[Congressional Record Volume 146, Number 99 (Wednesday, July 26, 2000)]
[Senate]
[Pages S7678-S7687]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. DOMENICI (for himself, Mr. Wyden, Mr. Grassley, and Mr. 
        Kerrey):
  S. 2937. A bill to amend title XVIII of the Social Security Act to 
improve access to Medicare+Choice plans through an increase in the 
annual Medicare+Choice capitation rates and for other purposes; to the 
Committee on Finance.

[[Page S7679]]

            the medicare geographic fair payment act of 2000

  Mr. DOMENICI. Mr. President, I rise today with some very 
distinguished colleagues from both sides of the aisle--Senator Wyden, 
who is here, and Senator Grassley, who is not here--who are cosponsors 
of this measure, along with Senator Bob Kerrey of Nebraska.
  Mr. President, let me suggest for Senators' staff who are looking at 
this to look alphabetically. You will find how much is being reimbursed 
in your cities for the Medicare+Choice reimbursement. Look at it, and 
you will see how the HMOs are reimbursed to provide this rather good, 
fair, and competitive coverage to the senior citizens. You will be 
astounded. Many people think New York is covered. They are getting a 
very high rate of reimbursement because they started high. But look at 
some of the cities in New York. You will find that New York has a 
number of cities that are under $450. We reimburse them on the high 
level--as high as $800.
  The bill we are introducing today we are going to call the Medicare 
Geographic Fair Payment Act. Week after week, the Federal Government 
deducts a portion of everyone's paycheck to support the Medicare 
program. After our seniors have retired and begin to take advantage of 
the program they have supported for so many years, I think it is fair 
that they continue to have a choice.
  Right now they have a choice. But the choice is really not for all 
seniors because we made a decision when we put in the Medicare+Choice 
Program, which was really an alternative that seniors could choose. We 
made a decision as to how we would reimburse the provider. That 
decision was made based upon, as I understand from my good friend, 
Senator Wyden--allegedly based on what they needed to get the job done 
to get the program going.
  I don't intend to be critical, but in many instances those who had 
not been frugal, had not been careful about costs, got high 
reimbursements. But if you lived in Senator Wyden's State or New 
Mexico, where they were being extremely frugal in what they charged for 
the services, they got a very low rate.
  It is unfortunate, but for Staten Island the rates of reimbursement 
are $814; $794 for Dade County--I am not complaining; I am stating a 
dollar amount--$702 for New Orleans; and $661 for Los Angeles.
  Senator Wyden, perhaps, could intervene and tell me what it is in 
Portland.
  Mr. WYDEN. $445.
  Mr. DOMENICI. $445; Albuquerque is $430, $15 under Oregon. That is 
all the government will give as reimbursement if you decide to get into 
the HMO business with hospitals and everybody else joining together, if 
you are going to furnish this service. Remember, there are some places 
getting $800-plus.
  I am not here to take away anything from anyone. That is how our 
amendment is different. We are not trying to take the pie, leave it the 
same size, and say those who are getting more money have to cut back. 
Rural areas are even lower and are expected to provide the same level 
of benefits or nearly half the reimbursement.
  There were seniors who had a marvelous Medicare+Choice Program. Why 
was it good? It was good because for a reasonable cost they were 
getting prescription drugs, which you don't get under Medicare, and the 
whole package was new benefits. Some of them got dental insurance, 
which they don't get. Some of them got a number of different things 
they don't get under Medicare, for a premium they could afford.
  These programs are being closed down every day we delay. Thousands of 
seniors are getting notices. They had a good program, but they won't 
have it in January. I want everybody to know if there are going to be 
any entitlement bills getting out of here on anything that is even 
close to Medicare, this is an amendment that will be on there--or 
something better. This amendment says by January 1st of this year, the 
rates are raised. They are these low rates we are talking about. Very 
simply, under this bill, we will change the rates.
  It is pretty easy for everybody to understand. This is not a 
complicated bill. What we are doing is saying for those metropolitan 
areas which are 250,000 or more, the minimum reimbursement will be 
$525. If we can't get that through here to preserve some of these plans 
where seniors are just falling off the log, desperately getting their 
notices, and raising it to $525, then I don't know what is fair around 
here anymore. For all the rural counties, we have raised the minimum to 
$475.
  My friend, Senator Wyden, can talk about his State and about his 
observations. Clearly, he has been asking everybody around here, 
including the Budget Committee, to have hearings on this great 
disparity which he calls penalizing efficiency.
  The truth of the matter is in my home city and in my State of New 
Mexico, what is happening, the HMO companies can no longer stay in 
business. Seniors are getting notified. In fact, we don't have a lot of 
people under this program--15,000 are going to get knocked off the 
program right now, very soon. If you think they are not going to 
meetings, they met with Heather Wilson, one of our representatives, and 
400 people showed up because they read in the newspaper she was holding 
a meeting and they already got their notices: Come January, find a new 
plan. They are asking: Why? The plan is good. It is very good for me. I 
have been paying all my life. Why are you taking this away?

  I ask Senators to take a look. In my case, we will get $34 million in 
additional reimbursements during the first year and $170 out of this 
bill. Incidentally, this bill will cost $700 million the first year. I 
say to the thousands of seniors who may be able to keep their insurance 
and be under this kind of program, that is a pretty good bargain. Over 
5 years, it will cost $3.7 billion.
  It also includes a third provision which I ask Senators to look at. 
It is the product of some very wise thinking by Senator Grassley. It 
should have been separately called the Grassley bill, but it is 
packaged in this as our third title. It says essentially hospitals will 
hereinafter be reimbursed on labor costs--on what the actual cost is, 
not on what the stated cost is. That makes the payment to hospitals go 
up substantially. My small State will go up about $6.5 million over the 
year. I don't know what it would be in a State such as Ohio, but it 
would be rather substantial.
  I have extensive research, with cities alphabetically listed. Just 
look for your city and see what the reimbursement rate is. If it is 
under $525, we will take it to $525. If there are rural counties that 
are not in these lists, call home and ask what some of the counties are 
getting reimbursed. Raising it to $475 will help an awful lot of 
people. Is it enough? I don't know. I want to get something done. My 
friend wants to get something done, as do my two cosponsors. I assume 
in a couple of days or a week we will have a lot more Senators, 
bipartisan, asking to be on this.
  I remind everyone, the total cost of doing a bit of fairness to 
seniors and ending discrimination by region is going to be $700 million 
in the first year and $3.7 over 5. We have been talking about 
astronomical numbers for Medicare reform, prescription drugs. I don't 
know where we will end up. I hope in the heat of this political 6 weeks 
we don't do anything major, because it will be wrong, but clearly we 
have to do something.
  Come January 1, if we don't put money into this reimbursement 
program, I think my friend, who has followed this carefully, will say 
hundreds of thousands of seniors will be denied the option to buy 
coverage which they think is rather good in many cases, including 
prescription drugs, for which they only have to pay $50 extra. They 
can't get that anywhere else. They got extensive coverage of items in 
their health care needs that are not covered anywhere.
  I very much thank the Senators who are cosponsoring, Senators Wyden, 
Grassley, and Bob Kerrey of Nebraska. We will have more.
  Mr. President, I ask unanimous consent that the bill and additional 
material be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                S. 2937

       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 ``Medicare Geographic Fair 
     Payment Act of 2000''.

