternative payment system.--Notwithstanding any
other provision of this section, the State plan may provide
for payment in any fiscal year to a Federally-qualified
health center for services described in section 1905(a)(2)(C)
or to a rural health clinic for services described in section
1905(a)(2)(B) in an amount that is in excess of the amount
otherwise required to be paid to the center or clinic under
this subsection.''.
(c) Conforming Amendments.--
(1) Section 4712 of the Balanced Budget Act of 1997 (Public
Law 105-33; 111 Stat. 508) is amended by striking subsection
(c).
(2) Section 1915(b) (42 U.S.C. 1396n(b)) is amended by
striking ``1902(a)(13)(E)'' and inserting ``1902(aa)''.
(d) Effective Date.--The amendments made by this section
shall take effect on October 1, 1999.
Mr. KENNEDY. Mr. President, we all want to express our appreciation
to our leader, Senator Daschle, for the development of this proposal.
As he has pointed out, we have worked closely with Senator Moynihan and
the members the Finance Committee. We hope this will be the basis of
the coming together here in the Senate. This should not be a partisan
issue. The kinds of problems Senator Daschle pointed out are problems
not only in urban areas but in rural communities, too. The program he
has advocated touches the health care needs of people all over this
country. This particular issue cries for a response and action from
this Congress in these final few days.
I join with him and others who say we should not leave, we cannot
leave, we will not leave this session without addressing these
problems. We have the time now to work this process through. I think
the way this has been fashioned has demonstrated a sensitivity to the
range of different emergencies that are out there across the landscape
affecting real people.
So I join others on our side in commending him for the leadership he
has provided on this issue as in so many other areas. Hopefully, he
will be successful in reaching across the aisle so that we can all work
on this issue together.
Mr. President, no senior citizen should be forced to enter a hospital
or a nursing home because Medicare can't afford to pay for services to
keep her in her own home and in her own community.
No person with a disability should be told that occupational therapy
services are no longer available because legislation to balance the
budget reduced the rehabilitation services they need.
No community should be told that their number one employer and
provider of health care will be closing its doors or engaging in
massive layoffs because Medicare can no longer pay its fair share of
health costs.
No freestanding children's hospital should wonder whether it can
continue to train providers to care for children because it receives no
federal support for its teaching activities. Yet these scenes and many
others are playing out in towns and cities across the country today, in
large part due to the unexpectedly deep Medicare cuts in the Balanced
Budget Act passed two years ago.
The 1997 Act was the final part of a process undertaken since 1993 to
balance the federal budget and lay the groundwork for the current
economic boom and the large budget surpluses we anticipate in the years
ahead. However, our ability to balance the budget was primarily
attributable to deep savings achieved by cuts in Medicare--by
[[Page S11769]]
slowing the rate of growth in provider payments and other policy
reforms. These cuts were expected to total $116 billion over five
years, and nearly $400 billion over ten years. Clearly, as experience
now shows, these cuts are too deep for the Medicare program to sustain.
In fact, these cuts were more than double the amount ever enacted in
any previous legislation. The Congressional Budget Office has now
increased the estimate of the savings to total $200 billion over five
years and more than $600 billion over ten years--far greater than
Congress intended.
Not surprisingly, we are now hearing from large numbers of the
nation's safety net providers--especially teaching hospitals, community
hospitals, and community health centers. We are hearing from those who
care for the elderly and disabled when they leave the hospital--nursing
homes, home health agencies and rehabilitation specialists. We are
hearing from virtually every group that cares for the 40 million senior
citizens and disabled citizens on Medicare. They are saying--with great
alarm and anxiety--that Congress went too far.
The Medicare Beneficiary Access to Quality Health Care Act that we
are introducing today will alleviate much of this damage. It will
provide $20 billion over the next ten years to reduce the pain created
by the harshest cuts in the Balanced Budget Act. It will ensure that
the nation's health care system is able to care responsibly for today's
senior citizens, and is adequately prepared to take care of those who
will be retiring in the future.
The current Balanced Budget Act is unfairly imposing a $1.7 billion
cut over the next five years for Massachusetts hospitals alone. Our
community hospitals are reeling. Many of our teaching hospitals have
laid off staff, and are unable to continue to participate in Medicare
HMO contracts. Some say that these cuts are needed to make Medicare
more efficient. But Massachusetts teaching hospitals are already
efficient. In the past six years, one out of five of our teaching
hospitals and one out of four hospital beds have been closed. We cannot
afford to compromise on patient care, doctor training, and the state-
of-the-art medical research conducted at the nation's top hospitals.
In addition, children's hospitals deserve help as well. They
currently receive almost no federal support for their important
teaching and training activities. They train a majority of the nation's
pediatricians and pediatric specialists. Yet current rules keep them
from receiving the level of federal support available to other teaching
hospitals. While this particular legislation does not address this
problem, Senator Bob Kerrey and I have proposed a separate bill with
strong bipartisan support to correct this injustice and give children's
hospitals the funding they deserve to train the pediatricians needed to
care for the nation's children in the years ahead.
The home-bound elderly--our most vulnerable senior citizens--are also
suffering. In Massachusetts alone, home health agencies are losing $160
million annually, and 20 agencies have closed their doors since the
Balanced Budget Act went into effect. The ones that remain are seeing
fewer patients, and seeing their current patients less often.
