[Congressional Record Volume 145, Number 163 (Wednesday, November 17, 1999)]
[Senate]
[Pages S14705-S14707]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. JEFFORDS:
  S. 1942. A bill to amend the Older Americans Act of 1965 to establish 
grant programs to provide State pharmacy assistance programs and 
medication management programs; to the Committee on Health, Education, 
Labor, and Pensions.


               PHARMACEUTICAL AID FOR OLDER AMERICANS ACT

  Mr. JEFFORDS. Mr. President, there has been considerable attention 
rightfully paid by our colleagues this year to the issue of providing 
prescription drug coverage for our older American citizens. Estimates 
of the number of older Americans without some form of added coverage 
for prescription drugs vary between a low of 16.7 percent to 50 
percent. About 7.7 million Medicare beneficiaries with annual incomes 
below 200 percent of poverty have no prescription drug coverage, 
despite some evidence indicating they are in poorer health than those 
beneficiaries with coverage. Those without added coverage for 
prescription benefits spend approximately 50 percent of their total 
income on out-of-pocket health care costs, and there are anecdotal 
reports that some elders forgo taking their prescribed medicines in 
order to have food to eat. Finally, there are econometric studies that 
conclude that a $1 increase in pharmaceutical expenditure is associated 
with a $3.65 reduction in hospital care expenditure.
  The problems posed by the lack of prescription drug coverage for the 
neediest elders is compounded by the well-documented effects of 
inappropriate drug use among the elderly. In 1995, the General 
Accounting Office (GAO) found that inappropriate drug use among elders 
is acute and that elders were particularly susceptible to unintended, 
adverse drug events (ADEs), due in part to the natural aging process 
and also to the likelihood that they are taking multiple medications. 
One study of drug use by the elderly, done by the Vermont Program for 
Quality in Health Care, found that it was not uncommon for elders to be 
taking more than a dozen drugs at one time. In fact, the Vermont study 
actually documented one case in which ``a single individual received 
prescriptions for 71 different drugs in a single year, several of which 
probably should not have been taken in combination.''
  The GAO report also cited studies showing that hospitalizations for 
elderly patients due to ADEs were six times greater than for the 
general population, with an estimated annual cost of $20 billion. 
However, a recent Journal of the American Medical Association article 
indicated that the level of ADEs could be reduced 66 percent, if a 
pharmacist participated in grand rounds. Clearly, more must be done to 
recognize the importance of medication management programs that ensure 
the quality of drug therapy, including patient evaluations, compliance 
assessments, and drug therapy reviews.
  We are all aware that prescription drug costs continue to grow at an 
alarming rate. Seniors are being forced to spend greater and greater 
portions of their fixed incomes on prescription drugs which they need 
to live. Research and development of prescription drugs have come a 
long way since Medicare was originally enacted in 1965. Today, drugs 
are just as important as hospital visits, and in many cases more 
important, and it just doesn't make sense for Medicare to reimburse 
hospitals for surgery but not to provide coverage for the drugs that 
might prevent surgery. We need to modernize the Medicare program so 
that it does not go bankrupt in the next 10 to 15 years, and at the 
same time we must ensure that any Medicare reform proposal we consider 
includes a prescription drug benefit that helps all seniors.
  Mr. President, I have already introduced two measures that will help 
our older citizens obtain the medicines they need and at prices they 
can afford. My first bill, S. 1462, the ``Personal Use Prescription 
Drug Importation Act of 1999,'' allows Americans of all ages to avail 
themselves of the lower prices for prescription medicines that are 
available in Canada. A second measure, S. 1725, the ``DrugGap Insurance 
for Seniors Act of 1999,'' would provide for a more comprehensive 
access to prescription drugs by Medicare beneficiaries through reform 
and modernization of the Medicare Supplemental, Medigap, program. Under 
this approach, all existing Medigap plans, and three new drug-only 
Medigap plans, would provide various levels of prescription drug 
benefits from which seniors could choose. And our neediest elders' 
needs would be supported through Federal contributions for the cost of 
their premiums.
  During the 1st Session of the 106th Congress, no fewer than eight 
bills have been introduced in the Senate to provide a prescription drug 
benefit for Medicare beneficiaries--with most proposals estimated to 
cost between $5 billion and $40 billion per year. While I'm hopeful 
that we will all work hard to include a prescription drug benefit for 
Medicare beneficiaries, I am also concerned that at the end of the 
Congress we may not be successful. That is why I am introducing a 
measure today, the ``Pharmaceutical Aid to Older Americans Act,'' which 
will serve as a backstop for our neediest elders. This program builds 
on State pharmacy assistance programs that are already in place, and it 
encourages States to begin them where they don't already exist.
  Fifteen States are cutting new and innovative paths for providing 
prescription drug coverage for their neediest citizens. Most of these 
programs are for elder citizens (more than half also cover people with 
disabilities), and cover a wide variety of drugs--though some are 
limited to certain drugs or conditions, some require cost sharing for 
prescription medicines, and some have annual enrollment fees or monthly 
premiums. As of 1997, these programs aided over 700,000 people. The