[[Page S7680]]

     SEC. 2. IMPROVED ACCESS TO MEDICARE+CHOICE PLANS THROUGH AN 
                   INCREASE IN THE ANNUAL MEDICARE+CHOICE 
                   CAPITATION RATES.

       Section 1853(c)(1)(B)(ii) of the Social Security Act (42 
     U.S.C. 1395w-23(c)(1)(B)(ii)) is amended--
       (1) by striking ``(ii) For a succeeding year'' and 
     inserting ``(ii)(I) Subject to subclause (II), for a 
     succeeding year''; and
       (2) by adding at the end the following new subclause:
       ``(II) For 2001 for any area in any Metropolitan 
     Statistical Area with a population of more than 250,000, $525 
     (and for any area outside such an area, $475).''.

     SEC. 3. REQUIREMENT THAT THE ACTUAL PROPORTION OF A 
                   HOSPITAL'S COSTS ATTRIBUTABLE TO WAGES AND 
                   WAGE-RELATED COSTS BE WAGE ADJUSTED.

       (a) In General.--The first sentence of section 
     1886(d)(3)(E) of the Social Security Act (42 U.S.C. 
     1395ww(d)(3)(E)) is amended by striking ``, (as estimated by 
     the Secretary from time to time) of hospitals' costs'' and 
     inserting ``of each hospital's costs (based on the most 
     recent data available to the Secretary with respect to the 
     hospital)''.
       (b) Special Rule for Hospitals Located in Puerto Rico.--
     Section 1886(d)(3)(E) of the Social Security Act (42 U.S.C. 
     1395ww(d)(3)(E)) is amended by adding at the end the 
     following new sentence: ``In the case of a hospital located 
     in Puerto Rico, the first sentence of this subparagraph shall 
     be applied as in effect on the day before the date of 
     enactment of the Geographic Adjustment Fairness Act of 
     2000.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply with respect to discharges occurring on or after 
     January 1, 2001.
                                  ____


   TABLE 1.--AVERAGE MEDICARE+CHOICE PAYMENT RATES PER AGED BENEFICIARY, PER MONTH, PER COUNTY IN METROPOLITAN
                      STATISTICAL AREAS AND PRIMARY METROPOLITAN STATISTICAL AREAS, FY 2000
----------------------------------------------------------------------------------------------------------------
                                                                                                         2000
  Population         Metropolitan statistical area                  State and county name               payment
     \1\                                                                                                 rate
----------------------------------------------------------------------------------------------------------------
           2   Akron, OH PMSA..........................  OH Summit..................................     $569.96
                                                         OH Portage.................................      517.50
           2   Albany-Schenectady-Troy, NY MSA.........  NY Rensselaer..............................      451.95
                                                         NY Albany..................................      426.70
                                                         NY Saratoga................................      426.15
                                                         NY Montgomery..............................      415.97
                                                         NY Schenectady.............................      414.50
                                                         NY Schoharie...............................      408.51
           2   Albuquerque, NM MSA.....................  NM Bernalillo..............................      430.44
                                                         NM Sandoval................................      402.64
                                                         NM Valencia................................      401.61
           2   Allentown-Bethlehem-Easton, PA MSA......  PA Northampton.............................      550.07
                                                         PA Carbon..................................      530.57
                                                         PA Lehigh..................................      520.68
           2   Ann Arbor, MI PMSA......................  MI Washtenaw...............................      557.62
                                                         MI Livingston..............................      535.35
                                                         MI Lenawee.................................      492.06
           2   Appleton-Oshkosh-Neehan, WI MSA.........  WI Calumet.................................      401.61
                                                         WI Outagamie...............................      401.61
                                                         WI Winnebago...............................      401.61
           1   Atlanta, GA MSA.........................  GA Clayton.................................      639.17
                                                         GA Douglas.................................      631.97
                                                         GA Coweta..................................      612.58
                                                         GA Henry...................................      578.76
                                                         GA Newton..................................      572.05
                                                         GA Fulton..................................      569.09
                                                         GA Walton..................................      562.39
                                                         GA Gwinnett................................      560.30
                                                         GA Forsyth.................................      560.28
                                                         GA Paulding................................      552.37
                                                         GA Cobb....................................      552.00
                                                         GA Barrow..................................      549.34
                                                         GA De Kalb.................................      549.32
                                                         GA Carroll.................................      538.55
                                                         GA Cherokee................................      536.79
                                                         GA Pickens.................................      532.62
                                                         GA Fayette.................................      531.71
                                                         GA Rockdale................................      528.77
                                                         GA Spalding................................      491.23
                                                         GA Bartow..................................      457.53
           2   Atlantic-Cape May, NJ PMSA..............  NJ Cape May................................      575.01
                                                         NJ Atlantic................................      564.89
           2   Augusta-Aiken, GA-SC MSA................  GA McDuffie................................      506.13
                                                         GA Columbia................................      480.21
                                                         GA Richmond................................      474.28
                                                         SC Aiken...................................      472.78
                                                         SC Edgefield...............................      401.61
           2   Austin-San Marcos, TX MSA...............  TX Travis..................................      457.95
                                                         TX Caldwell................................      449.43
                                                         TX Bastrop.................................      437.16
                                                         TX Hays....................................      429.58
                                                         TX Williamson..............................      411.43
           2   Bakersfield, CA MSA.....................  CA Kern....................................      549.94
           1   Baltimore, MD PMSA......................  MD Baltimore City..........................      671.43
                                                         MD Anne Arundel............................      596.99
                                                         MD Howard..................................      575.83
                                                         MD Baltimore...............................      573.77
                                                         MD Harford.................................      567.54
                                                         MD Carroll.................................      519.96
                                                         MD Queen Annes.............................      468.85
           2   Baton Rouge, LA MSA.....................  LA Ascension...............................      701.89
                                                         LA Livingston..............................      669.57
                                                         LA E. Baton Rouge..........................      574.48
                                                         LA W. Baton Rouge..........................      569.45
           2   Beaumont-Port Arthur, TX MSA............  TX Jefferson...............................      635.70
                                                         TX Orange..................................      628.21
                                                         TX Hardin..................................      580.77
           1   Bergen-Passaic, NJ PMSA.................  NJ Bergen..................................      559.77
                                                         NJ Passaic.................................      537.18
           2   Biloxi-Gulfport-Pascagoula, MS MSA......  MS Jackson.................................      630.08
                                                         MS Hancock.................................      612.91
                                                         MS Harrison................................      596.61
           2   Binghamton, NY MSA......................  NY Broome..................................      415.83
                                                         NY Tioga...................................      403.34
           2   Birmingham, AL MSA......................  AL Shelby..................................      686.53
                                                         AL Blount..................................      575.59
                                                         AL St. Clair...............................      570.54
                                                         AL Jefferson...............................      557.62
           2   Boise City, ID MSA......................  ID Ada.....................................      401.61
                                                         ID Canyon..................................      401.61
           1   Boston, MA-NH PMSA......................  MA Suffolk.................................      676.30
                                                         MA Norfolk.................................      628.81
                                                         MA Middlesex...............................      604.17
                                                         MA Plymouth................................      566.16
                                                         MA Essex...................................      542.07
                                                         NH Rockingham..............................      479.31
           2   Bridgeport, CT PMSA.....................  CT Fairfield...............................      546.20
           2   Brownsville-Harlingen-San Benito, TX MSA  TX Cameron.................................      439.76
           1   Buffalo-Niagara Falls, NY MSA...........  NY Niagara.................................      458.37