Massachusetts nursing homes are predicting losses of $500 million
over the next five years. Eleven facilities have declared bankruptcy
this year, and more are expected to follow.
With the impending retirement of the baby boom generation, the last
thing we should do now is jeopardize the viability and commitment of
the essential institutions that care for Medicare beneficiaries. Yet
that is now happening in cities and towns across the nation. In the
vast majority of cases, the providers who care for Medicare patients
are the same ones who care for working families and everyone else in
their community. When hospitals who serve Medicare beneficiaries are
threatened, health care for the entire community is threatened.
Nearly one million elderly and disabled Massachusetts residents rely
on Medicare for their health care. This legislation is a sensible,
affordable step to ensure that our health care system will continue to
be there for them when they need it. It deserves prompt consideration
and passage. I commend Senator Daschle for his leadership on this vital
issue, and I urge the Senate to approve this important measure.
The PRESIDING OFFICER. The Democratic leader.
Mr. DASCHLE. Mr. President, I congratulate and thank my colleague
from Massachusetts for his remarks and for his extraordinary commitment
to this effort. He has been at every meeting. He has been engaged from
the very beginning, and we are grateful, as on so many of the issues
our caucus cares deeply about, for the leadership he has provided.
I am proud of the fact we have had the participation of well over 20
Members, and the senior Senator from Massachusetts has been the leader
of the pack, as he is on so many other issues.
I also thank Senator Rockefeller for the extraordinary effort he has
put forth. As a member of the Finance Committee, no one has worked
harder on many of these issues than has he. I am grateful for the
participation and leadership he has provided to get us to this point.
Before I yield the floor, let me say how urgent this matter is. My
colleagues yesterday discussed the urgency of this legislation again
and again. I am disappointed and deeply concerned about the fact that,
at least to date, there is no date yet set for consideration and markup
of a bill to repair the damage done in the 1997 act. We have to address
and consider and ultimately pass such a bill prior to the time we leave
the Senate this year. We will do anything, and everything we know how,
to ensure this becomes one of the highest legislative priorities left
prior to the end of this session of Congress. It must be addressed. It
must be passed. We must take this legislation up soon in order for us
to accomplish what I know is a bipartisan recognition of the
shortcomings and the miscalculations made in the 1997 act.
I will say again, the fact that we have over half of our caucus
already, and will probably have two-thirds of our caucus as cosponsors
in the not-too-distant future, is a clear recognition of the depth of
feeling our Members have on this bill and the importance we place on
getting something done this year. We must do it. We will do it, and we
will work with our Republican colleagues to make that happen.
I yield the floor.
The PRESIDING OFFICER. The Senator from West Virginia.
Mr. ROCKEFELLER. Mr. President, I strongly agree with the words our
Democratic leader has offered, and I congratulate him for mobilizing
this effort, but it is a mobilization not so much of Democrats as it is
of Senators in general. Hospitals and patients and skilled nursing
facilities and home health agencies are not Republican or Democrat. The
shortages, the closings, the health care denied is not Republican or
Democrat. It has to do with the people of our States and of our
country.
This is a bipartisan matter. I know, without even having talked to
but five or six of my colleagues on the other side of the aisle, when
they went back to their homes during the August recess and when they
have been back since, this has been the subject with which we have all
been, in a sense, lobbied in the best sense; that is, lobbied by our
own constituents, by our own voters, by people who are patients, by
people who have had these problems.
It is right; we should be fixing this because Congress, in 1997, when
we passed the Balanced Budget Act, made changes that were larger in
Medicare than any in the history of the program, and we made mistakes.
This is actually one of the reasons our colleagues on the other side of
the aisle often criticize congressional action because we are trying to
play doctor. We often try, but we often do not do it very well. In this
case, we did not. We made mistakes.
When we make a mistake, we are causing skilled working facilities,
home health agencies, and hospitals to close; we are putting in
jeopardy margins of profit, which have gone into the red already, of
other hospitals, particularly rural hospitals. We have to correct it.
There is nothing more self-evident to me than the need for this
Congress to take up the BBA corrections and, in fact, do them on a
bipartisan basis. We do not have very much time. There
[[Page S11770]]
seems to be quite a lot of anxiousness to get out of here. That is not
shared by the junior Senator from West Virginia. In that case, it puts
more pressure on us to do it. We need a date. We need to do this. This
is not makeup stuff. These are real problems.
In my State of West Virginia, which is not large but our citizens are
no less important than anybody else's, and to me they are more
important, in the next 4 years our hospitals are going to face an
almost $600 million cut in payment because of mistakes we made in the
1997 Budget Act. They did not make the mistakes. They have not been
keeping their books incorrectly. They have not been trying to be
inefficient. We made the mistakes. We made the mistakes in Congress,
and it is up to us to correct them.
Many critical public health services will be cut back. That has
happened already. It will continue to happen. Home care agencies in my
State expect there will be almost 5,000 less Medicare patients being
admitted for their services than before.
Eleven home health care providers in West Virginia have closed. That
is not a lot, but that is a lot in West Virginia, and it is in a lot of
places. We have 55 counties and 1.8 million people. Eleven home health
agencies is a lot; 2,500 on a nationwide basis are closed. They are not
thinking about closing but have closed because of mistakes we in
Congress have made in making these enormous changes to Medicare. They
have been forced to close down because the current payment system does
not adequately reimburse them for what they have to do.