[[Page S14706]]

Pharmaceutical Aid to Older Americans Act is designed to assist States 
in their efforts to provide medicines and appropriate pharmacy 
counseling benefits for their neediest elders.
  This Act will strengthen the Older Americans Act by authorizing two 
discretionary grant programs, subject to appropriations, to fund State-
based pharmaceutical assistance and medication management programs. 
Under this measure, States would develop models that work best for them 
and would have the latitude to design and implement innovative 
approaches for providing benefits to their neediest elders. States 
awarded grant money would agree to: match Federal funds with 30 percent 
new or existing State funds or in-kind contributions and not supplant 
current State expenditures with Federal funds. In-kind contributions 
counting toward the match requirement could include assistance from 
pharmaceutical companies and organization- and community-based 
pharmacies, thereby making this approach a truly public-private 
partnership.
  Each application for pharmaceutical assistance funds must include a 
medication management program that ensures the quality of drug 
therapies through patient evaluations, compliance assessments, and drug 
therapy reviews. Federal funds could be used to provide drug coverage 
benefits only to eligible beneficiaries, defined as Medicare 
beneficiaries with incomes up to 200 percent of poverty but without any 
other coverage for prescription drug benefits (States could expand 
eligibility with State resources). All senior citizens could utilize 
the medication management portion of the program.

  This is not government control of drug prices or price-fixing. The 
States can purchase pharmaceuticals from any willing seller, including 
pharmaceutical manufacturers, pharmaceutical distributors, wholesalers, 
pharmacy benefit management firms (PBMs), and chain or local 
pharmacies, without any Federal requirement for wholesale prices or 
Medicaid-based rebates. In some instances, it's likely that States may 
be able to negotiate better purchasing prices than any of those set by 
some artificial, imposed ceiling. Finally, for those States that choose 
not to provide pharmaceutical benefits, the Act authorizes grants to 
States to create or support stand-alone Medication Management Programs 
that will involve the States in collaborative efforts with community, 
chain-based, and institutional pharmacists to implement medication 
management programs.
  As I mentioned earlier, Mr. President, I am fully committed to 
providing a prescription benefit for all our elders as we move forward 
on comprehensive reform of the Medicare program. I am equally committed 
to seeing that the Older Americans Act is reauthorized this Congress, 
and I will work diligently to get these jobs accomplished. However, if 
the latter effort succeeds and the former doesn't, then the 
Pharmaceutical Assistance for Older Americans Act will be in place to 
provide much-needed medicines for our neediest elders. I'm very pleased 
Mr. President, that this measure has received endorsement of two of the 
key advocacy organizations associated with the Older Americans Act, the 
National Association of Area Agencies on Aging and the National 
Association of State Units on Aging. Note that these guardians of the 
aged support this measure, like me, if and only if we are unsuccessful 
in passing a prescription drug benefit for the Medicare program.
  Mr. President, I ask unanimous consent that the bill and the text of 
these letters and this measure be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                S. 1942

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

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Pharmaceutical Aid to Older 
     Americans Act''.

     SEC. 2. AMENDMENT TO OLDER AMERICANS ACT OF 1965.

       Part B of title IV of the Older Americans Act of 1965 (42 
     U.S.C. 3034 et seq.) is amended by adding at the end the 
     following:

     ``SEC. 429K. GRANTS FOR STATE PHARMACY ASSISTANCE PROGRAMS.