[[Page S7681]]

 
                                                         NY Erie....................................      444.70
           2   Canton-Massillon, OH MSA................  OH Stark...................................      439.09
                                                         OH Carroll.................................      425.34
           2   Charleston, WV MSA......................  WV Kanawha.................................      485.94
                                                         WV Putnam..................................      459.31
           2   Charleston-North Charleston, SC MSA.....  SC Charleston..............................      480.38
                                                         SC Berkeley................................      455.71
                                                         SC Dorchester..............................      429.44
           1   Charlotte-Gastnia-Rockhill, NC-SC MSA...  NC Cabarrus................................      459.94
                                                         NC Gaston..................................      456.16
                                                         NC Mecklenburg.............................      433.27
                                                         NC Union...................................      433.15
                                                         NC Lincoln.................................      431.34
                                                         SC York....................................      430.89
                                                         NC Rowan...................................      429.39
           2   Chattanooga, TN-GA MSA..................  TN Marion..................................      689.49
                                                         GA Walker..................................      533.01
                                                         TN Hamilton................................      526.68
                                                         GA Catoosa.................................      503.89
                                                         GA Dade....................................      497.19
           1   Chicago, IL PMSA........................  IL Cook....................................      593.51
                                                         IL Will....................................      523.73
                                                         IL Grundy..................................      519.32
                                                         IL Du Page.................................      509.42
                                                         IL Lake....................................      507.05
                                                         IL Kane....................................      482.60
                                                         IL Mc Henry................................      466.26
                                                         IL Kendall.................................      444.33
                                                         IL De Kalb.................................      415.25
           1   Cincinnati, OH-KY-IN PMSA...............  OH Hamilton................................      505.97
                                                         OH Clermont................................      505.91
                                                         KY Boone...................................      502.28
                                                         KY Kenton..................................      483.13
                                                         KY Campbell................................      479.25
                                                         OH Brown...................................      473.04
                                                         IN Ohio....................................      471.63
                                                         IN Dearborn................................      469.59
                                                         KY Grant...................................      469.13
                                                         OH Warren..................................      468.11
                                                         KY Gallatin................................      457.05
                                                         KY Pendleton...............................      422.65
           1   Cleveland-Lorain-Elyria, OH PMSA........  OH Cuyahoga................................      575.59
                                                         OH Lorain..................................      522.63
                                                         OH Medina..................................      511.38
                                                         OH Lake....................................      506.72
                                                         OH Ashtabula...............................      503.62
                                                         OH Geauga..................................      484.81
           2   Colorado Spring, CO MSA.................  CO El Paso.................................      472.16
           2   Columbia, SC MSA........................  SC Lexington...............................      429.22
                                                         SC Richland................................      406.65
           2   Columbus, GA-AL MSA.....................  GA Chattahoochee...........................      486.30
                                                         AL Russell.................................      450.62
                                                         GA Muscogee................................      430.84
                                                         GA Harris..................................      401.61
           1   Columbus, OH MSA........................  OH Madison.................................      511.41
                                                         OH Franklin................................      496.33
                                                         OH Fairfield...............................      461.07
                                                         OH Pickaway................................      453.38
                                                         OH Delaware................................      450.01
                                                         OH Licking.................................      434.03
           2   Corpus Christi, TX MSA..................  TX Nueces..................................      515.88
                                                         TX San Patricio............................      501.62
           1   Dallas, TX PMSA.........................  TX Denton..................................      557.79
                                                         TX Collin..................................      547.45
                                                         TX Dallas..................................      545.56
                                                         TX Rockwall................................      511.05
                                                         TX Kaufman.................................      510.50
                                                         TX Henderson...............................      507.26
                                                         TX Ellis...................................      489.89
                                                         TX Hunt....................................      484.39
           2   Davenport-Moline-Rock Island, IA-AL MSA.  IA Scott...................................      420.23
                                                         IL Rock Island.............................      416.48
                                                         IL Henry...................................      401.72
           2   Daytona Beach, FL MSA...................  FL Volusia.................................      481.63
                                                         FL Flagler.................................      432.48
           2   Dayton-Springfield, OH MSA..............  OH Montgomery..............................      497.25
                                                         OH Clark...................................      487.66
                                                         OH Miami...................................      461.54
                                                         OH Greene..................................      438.27
           1   Denver, CO PMSA.........................  CO Denver..................................      534.62
                                                         CO Adams...................................      513.59
                                                         CO Arapahoe................................      484.26
                                                         CO Jefferson...............................      475.87
                                                         CO Douglas.................................      452.51
           2   Des Moines, IA MSA......................  IA Polk....................................      443.74
                                                         IA Warren..................................      405.72
                                                         IA Dallas..................................      401.61
           1   Detroit, MI PMSA........................  MI Wayne...................................      677.77
                                                         MI Oakland.................................      639.26
                                                         MI Macomb..................................      628.03
                                                         MI Monroe..................................      567.21
                                                         MI Lapeer..................................      541.44
                                                         MI St. Clair...............................      513.96
           2   Dutchess County, NY PMSA................  NY Dutchess................................      485.41
           2   El Paso, TX MSA.........................  TX El Paso.................................      481.85
           2   Erie, PA MSA............................  PA Erie....................................      461.47
           2   Eugene-Springfield, OR MSA..............  OR Lane....................................      424.21
           2   Evansville-Henderson, IN-KY MSA.........  KY Henderson...............................      487.38
                                                         IN Posey...................................      455.23
                                                         IN Warrick.................................      441.91
                                                         IN Vanderburgh.............................      439.14
           2   Fayetteville, NC MSA....................  NC Cumberland..............................      420.50
           2   Flint, MI PMSA..........................  MI Genesee.................................      654.33
           1   Fort Lauderdale, FL PMSA................  FL Broward.................................      690.17
           2   Fort Myers-Cape Coral, FL MSA...........  FL Lee.....................................      516.74
           2   Fort Pierce-Port St. Lucie, FL MSA......  FL St. Lucie...............................      582.27
                                                         MI FL Martin...............................      536.70
           2   Fort Wayne, IN MSA......................  IN Adams...................................      405.10
                                                         IN Allen...................................      403.97

[[Page S7682]]