CBO originally estimated home health reimbursement reductions would
be $16 billion. It turned out the reduction was $47 billion. That was
not the hospitals' fault; That was not the home health agencies' fault;
that was our fault. We made that mistake. We have to correct that
mistake.
The $1,500 cap on therapy is having bad results on nursing home
patients with Parkinson's disease, burns, and other things. We need to
correct that because we made the mistakes.
I will end by saying, I agree on teaching hospitals. We have three
teaching hospitals in West Virginia. Whatever happens in general
happens in a much worse way in rural States. That is by definition,
that is by nature, whether it is hospitals, nursing homes, or anything
else. That has always been the case.
Rural hospitals have very little to fall back on because they do not
have margins. They depend on Medicare more than those in larger and
more urban States. These were unintended cuts we made, but we
nevertheless made them. The mistake is ours. It is a bipartisan
mistake. It came along with a very good bill, the Balanced Budget Act
of 1997. Within it, there was some cancer, and the cancer was caused by
us, and it is the mistakes we made which are causing havoc all over the
health care world. We can change it easily and change it before we
leave here, and surely we should. I yield the floor.
Ms. MIKULSKI. Mr. President, I rise today as a cosponsor of Senator
Daschle's bill to address the draconian cuts to Medicare under the
Balanced Budget Act of 1997 (BBA). I thank Senator Daschle for
introducing this important piece of legislation.
I support this bill for two reasons. First, I believe the BBA went
too far when it cut reimbursements to Medicare. Second, as we move
towards the millennium and our senior population continues to grow, our
seniors must be able to rely on a sound and secure Medicare Program.
This bill will help them do just that.
When I travel throughout the State of Maryland, the issue my
constituents want to talk about most is cuts in services for the
elderly. I have worked long and hard to find solutions to these cuts.
That is why I cosponsored an amendment to the recent tax bill which
placed a priority on fixing Medicare before providing for a tax cut.
That is why I am working on a new and improved Older Americans Act, and
that is why I am cosponsoring Senator Daschle's legislation, which
helps providers who are struggling under BBA cuts to Medicare.
The BBA is one of the reasons why we have a projected budget surplus.
It put us on the right track of fiscal prudence, but it went too far in
the case of Medicare by imposing deep cuts on providers: It cut
reimbursements to home health agencies; it cut reimbursements to
nursing homes; it cut reimbursements to Medicare HMOs. Our seniors and
our providers are now feeling the effects of these cuts.
What exactly do these cuts mean? In my State of Maryland, this means
that 34 Home Health Agencies have closed their doors and only two
public Home Health Agencies remain. This is a particular problem in
rural counties in Maryland. Agencies in these areas are committed to
providing health care to those who cannot travel to hospitals or
doctors offices. In fact, they are so committed to providing home-bound
patients with care, I know some health care providers who have traveled
to homes by a snowmobile in winter months just to get to a patient. But
because of substantial cuts in reimbursements under BBA, these agencies
are left with no choice but to close their doors; families lose these
services, employees lose their jobs, and nobody wins.
Our Skilled Nursing Facilities (SNFs) also need the relief provided
by this legislation. The BBA changed the way that payments are
calculated so that facilities do not get paid more money when they
provide expensive services such as chemotherapy or prosthetics. In some
cases, the reimbursement is so low, that facilities cannot afford to
take the patients who need a high level of care. I hear stories about
patients who need chemotherapy treatment but cannot find a facility to
provide it. Why? The answer is because Medicare doesn't pay enough to
cover the cost of the chemotherapy treatment. Where does this patient
go? They could go to a hospital, but frequently this is more expensive,
or might not specialize in these services. Patients and their families
do not want to hear complex stories about payment methodologies, or
resource utilization groups. What these families want to hear is that
their loved ones can get the care that they need.
My State of Maryland has also had a devastating problem with Medicare
HMOs. Because of payment changes, reimbursements to many HMOs were cut.
What are the effects of these cuts? One HMO in my state is projecting
losses of over $5 million this year in the rural counties of Maryland
alone. This HMO can no longer afford to cover Medicare patients so it
is closing up shop. 14,000 senior citizens in Maryland will lose their
Medicare HMO. Where do these seniors go? In the rural counties of
Maryland, these seniors do not have any other Medicare HMO to choose.
They all left--not because they weren't making a profit--these HMOs
couldn't even break even. Rural counties throughout Maryland and the
nation will have seniors with little or no access to the extra benefits
many HMOs provide, including prescription drug coverage and preventive
benefits such as dental, vision and hearing screenings.
Imagine if your 85-year-old grandmother, living on a fixed income,
got a letter in the mail that says in 4 months she will no longer have
a Medicare HMO. She might not understand what it means. Is she losing
her health care coverage altogether? Is she losing her doctor? Is she
losing her medicine coverage? In many cases, my constituents aren't
wondering where they should go for a mammogram or prostate screening,
but if they can even go at all because their HMO is leaving town.