       ``(a) Program Authorized.--The Assistant Secretary may 
     award grants to States to provide and administer State 
     pharmacy assistance programs.
       ``(b) Preference.--In awarding grants under subsection (a), 
     the Assistant Secretary shall give preference to States that 
     propose to develop and implement State pharmacy assistance 
     programs, or to provide assistance to State pharmacy 
     assistance programs in existence on the date of enactment of 
     this section, that provide services for underserved 
     populations or for populations residing in rural areas.
       ``(c) Use of Funds.--A State that receives a grant under 
     subsection (a) shall use funds made available through the 
     grant to--
       ``(1) develop and implement a State pharmacy assistance 
     program, or to provide assistance to a State pharmacy 
     assistance program in existence on the date of enactment of 
     this section; and
       ``(2) prepare and submit an evaluation to the Assistant 
     Secretary on the implementation of, or provision of, or 
     assistance to a program described in paragraph (1).
       ``(d) Application.--To be eligible to receive a grant under 
     subsection (a), a State shall submit to the Assistant 
     Secretary an application at such time, in such manner, and 
     containing such information as the Assistant Secretary may 
     require, including--
       ``(1) a description of a State pharmacy assistance program 
     that such State plans to develop and implement, including 
     information on the anticipated number of individuals to be 
     served, eligibility criteria of individuals to be served, 
     such as the age and income level of such individuals, drugs 
     to be covered by the program, and performance measures to be 
     used to evaluate the program; or
       ``(2) a description of a State pharmacy assistance program 
     in existence on the date of enactment of this section that 
     such State plans to assist with funds received under 
     subsection (a), including information on the number of 
     individuals served, eligibility criteria of individuals 
     served, such as the age and income level of such individuals, 
     drugs covered by the program, and performance measures used 
     to evaluate the program.
       ``(e) Minimum Amount.--In awarding grants under subsection 
     (a), from the amount appropriated under subsection (l)(1) for 
     each fiscal year, the Assistant Secretary shall award, to 
     each eligible State, an amount that is not less than 
     $250,000.
       ``(f) Duration of Grant.--In awarding grants under 
     subsection (a), the Assistant Secretary shall award such 
     grants for periods of 2 years.
       ``(g) Matching Requirement.--The Assistant Secretary shall 
     not award a grant to a State under subsection (a) unless that 
     State agrees that, with respect to the costs to be incurred 
     by the State in carrying out the program for which the grant 
     was awarded, the State will make available (directly or 
     through donations from public or private entities) non-
     Federal contributions in an amount that is not less than 30 
     percent of Federal funds provided under the grant.
       ``(h) Supplement Not Supplant.--Funds made available under 
     this section shall be used to supplement, and not supplant, 
     any other Federal, State, or local funds expended by a State 
     to provide the services for programs described in this 
     section.
       ``(i) Evaluations and Report.--
       ``(1) Program evaluations.--Not later than 6 months after 
     the end of the period for which the grant is awarded under 
     subsection (a), the State shall prepare an evaluation of the 
     effectiveness of programs carried out with funds received 
     under this section. Not later than 6 months after the end of 
     such period, the State shall submit to the Assistant 
     Secretary a report containing the results of the evaluation, 
     in such form and containing such information as the Assistant 
     Secretary may require.
       ``(2) Report to congress.--Not later than 36 months after 
     the date of enactment of this section, the Assistant 
     Secretary shall prepare and submit to the Speaker of the 
     House of Representatives and the President pro tempore of the 
     Senate a report that describes the effectiveness of the 
     programs carried out with funds received under this section.
       ``(j) Sunset Provision.--This section shall not apply 
     beginning on the date of enactment of legislation that 
     provides comprehensive health care coverage for prescription 
     drugs under the medicare program under title XVIII of the 
     Social Security Act (42 U.S.C. 1395 et seq.) for all medicare 
     beneficiaries.
       ``(k) Definitions.--In this section:
       ``(1) Medication management.--The term `medication 
     management program' means a program of services for older 
     individuals, including pharmacy counseling, medicine 
     screening, or patient and health care provider education 
     programs, that--
       ``(A) provides information and counseling on the 
     prescription drug purchases that are currently the most 
     economical, and safe and effective;
       ``(B) provides services to minimize unnecessary or 
     inappropriate use of prescription drugs; and
       ``(C) provides services to minimize adverse events due to 
     unintended prescription drug-to-drug interactions.
       ``(2) State pharmacy assistance programs.--The term `State 
     pharmacy assistance program' means a program that provides 
     coverage for prescription drugs and medication management 
     programs for individuals who--
       ``(A) are not less than 65 years of age;