 
                                                         IN Whitley.................................      403.29
                                                         IN De Kalb.................................      401.61
                                                         IN Huntington..............................      401.61
                                                         IN Wells...................................      401.61
           1   Fort Worth-Arlington, TX PMSA...........  TX Tarrant.................................      529.17
                                                         TX Johnson.................................      502.06
                                                         TX Hood....................................      492.86
                                                         TX Parker..................................      488.76
           2   Fresno, CA MSA..........................  CA Madera..................................      473.12
                                                         CA Fresno..................................      438.04
           2   Gary, IN PMSA...........................  IN Lake....................................      564.82
                                                         IN Porter..................................      514.53
           2   Grand Rapids-Muskegon-Holland, MI MSA...  MI Allegan.................................      445.34
                                                         MI Muskegon................................      443.96
                                                         MI Kent....................................      423.54
                                                         MI Ottawa..................................      401.61
           1   Grnsboro-Winston-Salem-HI PT, NC MSA....  NC Davie...................................      461.90
                                                         NC Davidson................................      436.36
                                                         NC Guilford................................      434.67
                                                         NC Forsyth.................................      434.28
                                                         NC Stokes..................................      417.35
                                                         NC Yadkin..................................      415.82
                                                         NC Alamance................................      415.23
                                                         NC Randolph................................      414.23
           2   Greenville-Spartanburg-Anderson, SC MSA.  SC Cherokee................................      466.06
                                                         SC Anderson................................      409.97
                                                         SC Greenville..............................      405.47
                                                         SC Pickens.................................      401.61
                                                         SC Spartanburg.............................      401.61
           2   Hamilton-Middletown, OH PMSA............  OH Butler..................................      480.01
           2   Harrisburg-Lebanon-Carlisle, PA MSA.....  PA Dauphin.................................      511.84
                                                         PA Perry...................................      508.55
                                                         PA Cumberland..............................      454.13
                                                         PA Lebanon.................................      420.60
           1   Hartford, CT MSA........................  CT Tolland.................................      541.27
                                                         CT Hartford................................      525.95
                                                         CT Litchfield..............................      511.80
                                                         CT Windham.................................      505.42
                                                         CT Middlesex...............................      482.64
           2   Hickory-Morganton-Lenoir, NC MSA........  NC Alexander...............................      451.10
                                                         NC Burke...................................      437.35
                                                         NC Caldwell................................      429.74
                                                         NC Catawba.................................      408.16
           2   Honolulu, HI MSA........................  HI Honolulu................................      451.71
           1   Houston, TX PMSA........................  TX Liberty.................................      719.28
                                                         TX Chambers................................      719.23
                                                         TX Montgomery..............................      706.08
                                                         TX Harris..................................      631.59
                                                         TX Waller..................................      527.01
                                                         TX Fort Bend...............................      521.77
           2   Huntington-Ashland, WV-KY-OH MSA........  KY Boyd....................................      499.45
                                                         KY Greenup.................................      487.07
                                                         OH Lawrence................................      483.34
                                                         KY Carter..................................      434.54
                                                         WV Wayne...................................      428.33
                                                         WV Cabell..................................      427.27
           2   Huntsville, AL MSA......................  AL Limestone...............................      464.15
                                                         AL Madison.................................      454.59
           1   Indianapolis, IN MSA....................  IN Marion..................................      506.06
                                                         IN Madison.................................      492.95
                                                         IN Hendricks...............................      487.01
                                                         IN Hamilton................................      478.86
                                                         IN Shelby..................................      477.17
                                                         IN Morgan..................................      470.63
                                                         IN Hancock.................................      469.54
                                                         IN Boone...................................      462.42
                                                         IN Johnson.................................      442.74
           2   Jackson, MS MSA.........................  MS Madison.................................      446.48
                                                         MS Rankin..................................      445.23
                                                         MS Hinds...................................      442.96
           2   Jacksonville, FL MSA....................  FL Duval...................................      558.61
                                                         FL Nassau..................................      534.03
                                                         FL St. Johns...............................      503.27
                                                         FL Clay....................................      494.78
           2   Jersey City, NJ PMSA....................  NJ Hudson..................................      572.80
           2   Johnson City-Kingsport-Bristol, TN-VA     TN Unicol..................................      486.65
                MSA.
                                                         TN Hawkins.................................      475.81
                                                         VA Scott...................................      475.48
                                                         TN Washington..............................      460.53
                                                         TN Sullivan................................      451.21
                                                         VA Bristol City............................      445.38
                                                         TN Carter..................................      419.53
                                                         VA Washington..............................      401.61
           2   Kalamazoo-Battle Creek, MI MSA..........  MI Calhoun.................................      497.87
                                                         MI Van Buren...............................      468.21
                                                         MI Kalamazoo...............................      457.00
           1   Kansas City, MO-KS MSA..................  KS Wyandotte...............................      539.21
                                                         MO Jackson.................................      535.72
                                                         MO Ray.....................................      521.98
                                                         MO Clay....................................      519.84
                                                         KS Johnson.................................      506.41
                                                         KS Leavenworth.............................      503.12
                                                         KS Miami...................................      494.24
                                                         MO Platte..................................      493.90
                                                         MO Lafayette...............................      486.11
                                                         MO Cass....................................      479.90
                                                         MO Clinton.................................      428.27
           2   Killeen-Temple, TX MSA..................  TX Coryell.................................      415.61
                                                         TX Bell....................................      407.33
           2   Knoxville, TN MSA.......................  TN Loudon..................................      506.47
                                                         TN Knox....................................      484.18
                                                         TN Anderson................................      460.95
                                                         TN Union...................................      453.63
                                                         TN Blount..................................      446.59
                                                         TN Sevier..................................      439.09
           2   Lafayette, LA MSA.......................  LA Lafayette...............................      512.01
                                                         LA St. Landry..............................      492.02
                                                         LA Acadia..................................      463.22
                                                         LA St. Martin..............................      460.29

[[Page S7683]]