Some will say these cuts aren't so bad--why can't you just buy a
Medigap policy? For around $150 a month you could get some of the
supplemental benefits that HMOs provide. But many of these senior
citizens only have $11,000 or $12,000 a year in retirement income and
many times their income is much less. These seniors cannot afford $150
a month for a Medigap policy, so many of them will be forced to make
difficult choices between food, rent, health care and prescription
medications. This legislation provides needed relief so that our
seniors would not have to make these terrible decisions.
I also know that our non-profit health facilities are having a
particularly rough time. These are providers such as Hebrew Home in
Rockville, Maryland, or Mercy Hospital in Baltimore, who are struggling
to provide care under current reimbursements. It is especially
difficult for these providers because the care they provide is
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frequently uncompensated. This is health care that they frequently do
not get reimbursed for, also known as charity care. In many cases, they
provide the health services to seniors who have no other place to go.
If we do not take steps to fairly reimburse them, where will these
seniors go to get the care they need?
One of my priorities as a United States Senator has always been to
honor your mother and father. It is a good commandment and good public
policy--in the federal law books and checkbooks. We must address these
cuts in Medicare because our safety net for seniors is badly frayed,
and senior citizens are being left stranded because many health care
providers have no choice but to close their doors.
In 1965 when Medicare was created, the Federal Government promised
that Americans who work hard all of their lives can count on Medicare
when they retire. I believe that promises made should be promises kept.
Senator Daschle's bill will help us keep the promise we have made to
the Nation's senior citizens.
Mr. JOHNSON. Mr. President, I am pleased to cosponsor the Medicare
Beneficiary Access to Quality Health Care Act introduced today that
works to correct the inequities of Medicare reforms included in the
Balanced Budget Act of 1997.
I commend Senator Daschle for his tremendous efforts on this issue
and for his leadership with the introduction of this bill. As well, I
congratulate a number of my other colleagues who have contributed
immensely to the crafting of this critical piece of legislation,
including Senators Moynihan, Kennedy, Rockefeller, Baucus, Conrad, and
others.
As part of the effort to balance the Federal budget, the Balanced
Budget Act of 1997 (BBA) provided for major reforms in the way Medicare
pays for medical services. The Balanced Budget Act of 1997 (BBA)
included numerous cuts in Medicare payments to health care providers.
These changes were originally expected to cut Medicare spending by
about $115 over five years, but recent CBO projections show spending
falling nearly twice that much. In the face of these deep cuts, health
care providers are struggling, and beneficiary access to care is
threatened. The Medicare Beneficiary Access to Care Act is a targeted
solution to certain specific problems that the Balanced Budget Act has
created.
As implementation of these reforms proceeds, health care providers
and patient advocacy groups have asserted that some of the reforms are
having--or are likely to have--undesirable or unintended consequences.
Areas in patient care such as rehabilitative therapy, skilled nursing
facilities, home health services, and hospital outpatient services have
already begun to feel the effects of the reforms set forth in 1997.
Not surprising, I have heard from many safety net providers in South
Dakota about the devastating effects such reductions in reimbursements
are having throughout the health care industry. Consumers are also
feeling the pain, as many individuals are being turned away from
hospitals and nursing homes who cannot afford to accept new patients
because of the lower reimbursement rates included in the Balanced
Budget Act. These cuts are devastating and feared to have severe
implications on the quality and access of health care throughout our
nation, including South Dakota, unless Congress acts immediately to
correct these problems. In South Dakota, and other rural parts of the
country, hospitals and other health care providers have an extremely
high percentage of Medicare beneficiaries making these cuts in
reimbursement even more devastating. If Congress does not act in a
timely fashion many of these providers may be forced to close their
doors.
I look forward to continue working with my colleagues on passage of
the Medicare Beneficiary Access to Quality Health Care Act which
develops creative, cost-effective approaches to address the unintended,
long-term consequences of the BBA. The proposed budget surplus provides
Congress the unique opportunity to address many of the deficiencies in
our nation's health care system. We need to address the valid concerns
of teaching hospitals, skilled nursing facilities, home health
providers, rural and community hospitals, and other health care
providers who require relief from the consequences of the BBA.
Mr. CLELAND. Mr. President, we are all hearing from our constituents
about the hardships they have encountered from the unintended
consequences of the Balanced Budget Act (BBA) of 1997. From rural
hospitals to home health care agencies, cuts in Medicare reimbursement
have forced these health care providers to absorb tremendous debt and
have threatened patients' access to care. Senator Daschle has proposed
over 30 items that will provide immediate relief across the health care
continuum. Among these provisions, the bill would redirect BBA surplus
monies to provide a cap on hospital outpatient Prospective Payment
System (PPS) loss, a delay on the proposed 15 percent cut to home
health care reimbursement, a fix for the graduate medical education
resident cap and the indigent care problem, the repeal of nursing home
therapy caps, a technical correction to limit oscillations to Medicare
physician reimbursement, a delay of risk adjustment for frail elderly/
Evercare. Senator Daschle is to be commended for developing this
comprehensive BBA relief bill in an incredibly short period of time. My
colleague has more than met the challenge of this urgent health care
dilemma. I am proud to be an original cosponsor of this critical
remedial legislation for a BBA fix. I will support Senator Daschle with
all my resources to pass a BBA fix this session.
Mr. KERREY. Mr. President, I support the legislation offered earlier
by the Senator from South Dakota, the Medicare Beneficiary Access to
Care Act of 1999.