[[Page S14707]]

       ``(B) are not eligible for medical assistance under title 
     XIX of the Social Security Act (42 U.S.C. 1396 et seq.);
       ``(C) are from families with incomes at or below 200 
     percent of the poverty line; and
       ``(D) have no coverage for prescription drugs other than 
     coverage provided by a State pharmacy assistance program.
       ``(l) Authorization of Appropriations.--
       ``(1) In general.--There are authorized to be appropriated 
     to carry out this section, $25,000,000 for fiscal year 2001, 
     and such sums as may be necessary for each of fiscal years 
     2002 through 2005.
       ``(2) Reservation.--From the amount appropriated under 
     paragraph (1), for each fiscal year, the Assistant Secretary 
     shall reserve not less than 33.3 percent of such amount to 
     enable States to assist State pharmacy assistance programs in 
     existence on the date of enactment of this section.

     ``SEC. 429L. GRANTS FOR MEDICATION MANAGEMENT PROGRAMS.

       ``(a) Program Authorized.--The Assistant Secretary may 
     award grants to State agencies to assist such agencies or 
     area agencies on aging in providing and administering 
     medication management programs.
       ``(b) Use of Funds.--A State agency or area agency on aging 
     that receives funds through a grant awarded under subsection 
     (a) shall use such funds to--
       ``(1) develop and implement a medication management 
     program, or to provide assistance to a medication management 
     program in existence on the date of enactment of this 
     section; and
       ``(2) prepare an evaluation on the implementation of or 
     provision of assistance to a program described in paragraph 
     (1), and, in the case of an area agency on aging, submit the 
     evaluation to the appropriate State agency.
       ``(c) Application.--To be eligible to receive a grant under 
     subsection (a), a State agency shall submit to the Assistant 
     Secretary an application at such time, in such manner, and 
     containing such information as the Assistant Secretary may 
     require.
       ``(d) Minimum Amount.--In awarding grants under subsection 
     (a), from the amount appropriated under subsection (j) for 
     each fiscal year, the Assistant Secretary shall award, to 
     each eligible State agency, an amount that is not less than 
     $50,000.
       ``(e) Duration of Grant.--In awarding grants under 
     subsection (a), the Assistant Secretary shall award such 
     grants for a period of 2 years.
       ``(f) Matching Requirement.--The Assistant Secretary shall 
     not award a grant to a State agency under subsection (a) 
     unless that State agency agrees that, with respect to the 
     costs to be incurred in carrying out programs for which the 
     grant was awarded, the State agency will make available 
     (directly or through donations from public or private 
     entities) non-Federal contributions in an amount that is not 
     less than 30 percent of Federal funds provided under the 
     grant.
       ``(g) Supplement Not Supplant.--Funds made available under 
     this section shall be used to supplement, and not supplant, 
     any other Federal, State, or local funds expended by a State 
     agency or area agency on aging to provide the services for 
     programs described in this section.
       ``(h) Reports.--
       ``(1) Report to assistant secretary.--Not later than 24 
     months after receipt of a grant under subsection (a), a State 
     agency shall prepare and submit to the Assistant Secretary a 
     report on the medication management programs carried out by 
     the State agency or area agencies on aging in the State in 
     such form and containing such information as the Assistant 
     Secretary may require, including an analysis of the 
     effectiveness of the programs. Such report shall in part be 
     based on evaluations submitted under subsection (b)(2).
       ``(2) Report to congress.--Not later than 36 months after 
     grants have been awarded under subsection (a), the Assistant 
     Secretary shall prepare and submit to the Speaker of the 
     House of Representatives and the President pro tempore of the 
     Senate a report that describes the effectiveness of the 
     programs carried out with funds received under this section.
       ``(i) Medication Management Programs.--In this section, the 
     term `medication management program' means a program of 
     services for older individuals, including pharmacy 
     counseling, medicine screening, or patient and health care 
     provider education programs, that--
       ``(1) provides information and counseling on the 
     prescription drug purchases that are currently the most 
     economical, and safe and effective;
       ``(2) provides services to minimize unnecessary or 
     inappropriate use of prescription drugs; and
       ``(3) provides services to minimize adverse events due to 
     unintended prescription drug-to-drug interactions.
       ``(j) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section, 
     $15,000,000 for fiscal year 2001, and such sums as may be 
     necessary for each of fiscal years 2002 through 2005.''.
                                  ____