 
           2   Lakeland-Winter Haven, FL MSA...........  FL Polk....................................      437.74
           2   Lancaster, PA MSA.......................  PA Lancaster...............................      416.00
           2   Lansing-East Lansing, MI MSA............  MI Ingham..................................      519.79
                                                         MI Eaton...................................      495.86
                                                         MI Clinton.................................      473.56
                                                         ...........................................  ..........
           2   Las Vegas, NV-AZ MSA....................  NV Clark...................................      554.90
                                                         AZ Mohave..................................      522.27
                                                         NV Nye.....................................      513.76
           2   Lexington, KY MSA.......................  KY Madison.................................      459.32
                                                         KY Bourdon.................................      445.13
                                                         KY Scott...................................      417.38
                                                         KY Fayette.................................      413.37
                                                         KY Clark...................................      413.34
                                                         KY Jessamine...............................      407.65
                                                         KY Woodford................................      401.61
           2   Little Rock-N. Little Rock, AR MSA......  AR Pulaski.................................      498.44
                                                         AR Saline..................................      488.13
                                                         AR Lonoke..................................      472.87
                                                         AR Faulkner................................      462.94
           1   Los Angeles-Long Beach, CA PMSA.........  CA Los Angeles.............................      660.65
           2   Louisville, KY-IN MSA...................  KY Bullitt.................................      546.27
                                                         KY Oldham..................................      509.91
                                                         IN Clark...................................      506.02
                                                         KY Jefferson...............................      499.44
                                                         IN Floyd...................................      495.70
                                                         IN Scott...................................      476.68
                                                         IN Harrison................................      454.42
           2   Macon, GA MSA...........................  GA Houston.................................      548.86
                                                         GA Bibb....................................      518.70
                                                         GA Jones...................................      488.31
                                                         GA Peach...................................      470.78
                                                         GA Twiggs..................................      461.55
           2   Madison, WI MSA.........................  WI Dane....................................      421.05
           2   McAllen-Edinburg-Mission, TX MSA........  TX Hidalgo.................................      437.02
           2   Melbourne-Titusvlle-Palm Bay, FL MSA....  FL Brevard.................................      527.54
           1   Memphis, TN-AR-MS MSA...................  TN Shelby..................................      491.67
                                                         MS De Soto.................................      490.50
                                                         TN Tipton..................................      479.39
                                                         TN Fayette.................................      476.86
                                                         AR Crittenden..............................      472.60
           1   Miami, FL PMSA..........................  FL Dade....................................      794.02
           1   Middlesex-Somerset-Hunterdon, NJ PMSA...  NJ Middlesex...............................      558.12
                                                         NJ Hunterdon...............................      516.24
                                                         NJ Somerset................................      491.08
           1   Milwaukee-Waukesha, WI PMSA.............  WI Milwaukee...............................      470.57
                                                         WI Waukesha................................      435.85
                                                         WI Ozaukee.................................      424.93
                                                         WI Washington..............................      411.74
           1   Minneapolis-St. Paul, MN-WI MSA.........  MN Ramsey..................................      470.65
                                                         MN Hennepin................................      457.66
                                                         MN Anoka...................................      453.31
                                                         MN Chisago.................................      443.66
                                                         MN Dakota..................................      438.75
                                                         MN Washington..............................      427.94
                                                         MN Carver..................................      420.00
                                                         MN Isanti..................................      416.79
                                                         MN Wright..................................      405.57
                                                         MN Scott...................................      401.61
                                                         MN Sherburne...............................      401.61
                                                         WI Pierce..................................      401.61
                                                         WI St. Croix...............................      401.61
           2   Mobile, AL MSA..........................  AL Mobile..................................      561.50
                                                         AL Baldwin.................................      485.76
           2   Modesto, CA MSA.........................  CA Stanislaus..............................      509.26
           2   Monmouth-Ocean, NJ PMSA.................  NJ Monmouth................................      542.02
                                                         NJ Ocean...................................      534.05
           2   Montgomery, AL MSA......................  AL Montgomery..............................      483.38
                                                         AL Autauga.................................      481.43
                                                         AL Elmore..................................      480.94
           2   Nashville, TN MSA.......................  TN Wilson..................................      630.43
                                                         TN Davidson................................      547.87
                                                         TN Williamson..............................      538.17
                                                         TN Cheatham................................      537.65
                                                         TN Sumner..................................      529.86
                                                         TN Robertson...............................      527.44
                                                         TN Rutherford..............................      494.76
                                                         TN Dickson.................................      491.06
           1   Nassau-Suffolk, NY PMSA.................  NY Nassau..................................      622.51
                                                         NY Suffolk.................................      592.30
           2   New Haven-Meriden, CT PMSA..............  CT New Haven...............................      528.19
           2   New London-Norwich, CT-RI MSA...........  CT New London..............................      492.51
           1   New Orleans, LA MSA.....................  LA Plaquemines.............................      772.26
                                                         LA St. Bernard.............................      763.90
                                                         LA St. Charles.............................      675.95
                                                         LA Jefferson...............................      674.13
                                                         LA St. Tammany.............................      669.91
                                                         LA St. John Baptist........................      668.62
                                                         LA Orleans.................................      651.27
                                                         LA St. James...............................      589.96
           1   New York, NY PMSA.......................  NY Richmond................................      814.32
                                                         NY Bronx...................................      772.81
                                                         NY New York................................      756.77
                                                         NY Kings...................................      748.55
                                                         NY Queens..................................      699.17
                                                         NY Rockland................................      630.25
                                                         NY Putnam..................................      628.30
                                                         NY Westchester.............................      608.47
           1   Newark, NJ PMSA.........................  NJ Essex...................................      578.68
                                                         NJ Warren..................................      568.99
                                                         NJ Union...................................      545.04
                                                         NJ Morris..................................      525.78
                                                         NJ Sussex..................................      511.04
           2   Newburgh, NY-PA PMSA....................  NY Orange..................................      524.02
                                                         PA Pike....................................      500.29
           1   Norfolk-Va Beach-Newport News, VA-NC MSA  VA Chesapeake City.........................      484.88
                                                         VA Williamsburg City.......................      479.54
                                                         VA Suffolk City............................      476.74
                                                         VA Norfolk City............................      470.52

[[Page S7684]]