I supported strongly the balanced budget amendment of 1997, the
deficit reduction acts of 1993 and 1990, and am proud of the supporting
role I played over the last 7 or 8 years in taking the United States of
America to the point where the Federal Government was borrowing
hundreds of billions of dollars--$300 billion when I came in 1989--to a
point where we now have a surplus. It is quite an exciting change in
the dynamics of this country.
This morning's New York Times had a story by Louis Uchitelle about
1.1 million Americans having been lifted off the rolls of poverty as a
consequence of demands of wages that occur because interest rates are
low, corporate profits are good, and the American economy is as strong
as it has been in my lifetime. It is quite impressive what a strong
economy will do with low interest rates and what increased rates in
productivity will do. The report also pointed out the significant
problems we still have with income growth, especially with African
Americans.
But I am proud of the role I played in eliminating the deficit and
creating a surplus that has contributed enormously to the growth of the
U.S. economy. Certainly lots of action in the private sector
contributed to it, but Congress and those who were here--Republicans
and Democrats--over the last 7 or 8 years who voted for these three
pieces of legislation can take some pride in taking the United States
not just into recovery economically, but I remember how frustrating the
deficit was--politically frustrating--that caused Americans to lose
confidence that Congress could get anything done. It seemed a
relatively small ``bone'' in a great nation and I am glad we finally
coughed it up. I don't want to backtrack on that.
That is why I am pleased Senator Daschle has indicated this bill has
to be paid for. Not only do we have to be careful to not drain the
Social Security trust fund, but we have to be careful we not do this in
a fashion that takes America back to the bad old days of deficit
financing. It is easy to do that.
The 1997 act had an impressive number of people in the Senate and the
House voting for the legislation. The United States was to produce $100
million of savings in 10 years. It is now estimated it will produce
$200 million in savings. I voted for $100 million. That is what I
thought the legislation would produce. Not all of that $200 million
estimate occurs as a consequence of the changes in reimbursement. Some
has occurred as a result of the vigorous effort by Secretary Shalala
and HCFA to reduce fraud and, as a consequence, save taxpayer money.
They made billing changes that produced some savings. They are doing a
better job of
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managing the taxpayers' money. Some of the savings has occurred as a
consequence.
There is no question there is a fraction of that excess $100 million
that has come as a result of our making some changes to take more out
of the providers than anyone anticipated. This legislation will put $23
billion back. I believe that is fair, reasonable, and defendable. I
think it will have a tremendously positive impact on the ability of my
State of Nebraska to get high-quality health care; that is what is at
stake. What is at stake is not just the health of health care
institutions but the health of the citizens of the country who depend
upon those institutions.
I believe this piece of legislation is needed. It is needed in
Nebraska and by citizens who depend upon their doctors, who depend upon
their hospitals, who depend upon this thing we call the health care
system in the United States of America. It is an issue of life and
death for them. It is a very important issue. It is a very personal
issue.
When we talk to somebody in a hospital, it is easy to acquire the
right sense of urgency to overcome whatever ideological differences we
might have. The people of Nebraska need this Congress to act. It is not
just something that we are being asked to do; it is something that is
necessary in order to improve the quality of life in our State.
I will go through some of the things this legislation does. For
hospitals, the 1997 act cuts hospital payments in several ways: Lower
inpatient payments; a new outpatient prospective payment system; a
special payments cut for low-income patients: and cuts in graduate
medical education.
This legislation does not restore all of those cuts. It creates a 3-
year transition period to protect hospitals under this new outpatient
system, and there is additional protection for rural and cancer
hospitals. The bill also moderates the cut in DSH and GME payments, a
central concern of teaching and academic centers. And it takes action
for pediatric hospitals.
I urge colleagues who have not studied this to examine the very low
reimbursements for graduate medical education for pediatric hospitals.
There is a glaring difference and it will create tremendous problems as
we try to train pediatricians--a very important profession in the
health care industry.
There are a number of changes that increase the quality of care in
Nebraska hospitals and increase the chances, especially in rural
hospitals, that we will not see a continuation of what we had in 1998
when two rural hospitals closed. My hospital administrators tell me
there may be more of the same unless we make some reasonable
adjustments.
The Balanced Budget Act made some changes in skilled nursing
facilities. We understand the need to balance the budget. This does not
undo that. It is paid for. The Balanced Budget Act created a
prospective payment system for skilled nursing facilities. This does
not adequately account for the costs of very sick patients and rare
high-cost services. This bill attempts to address both of these
problems by increasing payments for groups of patients for whom payment
is low and by paying separately for high-cost services, such as
prosthetics, to ensure the nursing homes receive adequate payment.
We have heard about the impact of therapy caps. I hope in addition to
putting some money back into the providers, we can take the advice of
the Senator from Oklahoma and get some structural changes enacted in
Medicare. One of the problems we have as a Congress trying to make
changes in Medicare is we don't know the full impact of changes.
Senators Breaux and Thomas were proposing the creation of a new
Senate-confirmed board that has authority over HCFA to make certain
HCFA has the authority to offer fee-for-service plans on a competitive
basis and make sure competitors have a level playing field to compete
and offer their plans against the fee for service that HCFA has. I
think it would be easier to solve the problem of dealing with waste,
fraud, and abuse and make it more likely the consumers receive good
information when they are trying to make decisions about what to buy.