                                           National Association of


                                       Area Agencies on Aging,

                                 Washington, DC, November 9, 1999.
     Hon. James Jeffords,
     Chair, Committee on Health, Education, Labor & Pensions, U.S. 
         Senate, Washington, DC.
       Dear Senator Jeffords: The National Association of Area 
     Agencies on Aging (N4A) is pleased that you are introducing 
     the Pharmaceutical Aid to Older Americans Act. We believe 
     implementation of this Act could be an ideal interim measure 
     until a Medicare prescription drug benefit is enacted.
       As you know, a fast-growing aging population coupled with 
     escalating pharmaceutical costs makes the lack of 
     prescription drug coverage one of the most pressing problems 
     facing our nation's older Americans. The proposed State 
     Pharmacy Assistance Program would allow states with existing 
     benefit programs to expand services and provide a strong 
     incentive for other states to implement a prescription drug 
     program.
       Your legislative measure also goes far in addressing drug 
     misuse, which is another escalating and dangerous problem. 
     The proposed Medication Management Program would provide 
     states with a financial base to implement a statewide 
     information, education and counseling program that would 
     significantly benefit the health and welfare of older adults.
       While N4A supports your proposal in concept, we have some 
     specific questions about the implementation of these programs 
     and concerns about the roles and responsibilities of Area 
     Agencies on Aging (AAAs) and Title IV Native American 
     grantees. We welcome the opportunity to meet with you in the 
     near future to address these concerns.
       Again, we applaud your efforts and look forward to working 
     with you next session as you further define the proposal and 
     shepherd it through the legislative process.
           Sincerely,
                                                   Janice Jackson,
     Executive Director.
                                  ____

                                           National Association of


                                         State Units on Aging,

                                Washington, DC, November 10, 1999.
     Sean Donohue,
     U.S. Senate, Committee on Health, Education, Labor, and 
         Pensions, Washington, DC.
       Dear Sean: Dan Quirk and I reviewed the draft you sent last 
     week outlining Senator Jeffords' proposed Pharmaceutical Aid 
     to Older Americans Act. Overall, the proposal to provide 
     grants to states to support the development or expansion of 
     pharmaceutical assistance programs and medication management 
     programs is a good one, and using the existing infrastructure 
     of the Older Americans Act makes good sense. The aging 
     network is well suited to develop and administer these types 
     of programs. Your proposal was well developed and thoughtful.
       Both programs would provide valuable assistance to older 
     people who do not have any other prescription drug coverage 
     available. The requirement for a 30-percent state match seems 
     high, but allowing contributions to be ``in-kind'' will help 
     states in that regard. The income eligibility level of 200-
     percent of the federal poverty level may conflict with the 
     eligibility levels set by states in existing programs, though 
     I haven't done an analysis of this yet. As with other 
     programs under the Older Americans Act, if state-funded 
     programs already exist that provide the same services, and 
     eligibility or cost sharing requirements are at odds with the 
     federal program, it requires states essentially to manage two 
     different funding streams for the same program or set of 
     services. As always, giving states the flexibility to blend 
     federal funds with state funds to develop one program would 
     decrease administrative expenses for the states and allow the 
     money saved to be used for direct services.
       NASUA continues to support overall reform of the Medicare 
     program that would provide a comprehensive prescription drug 
     benefit to beneficiaries. In the meantime, state-funded 
     programs that are being developed and which would be 
     supported under this proposal continue to fill in the gaps 
     for people with no coverage for prescription drugs. This 
     proposal would strengthen the existing infrastructure, and 
     perhaps could serve to support a prescription program under 
     Medicare whenever it may be implemented in the future.
       We hope this proposal will generate some further interest 
     in reauthorizing the Older Americans Act as soon as possible, 
     hopefully before the end of the 106th Congress. We were very 
     disappointed that reauthorization was stalled over long-
     standing disagreements over the Title V program.
       If there is anything NASUA can do to support Senator 
     Jeffords proposal and reauthorization, please let me know.
       Thanks for the opportunity to review the Pharmaceutical Aid 
     to Older Americans Act.
           Sincerely,
                                                Kathleen C. Konka,
                                                 Policy Associate.
                                 ______