 
                                                         VA Portsmouth City.........................      470.52
                                                         VA Virginia Beach City.....................      463.75
                                                         VA Isle Of Wight...........................      461.15
                                                         VA Poquoson................................      458.58
                                                         NC Currituck...............................      455.80
                                                         VA James City..............................      446.91
                                                         VA Hampton City............................      443.76
                                                         VA York....................................      430.15
                                                         VA Newport News City.......................      423.90
                                                         VA Gloucester..............................      414.28
                                                         VA Mathews.................................      405.39
           1   Oakland, CA PMSA........................  CA Contra Costa............................      629.07
                                                         CA Alameda.................................      617.69
           2   Oklahoma City, OK MSA...................  OK Oklahoma................................      472.85
                                                         OK Cleveland...............................      469.40
                                                         OK Canadian................................      461.36
                                                         OK Mcclain.................................      453.93
                                                         OK Logan...................................      431.02
                                                         OK Pottawatomie............................      401.61
           2   Omaha, NE-IA MSA........................  NE Douglas.................................      471.42
                                                         IA Pottawattamie...........................      458.62
                                                         NE Sarpy...................................      428.48
                                                         NE Cass....................................      420.07
                                                         NE Washington..............................      411.08
           1   Orange County, CA PMSA..................  CA Orange..................................      609.63
           1   Orlando, FL MSA.........................  FL Osceola.................................      595.95
                                                         FL Orange..................................      553.31
                                                         FL Seminole................................      536.05
                                                         FL Lake....................................      489.82
           2   Pensacola, FL MSA.......................  FL Santa Rosa..............................      503.69
                                                         FL Escambia................................      502.10
           2   Peoria-Pekin, IL MSA....................  IL Tazewell................................      421.61
                                                         IL Peoria..................................      414.60
                                                         IL Woodford................................      401.61
           1   Philadelphia, PA-NJ PMSA................  PA Philadelphia............................      747.35
                                                         PA Delaware................................      626.24
                                                         PA Bucks...................................      610.87
                                                         NJ Camden..................................      593.47
                                                         NJ Gloucester..............................      591.58
                                                         NJ Salem...................................      584.62
                                                         PA Chester.................................      553.66
                                                         NJ Burlington..............................      552.60
                                                         PA Montgomery..............................      548.59
           1   Phoenix-Mesa, AZ MSA....................  AZ Pinal...................................      551.74
                                                         AZ Maricopa................................      524.36
           1   Pittsburgh, PA MSA......................  PA Allegheny...............................      632.02
                                                         PA Fayette.................................      619.07
                                                         PA Westmoreland............................      594.10
                                                         PA Washington..............................      590.58
                                                         PA Beaver..................................      544.52
                                                         PA Butler..................................      542.33
           1   Portland-Vancouver, OR-WA PMSA..........  OR Washington..............................      460.95
                                                         OR Columbia................................      452.07
                                                         OR Multnomah...............................      445.25
                                                         OR Clackamas...............................      438.74
                                                         WA Clark...................................      433.86
                                                         OR Yamhill.................................      425.86
           1   Providence-Fall River-Warwck, RI-MA MSA.  RI Kent....................................      519.29
                                                         RI Washington..............................      512.79
                                                         MA Bristol.................................      501.50
                                                         RI Providence..............................      498.70
                                                         RI Newport.................................      484.96
                                                         RI Bristol.................................      473.50
           2   Provo-Orem, UT MSA......................  UT Utah....................................      427.96
           2   Raleigh-Durham-Chapel Hill, NC MSA......  NC Orange..................................      480.56
                                                         NC Johnson.................................      475.66
                                                         NC Wake....................................      464.96
                                                         NC Franklin................................      452.16
                                                         NC Durham..................................      441.05
                                                         NC Chatham.................................      437.33
           2   Reading, PA MSA.........................  PA Berks...................................      452.56
           2   Reno, NV MSA............................  NV Washoe..................................      492.94
           2   Richmond-Petersburg, VA MSA.............  NA New Kent................................      522.64
                                                         VA Charles City............................      508.84
                                                         VA Hanover.................................      490.45
                                                         VA Richmond City...........................      488.94
                                                         VA Prince George...........................      483.13
                                                         VA Petersburg City.........................      479.97
                                                         VA Dinwiddlie..............................      477.64
                                                         VA Hopewell City...........................      475.67
                                                         VA Powhatan................................      467.99
                                                         VA Chesterfield............................      463.81
                                                         VA Henrico.................................      463.29
                                                         VA Colonial Heights City...................      449.40
                                                         VA Goochland...............................      445.19
           1   Riverside-San Bernardino, CA PMSA.......  CA San Bernardino..........................      565.55
                                                         CA Riverside...............................      553.64
           1   Rochester, NY MSA.......................  NY Monroe..................................      449.04
                                                         NY Genesee.................................      435.80
                                                         NY Livingston..............................      429.12
                                                         NY Orleans.................................      417.78
                                                         NY Wayne...................................      415.82
                                                         NY Ontario.................................      405.78
           2   Rockford, IL MSA........................  IL Boone...................................      406.73
                                                         IL Ogle....................................      401.61
                                                         IL Winnebago...............................      401.61
           1   Sacramento, CA PMSA.....................  CA Sacramento..............................      545.65
                                                         CA Placer..................................      527.72
                                                         CA El Dorado...............................      515.35
           2   Saginaw-Bay City-Midland, MI USA........  MI Saginaw.................................      488.38
                                                         MI Bay.....................................      488.15
                                                         MI Midland.................................      468.12
           2   Salem, OR PMSA..........................  OR Marion..................................      401.61
                                                         OR Polk....................................      401.61
           2   Salinas, CA MSA.........................  CA Monterey................................      542.83
           1   Salt Lake City-Ogden, UT MSA............  UT Salt Lake...............................      418.00
                                                         UT Davis...................................      415.88
                                                         UT Weber...................................      407.27
           1   San Antonio, TX MSA.....................  TX Bear....................................      512.11

[[Page S7685]]

 
                                                         TX Wilson..................................      432.60
                                                         TX Guadalupe...............................      417.56
                                                         TX Comal...................................      415.47
           1   San Diego, CA MSA.......................  CA San Diego...............................      563.76
           1   San Francisco, CA PMSA..................  CA San Francisco...........................      571.60
                                                         CA Marin...................................      563.18
                                                         CA San Mateo...............................      518.73
           1   San Joae, CA PMSA.......................  CA Santa Clara.............................      543.23
           2   Santa Rosa, CA PMSA.....................  CA Sonoma..................................      531.59
           2   Sarasota-Bradenton, FL MSA..............  FL Sarasota................................      500.10
                                                         FL Manatee.................................      476.27
           2   Savannah, GA MSA........................  GA Bryan...................................      607.83
                                                         GA Effingham...............................      551.72
                                                         GA Chatam..................................      534.76
           2   Scranton-Wilkes-Barre-Hazleton, PA MSA..  PA Lackawanna..............................      529.65
                                                         PA Luzerne.................................      511.96
                                                         PA Wyoming.................................      504.41
                                                         PA Columbia................................      463.56
           1   Seattle-Bellevue-Everett, WA PMSA.......  WA King....................................      482.58
                                                         WA Snohomish...............................      465.44
                                                         WA Island..................................      429.61
           2   Shreveport-Bossier City, LA MSA.........  LA Webster.................................      498.03
                                                         LA Bossier.................................      489.39
                                                         LA Caddo...................................      485.94
           2   Spokane, WA MSA.........................  WA Spokane.................................      467.75
           2   Springfield, MA MSA.....................  MA Hampdon.................................      479.61
                                                         MA Franklin................................      467.86
                                                         MA Hampshire...............................      462.21
           2   Springfield, MO MSA.....................  MO Greene..................................      420.15
                                                         MO Christian...............................      414.31
                                                         MO Webster.................................      410.20
           1   St. Louis, MO-IL MSA....................  MO St. Louis City..........................      575.17
                                                         MO Jefferson...............................      527.45
                                                         MO Warren..................................      527.07
                                                         MO Lincoln.................................      524.23
                                                         MO St. Charles.............................      501.12
                                                         MO St. Louis...............................      500.86
                                                         IL St. Clair...............................      500.06
                                                         IL Clinton.................................      499.07
                                                         IL Madison.................................      482.50
                                                         MO Franklin................................      440.86
                                                         MO Crawford................................      436.38
                                                         IL Jersey..................................      435.63
                                                         IL Monroe..................................      425.58
           2   Santa-Barbara-Santa Maria-Lompoc, CA MSA  CA Santa Barbara...........................      455.77
           2   Stockton-Lodi, CA MSA...................  CA San Joaquin.............................      495.62
           2   Syracuse, NY MSA........................  NY Cayuga..................................      434.08
                                                         NY Oswego..................................      418.50
                                                         NY Onondaga................................     417.97]
                                                         NY Madison.................................      410.00
           2   Tacoma, WA PMSA.........................  WA Pierce..................................      456.83
           2   Tampa-St. Petersburg-Clearwater, FL MSA.  FL Pasco...................................      572.46
                                                         FL Hernando................................      542.69
                                                         FL Pinellas................................      533.00
                                                         FL Hillsborough............................      521.34
           2   Toledo, OH MSA..........................  OH Lucas...................................      605.01
                                                         OH Wood....................................      498.46
                                                         OH Fulton..................................      476.56
           2   Trenton, NJ PMSA........................  NJ Mercer..................................      590.38
           2   Tucson, AZ MSA..........................  AZ Pima....................................      499.04
           2   Tulsa, OK MSA...........................  OK Wagoner.................................      518.50
                                                         OK Rogers..................................      484.50
                                                         OK Creek...................................      467.80
                                                         OK Tulsa...................................      467.54
                                                         OK Osage...................................      445.45
           2   Utica-Rome, NY MSA......................  NY Oneida..................................      405.03
                                                         NY Herkimer................................      401.61
           2   Vallejo-Fairfield-NAPA, CA PMSA.........  CA Napa....................................      596.07
                                                         CA Solano..................................      552.60
           2   Ventura, CA PMSA........................  CA Ventura.................................      545.69
           2   Visalia-Tulare-Porterville, CA MSA......  CA Tulare..................................      452.57
           1   Washington, DC-MD-VA-WV PMSA............  MD Prince Georges..........................      639.21
                                                         DC The District............................      619.89
                                                         MD Charles.................................      599.55
                                                         MD Montgomery..............................      535.62
                                                         MD Calvert.................................      517.03
                                                         VA Alexandria City.........................      501.57
                                                         VA Arlington...............................      501.02
                                                         VA Falls Church City.......................      497.85
                                                         VA Manassas Park City......................      497.04
                                                         VA Prince William..........................      493.46
                                                         VA Stafford................................      489.44
                                                         VA Fredericksburg City.....................      488.13
                                                         VA Spotsylvania............................      484.82
                                                         MD Frederick...............................      477.87
                                                         VA Fairfax City............................      473.73
                                                         VA King George.............................      471.99
                                                         VA Loudoun.................................      468.81
                                                         VA Fauquier................................      462.06
                                                         VA Fairfax.................................      460.45
                                                         VA Culpeper................................      450.19
                                                         VA Manassas City...........................      445.63
                                                         VA Warren..................................      442.67
                                                         WV Berkeley................................      438.86
                                                         WV Jefferson...............................      426.32
                                                         VA Clarke..................................      409.66
           2   West Palm Beach-Boca Raton, FL MSA......  FL Palm Beach..............................      600.62
           2   Wichita, KS MSA.........................  KS Sedgwick................................      480.50
                                                         KS Butler..................................      427.72
                                                         KS Harvey..................................      403.67
           2   Wilmington-Newark, DE-MD PMSA...........  MD Cecil...................................      548.76
                                                         DE New Castle..............................      547.20
           2   Worcester, MA-CT PMSA...................  MA Worcester...............................      559.24
           2   York, PA MSA............................  PA York....................................      421.90
           2   Youngstown-Warren, OH MSA...............  OH Trumbull................................      565.28
                                                         OH Mahoning................................      508.37
                                                         OH Columbiana..............................      478.90
----------------------------------------------------------------------------------------------------------------
\1\ 1=greater than 1 million; 2=250,000 to 1 million.
 