Consolidating Part A and Part B was also in the proposal of Senator
Breaux, and as a consequence of consolidating those two programs, it
would make it much more likely when dealing with medical procedures,
such as therapy, that we get it right.
What we did with the Balanced Budget Act is create a 1,500-per-
annual-beneficiary cap, but these are arbitrary. They don't allow any
flexibility based upon the need of the patient. What we have done with
the legislation is repeal the caps until 2003 and require HCFA to
implement a new system for therapy payments that is budget neutral to
caps. It is designed to address the needs for varying amounts of
therapy based upon a patient's condition. That is the point I was
trying to make earlier, why we need structural changes, as well.
There are varying needs of the patient that are extremely difficult
for HCFA to address. It is a central system. They have fiscal
intermediaries in the country making payments. It is still a centrally
controlled system and awfully difficult to get it right in Ohio,
Nebraska, and Missouri simultaneously. They have to apply a system
nationwide. It is better, in my judgment, if we have a board of
directors, Senate-confirmed, to manage HCFA, moving in a direction
where the private sector is able to compete for HCFA's fee for service
simultaneously, with HCFA offering its fee-for-service plans.
It makes changes in home health. We created under the BBA an interim
payment system for home health agencies which limits payments on both a
per beneficiary as well as a per visit basis. The temporary system
locked in very low rates. This affects rural areas more than urban
areas. There are very low rates for areas that had traditionally low
costs such as Nebraska. We have low costs.
The IPS locked in those very low costs in October 2000, and the IPS
is scheduled to be replaced by a new PPS system for home health
services. Those payments will be reduced in an arbitrary fashion by 15
percent. We make three changes in the legislation that are vital:
First, we postpone this 15-percent cut for 2 years; second, we assist
low-cost agencies that have been disadvantaged under the IPS by
increasing the per visit limit; finally, the bill reduce administrative
burdens placed upon the providers by eliminating interest on
overpayments, eliminating a 15-minute reporting requirement, and
eliminating a requirement for home health agencies to do the billing
for durable medical equipment.
We make changes for physicians. The BBA created a new system for
physician payments based on a target rate of growth. The system
includes bonus payments and reductions intended to create incentives to
meet the target rate of growth. However, what we have done will cause
payments to fluctuate widely, creating tremendous uncertainty in the
physician communities and causing physicians who are out there trying
to manage a clinic or their business to say: We can't depend upon HCFA.
We can't depend upon a revenue stream. There is too much uncertainty in
the system. We may opt out as a consequence.
They are facing a very big challenge in dealing with HCFA's
representation that there may be fraud when, in fact, all that has
occurred is there are a number of additional changes that will be very
constructive for physicians, for Medicare+Choice, for rural health
clinics, federally qualified health centers, and for hospice care where
we have not had any rebasing of payments since 1982. It is a $1
billion--an extremely important program.
Unfortunately, we do not pay a lot of attention to the problem we are
facing when individuals know for certain they are dying. Hospice
addresses that. This is an important change, in my view, and I urge
colleagues on both sides of the aisle to say, whether it is with the
Daschle bill, which I support, or a bill that comes out of the Finance
Committee, which I am apt to support as well: This is one of the things
we need to do. We need to get this done.
I hope we can at least get some minimal changes in Medicare as well,
but we need to address this.
Mr. BINGAMAN. Mr. President, I rise today to join my colleagues in
introducing the ``Medicare Beneficiary Access to Care Act of 1999.'' I
want to commend the leadership in the development of this legislation
and hope
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that the Congress will act upon this now, before we adjourn.
The bill is designed to modify some of the many, unforseen
consequences of the Balanced Budget Act of 1997. Daily I receive
letters and calls citing the negative impact of the Balanced Budget Act
on access to patient care and to the delivery of quality care in an
ongoing and coordinated fashion. In my State of New Mexico, the health
care delivery system has been particularly hard hit. Essentially, the
system for delivery of health care that we have worked so hard to
attain is being eroded and must be bolstered before patients face a
crisis.
I represent a state where 21 out of 33 counties are designated as
health professional shortage areas. I represent a state that has seen
an exodus of physician specialists and rural doctors this past year.
Over the last year, New Mexico had 70 home care agencies close despite
yeoman's efforts to keep these agencies open and serving our citizens.
This represents closure of over 40 percent of our home health care
agencies. We currently have one county, Catron, that has no home care
entity available for serving patients. Failure to deal with the
additional 15-percent cut that is slated to go into effect in October
of 2000 would be the end of numerous other home health agencies
throughout my state. It would be inexcusable not to address this issue
this session.
Additionally, the system is further under stress in the nursing home
arena. We have seen one nationally based entity declare bankruptcy and
face the demise of others. Long term care facilities must be reimbursed
at a level that reflects the acuity of the residents for whom they
care. Long term care is key not only for the residents but for their
families near and far.
Mr. President, several of my colleagues have addressed the issue of
GME and the plight of our teaching hospitals. Hospitals have a
multitude of services that they provide and which we should bolster. I
must note, for example, that in New Mexico, declining Medicare
reimbursement is forcing the only acute care hospital in Dona Anna
County to close a 15 bed skilled nursing unit because of mounting
financial losses. Realities such as this must make us mindful of the
far reaching and adverse effects the BBA of 1997 is now having on
communities and their residents. We want to ensure that no other
facilities face closure.