Source: Table prepared by the Congressional Research Service using data from the Health Care Financing
  Administration.
Note: A Metropolitan Statististical Area is a city with 50,000 or more enhabitants, or a Census Bureau-defined
  urban area of at least 50,000 inhabitants, and a total metropolitan population of at least 100,000 (75,000 in
  New England). This study specifically examines MSAs that contain 250,000 or more enhabitants. If an MSA has a
  population of over 1 million and the population can be separated into component parts, then the primary
  component part is desginated the Primary Metropolitan Statistical Area (PMSA). For more information see,
  [http://www.census.gov/population/www/estimates/aboutmetro.html].


[[Page S7686]]

  Mr. WYDEN. Mr. President, before he leaves the floor, I thank the 
chairman of the Budget Committee for the opportunity to be involved in 
this issue. I think the chairman has said it very well. In effect, what 
he has done is make the case for why the bill we are proposing is 
absolutely essential to modernize the Medicare program.
  If there is one principle that Medicare is going to have to stand for 
in the 21st century, it is that we must change this system which now 
literally rewards waste and penalizes frugality.
  Medicare has an HMO reimbursement system today which is, even by 
beltway standards, perverse. It sends the message if you are really 
inefficient, if you have not taken the steps that Colorado and Oregon 
and other States have taken, don't worry about it, don't go out and 
make the tough choices about introducing competition to your community. 
The Federal Government will just keep sending you big checks.
  I think it is absolutely key, especially given the fact that close to 
a million seniors are going to lose their HMO coverage this year--close 
to a million seniors will lose their coverage this year--that we pass 
this bipartisan legislation. I think the chairman is right. I think by 
the end of the next couple of days, we will have many other colleagues 
from both political parties here. I see my friend, Senator Smith of 
Oregon, has come into the Chamber. He and I have worked on this issue 
since he has come to the Senate as part of our bipartisan agenda for 
Oregon. I am going to talk for a few minutes to try to elaborate on 
some of the themes Chairman Domenici has so eloquently addressed.
  As we have seen in Oregon and New Mexico and so many other States, 
the present HMO reimbursement system is literally driving HMO plans out 
of the program and leaving seniors across this country petrified about 
their future health care in their communities. What senior after senior 
asks at this point is how can it be that since they pay the same amount 
for hospitalization and outpatient services, if they live in Pendleton 
or they live in Portland, they pay the same amount for outpatient and 
hospitalization services as seniors in other parts of the country yet 
the Federal Government does not send an equal payment to folks in 
Pendleton and Portland? As Chairman Domenici has very specifically and 
eloquently described, they send dramatically different payments to 
communities across this country. So you can have communities, for 
example, on the east coast, that literally get twice the reimbursement 
of communities in Oregon and New Mexico.
  We hear about it very bluntly from our constituents. You can have a 
senior in Pendleton or Coos Bay call up their cousin in one of the 
cities back East and ask their cousin about Medicare, how it is going.
  The senior back East says: You know, it goes great. I get 
prescription drugs for only a few dollars a month. I also get dental 
coverage. I get free hearing aids. How is it going for you there in 
Coos Bay or Pendleton or Albuquerque, NM? How is Medicare going for 
you?
  That senior in Albuquerque or Pendleton or Portland wants to throw 
the telephone through the living room window because they don't get 
that prescription drug coverage, hearing aids, or dental coverage 
because the reimbursement is as low as Chairman Domenici has described.
  The Congress was supposed to have begun, several years ago, a 
bipartisan effort to change this. The system was called a blended rate. 
In effect, over the next few years, we would move to a national system, 
so instead of driving some of these high-cost areas down precipitously, 
we would move low-cost areas up over the next few years. Unfortunately, 
that system has been delayed. It has been delayed, in my view, in a 
fashion that has made for many plans saying they can no longer afford 
to stay in business; certainly no longer afford to offer some of those 
benefits such as prescription drugs, which are so important to seniors.