Finally, I must add that rural and frontier clinics are critical
components to care for seniors and others in the community with limited
resources and serve to allow for timely, geographic access where there
otherwise would be no health care available. I am pleased that some
redress of their needs is provided in this legislation.
Others have outlined the components of this legislation and I will
not repeat the specifics. It is sufficient to say, that these changes
are needed to avert a crisis in the health care delivery system of this
country, to maintain access to quality care for our seniors and to
rectify problems for the system that were created inadvertently. We
must act now to provide for easy access to quality, continued health
care for our citizens.
I look forward to working with all of my colleagues here in the
Senate to see that this legislation is passed prior to adjournment.
Mr. MURRAY. Mr. President, I am pleased to join with my Democratic
colleagues in introducing this important legislation. In the Balanced
Budget Act of 1997, we reformed the Medicare program to extend its
solvency. In the past year, we have seen the dramatic and negative
impact of those reforms on patients and health care providers. The bill
we are introducing today will fix those unintended consequences and
will ensure that millions of seniors have access to high quality health
care. I urge the Republican leadership to act on it before we adjourn
for the year.
Two years ago, the Medicare Program was in serious trouble--facing
bankruptcy within 5 years. We had to make substantial changes to the
program to extend its solvency. It was a painful and difficult process,
but we made changes intended to slow the growth of Medicare
expenditures.
And overall, it worked. Medicare is still functioning and is on a
more sound financial footing.
But the revisions we implemented went too far. Let me give you an
example. Based on the estimates we had at the time, our changes were
supposed to reduce the overall growth in Medicare expenditures by $100
billion over 10 years. In reality, the changes we enacted will result
in more than $200 billion in lost Medicare revenue for health care
providers over the same period. This was not the order of change I
supported.
And today we see that those revisions are hurting our health care
providers and making it more difficult for them to give patients the
high quality care they need.
When I meet with health care providers in my state, this is their top
concern. Each day we delay making these corrections, we make it harder
for them to ensure that quality health care is available to millions of
seniors.
I have heard from hundreds of hospital administrators, home health
care workers, doctors, rehabilitation therapists, teaching hospitals,
skilled nursing facilities, and hospice providers. For example, I've
received letters from Providence General Medical Center in Everett,
Washington, from hospital caregivers at Prosser Memorial Hospital, from
the University of Washington's School of Medicine and from hundreds of
others. They have shared with me the impact of the 1997 changes and
what it means for patient care. I believe the situation is critical.
If we fail to correct this, we will see hospitals closing. We will
see home health agencies turning away patients. We will see skilled
nursing facilities unable to take complex patients. We will see a
devastated rural health system. Our health care system is in jeopardy.
The bill we are introducing today will go a long way toward
correcting some of the unintended consequences of the Balanced Budget
Act of 1997. I worked with my Democratic colleagues in drafting what I
believe is a reasonable bill that provides immediate relief to
hospitals, home health care agencies, skilled nursing facilities and
hospice care to ensure that seniors in this country have access to
quality, affordable health care services. The bill we have put forth is
modest. It is not a cure-all, but it addresses the most pressing
challenges. This is not about repealing the fiscal discipline imposed
in BBA97. This is about adjusting the changes we made to reflect the
current estimates. Our bill fixes the problems and provides legislative
remedies. It does not jeopardize the solvency of Medicare. We can and
should make changes to improve access and ensure access without
jeopardizing solvency.
There is still much we have to address from quality care to
affordable health insurance to prescription drugs. However, if the
hospitals close or seniors are denied quality care, the ability to pay
is not an issue. The very foundation of our health care system is at
stake. This legislation is long overdue. We need to pass it and make
the Medicare Program function better today.
Mr President, at the same time, we cannot forget that the entire
Medicare Program will run out of money in 2015. So, I want to remind my
colleagues there is still much work to be done to ensure Medicare
remains a stable program that our children will be able to count on for
their health care.
Mr. President, from my point of view, this Congress has failed on too
many vital issues this year. This Congress failed to pass a real
Patients' Bill of Rights--that would put patients and doctors, not
insurance companies, in charge of their medical decisions. Earlier this
week, this Senate failed our children, by cutting our commitment to
putting 100,000 teachers in the classroom to reduce the size of our
overcrowded classrooms. This Congress failed to help our farmers, and
all those facing too many challenges in rural America. Let me just say,
that I am not giving up or letting up on any of those fights--because
they are too important. And let's not forget that this Congress even
failed to do one of its most basic work--passing our appropriations
bill on time, with real numbers--not gimmicks.
Mr. President, it is high time we bring some good news back to our
constituents. I want my hospitals and health care providers, as well as
the senior citizens in Washington State, to know I have heard their
concerns and I recognize the dangerous implications of BBA97 on health
care. It is high time
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we show them we see the problems facing Medicare, we understand them,
and we are acting to fix them. It is high time we move on our
priorities. This is one of them. I urge my colleagues to support this
legislation.
Mrs. LINCOLN. Mr. President, today I rise to voice my support for a
bill which addresses the unintended consequences of the Balanced Budget
Act of 1997. I am pleased to join my Democratic colleagues as an
original cosponsor of the Medicare Beneficiaries Access to Care Act.
Since I've been in the Senate, one of the greatest concerns of
Arkansans is the lowered Medicare reimbursement rate for a variety of
services that resulted from the Balanced Budget Act. Yes, we must
continue to rid our Medicare system of waste, fraud and abuse. That is
a high priority for our government and it should remain so. However,
when Medicare changes were made as part of the Balanced Budget Act of
1997, Members of Congress did not intend to wreak havoc on the health
care industry.
Enough time has elapsed to know the unintended consequences of the
Balanced Budget Act. Hospitals have lost tremendous amounts of money
due to changes in the outpatient prospective payment system. Many
hospitals in my state are on the brink of closing due to the tremendous
financial losses they have suffered. Nursing homes have not been
reimbursed by Medicare at rates that cover the cost of patients with
acute care needs. Payments for physical and rehabilitation therapy have
been arbitrarily capped. Teaching hospitals have lost funding to
support their training programs. Home health agencies have been forced
to absorb huge losses and limit services to the elderly. Rural health
clinics have been forced to cope with even more losses and operate on a
shoestring budget.
Not only do these cuts and changes in Medicare reimbursement wreak
havoc on the health care community and force them to absorb unfair
financial losses, but Medicare beneficiaries, the very people that
Medicare was set up to help, lose access to critical services. We
cannot allow our parents and grandparents to be denied access to
coverage or receive limited medicare care because we didn't take action
to correct the devastating cuts of the Balanced Budget Act.
As a member of the Senate Rural Health Caucus and a member of the
Senate Special Committee on Aging, I care deeply about the quality of
health care and our citizens' access to health care. Over the past few
months I have cosponsored various pieces of legislation which address
all of the above-mentioned issues and the need to restore Medicare
cuts. However, this legislation is ``all encompassing'' and if passed,
would ensure that hospitals, skilled nursing facilities, physical
therapy clinics, home health agencies, rural health clinics, and
hospice programs receive important financial relief.
Above all, this legislation is about priorities. Ensuring the health
and well-being of our Nation's seniors and most vulnerable citizens
should be our highest priority. I thank my colleagues for their hard
work on this proposal and I look forward to the quick passage of this
legislation so we can deliver relief to our health care communities and
let them know how much we value their services.
Mr. KERRY. Mr. President, I am pleased to join with Senators Daschle,
Kennedy, Rockefeller and others to introduce the Medicare Beneficiary
Access to Care Act of 1999.
In July, during consideration of tax relief legislation, I offered an
amendment on the floor of the Senate to carve out $20 billion from the
tax bill and devote it towards relief for Medicare providers from the
unintended consequences of the Balanced Budget Act. Although the
amendment received the support of 50 Senators, including seven of my
Republican colleagues, it did not gather the necessary three-fifths
majority required for passage. Today's legislation, a $20 billion
package of specific measures to address the shortcomings of the
Balanced Budget Act, represents the embodiment of our continued
commitment to ensure that this relief is enacted before the end of the
congressional session.
Mr. President, I cannot fully express the urgency of this matter.
Here in Washington, we often throw around numbers with little
realization of the real impact on America's communities. In this
instance, I assure you, the impact is real. Take the town of Quincy,
Massachusetts, population 88,000, and the birthplace of former
presidents John Adams and John Quincy Adams. As we introduce this bill,
the community hospital in Quincy, Massachusetts stands at the edge of
closure. Jeffrey Doran, the hospital's CEO, has been working overtime
to ensure that if the hospital closes, patients will be safely
transferred to health care providers outside the community. Over the
past several weeks, I have been on the phone multiple times with our
State leaders asking them to step in and provide the needed relief
where the Federal Government has failed. Failed, Mr. President, because
the Medicare cuts enacted in 1997 have gone above and beyond what we
intended or desired. The budget savings have exceeded the levels we
envisioned at the time of enactment.
Alternatively, Mr. President, let's take a look at the home health
care industry. Home health care providers deliver rehabilitative
services to Medicare beneficiaries in the safety and comfort of their
home. In the State of Massachusetts, just since passage of the Balanced
Budget Act, we have witnessed the closure of 20 home health care
agencies who are no longer able to cover their costs as a result of
cuts in Medicare payment reimbursements. The same is true with our
nursing homes and extended care facilities.
And just to provide some perspective, the cost of the legislation we
introduce today amounts to less than three percent of the cost of the
tax bill President Clinton vetoed last month. The cost of the entire
bill is less than one provision in the tax bill to subsidize the
interest expenses of American multinational corporations operating
overseas. In fact, we could have passed this bill, repealed the
interest expense provision, and saved American taxpayers an additional
$4 billion.
What a sad reflection on our state of affairs when the Senate would
approve a tax provision to expand eligibility for Roth IRAs for people
making over $100,000 a year, a provision that would cost over $6
billion, but has yet to address the dire needs of our teaching
hospitals. A full legislative remedy for the Medicare payment problems
facing teaching hospitals would cost $5.7 billion.
Mr. President, the time will come for this debate, and the time will
come before we adjourn. The bipartisan support exists. Let's keep the
doors of our teaching and community hospitals, nursing homes, home
health care agencies, and rural clinics open. Let's accept
responsibility for the unintended effects of our previous legislation.
Let's not wait any longer.
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