  That is why Chairman Domenici and I and Senator Grassley and Senator 
Kerrey and I know many of our colleagues are going to join in a 
bipartisan effort, first, to establish a minimum payment floor for 
urban counties; second, to boost the rural counties where, again, these 
programs have barely been able to survive as a result of low 
reimbursement rates; and, third, to address the concerns with respect 
to wages that Senator Grassley has so eloquently described. But I am of 
the view that if this Congress is to modernize the Medicare program, 
the essence of such a modernization effort is to create more options 
and more choices. That will not be possible if you perpetuate an HMO 
reimbursement system that day after day after day penalizes frugality 
and rewards waste.
  For those who really want to get into the details of this subject, 
the system is known as the AAPCC, the average adjusted per capita cost. 
The way it has worked, the HMOs are reimbursed by the Federal 
Government through a system that historically has looked at average 
local costs of various procedures, such as a heart bypass in Pendleton 
or cataract operation in Portland--and then you calculate a formula for 
reimbursing these HMOs, using a percentage of the fee-for-service costs 
for health care in the area.
  But at the end of the day, the message is, if you are wasteful, don't 
worry about it. If you are inefficient, the Federal Government is going 
to say maybe that is not ideal, but we will just send you a check to 
reflect the fact that you are not taking steps to hold down your costs 
and we are not going to give you any consequences as a result.
  That makes no sense to Senator Domenici and me and our cosponsors. I 
know it makes no sense to the Presiding Officer because he and I have 
talked about this innumerable times. We tried to boost reimbursement 
rates for the people of Oregon. We have to change the Medicare program 
to eliminate the discrimination against communities that control costs 
while offering good quality care.
  Our bipartisan legislation is not just a one-time infusion of money. 
We structured it so that money becomes part of a base for future 
increases, which in my view helps to jump-start what Congress intended 
several years ago by passing legislation to promote a nationwide 
blended rate.
  We all understand that at present, as we look to the last days of the 
session, with the budget surplus, it is going to be possible to use a 
portion of that surplus, after we have helped pay down the debt, after 
hopefully there is a targeted tax cut; at that point, we will have some 
dollars to take the steps to better meet the health care needs of older 
people and also jump start the modernization of the Medicare program.
  Our legislation, I hope, will be part of that effort. I think 
Chairman Domenici and Senator Grassley, among our cosponsors, are very 
likely to be in the room at the end of the day when that legislation is 
being offered. I and others are going to do our best to support those 
efforts in the Budget Committee. I know the Presiding Officer and I 
have used every opportunity to raise these issues, and we are going to 
continue to do so.
  Our State has been a pioneer in the health care reform area. We are 
proud of the fact that we are the first State in the country to have 
made tough choices about health care priorities through the Oregon 
health plan. We are proud of the fact that we have been able to 
introduce more choices and more competition to the health care system 
and, as a result, seniors in our State are able to get more for their 
health care dollar.

[[Page S7687]]

  It is not right for older people in Oregon, New Mexico, Iowa, and in 
other States where they have done the heavy lifting and they have taken 
steps to hold down their costs, to be discriminated against by the 
Federal Government.
  This bipartisan legislation, in my view, is going to help keep HMOs 
that are currently in the program in the program, and it will begin the 
process of bringing back to Medicare some of those we have lost because 
they have been discriminated against in the past with respect to 
reimbursement and they could not keep their doors open.
  We will be talking about this legislation frequently in the last few 
days of this Congress and in the fall, and I believe passing this 
legislation, as we look at that final budget bill that is sure to be 
part of our fall debates, that this is one of the best ways we can 
target dollars that need to be spent carefully so as to maximize the 
values of what we are getting in health care for older people.
  Mr. President, I yield the floor.
  Mr. VOINOVICH. Mr. President, I could not help but hear the words of 
Senator Wyden and Senator Domenici about the terrible situation we have 
across this country today in regard to HMOs dropping senior citizens 
off the Medicare Plus Choice Program.
  While I was Governor of the State of Ohio, we had several instances 
where people were thrown off the rolls of their HMO and forced to be 
without any kind of supplemental insurance or prescription drug 
benefits. It is a growing epidemic today in the United States of 
America. I want to go on record in support of the legislation of 
Senator Wyden and Senator Domenici. In fact, earlier today I asked 
Senator Domenici if I could be a cosponsor of this legislation.
  It is important to point out that some of the on-budget surplus that 
we now have in the year 2000 and the projected $102 billion in 2001 is 
generated by the fact that projected Medicare costs are coming in far 
below what they anticipated because of the formula that was adopted in 
1997. It seems to me we ought to look at the situation as it really is, 
increase the reimbursement to those HMOs so individuals can stay in 
those programs, and so they don't have to buy Medigap insurance to 
cover out-of-pocket expenses and prescription drugs.
  It seems to me it should be our responsibility to make sure those who 
are now covered remain covered and not be thrown out on the street. I 
have read so often: Don't worry about those people, somebody else will 
pick them up, or they can go to fee for service. When they go to fee 
for service, they don't get their 20 percent out-of-pocket paid for, 
nor does Medicare pick up prescription drugs.
  It is time for this Congress to step in and change the system, 
increase the reimbursement, keep those individuals who are on Medicare 
Plus Choice Programs so they can maintain coverage for out-of-pocket 
expenses and maintain the prescription drug coverage they have.
  Mr. GRASSLEY. Mr. President, I rise to note the introduction of the 
Medicare Geographic Fair Payment Act of 2000. I'm very pleased to join 
Senators Domenici, Wyden, and Kerrey in this effort. While we share the 
problem of low payment rates, Iowa and Nebraska are in a different 
situation than New Mexico and Oregon. Those two states are concerned 
about Medicare + Choice plans leaving, but for the most part we in Iowa 
are still waiting for plans to arrive. There are a number of things 
that have to fall into place for Medicare + Choice to become a reality 
in Iowa, but one of them is increasing payment rates. I want to make 
sure that if Congress provides any relief in Medicare + Choice this 
year, that low-cost areas are not forgotten. We need to make Medicare + 
Choice a truly national program.
  There are two simple Medicare + Choice payment provisions in the 
bill. It would raise the minimum payment floor for all counties from 
the current $415 to $475 in 2001. This would primarily benefit rural 
and small urban areas, including the vast majority of Iowa. Secondly, 
it would establish a new minimum payment floor of $525 for all counties 
in Metropolitan Statistical Areas (MSAs) with populations exceeding 
250,000. In Iowa, this would mean a substantial incentive for plans to 
enter the Des Moines and Quad Cities areas.
  As I've said so often throughout the five-plus years that I've been 
working on this issue, people in low-cost states like Iowa pay the same 
payroll taxes as those in high-cost areas. So it's a matter of simple 
fairness and equity that all seniors have access to the choices in 
Medicare, wherever they live. The problem with Medicare + Choice has 
been that payment rates are based on fee-for-service payment rates in 
the same county; thus, cost-effective regions like ours are punished. 
This makes no sense. We took our first step toward breaking that 
unfortunate link in 1997, and I have high hopes that we will take 
another big step with this bill in 2000.
  We in low-cost regions have to keep the fight for equity going on two 
fronts: Medicare + Choice payment, and traditional Medicare payment. 
The latter is harder for Congress to change, because we have to 
identify inequities in the various Medicare payment policies and fix 
them one by one. I thank my colleagues for including in this bill my 
earlier bill on the hospital wage index, which is one of those flaws in 
fee-for-service Medicare that cries out to be fixed.
  I look forward to the Finance Committee's Medicare discussions this 
fall; this is the kind of legislation that merits serious consideration 
there.
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