[Congressional Record Volume 146, Number 111 (Tuesday, September 19, 2000)]
[Senate]
[Pages S8748-S8750]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




           PRESCRIPTION DRUGS: IN THE BIG TENT OR A SIDE SHOW

  Mr. GRAHAM. Mr. President, this is the third in a series of five 
statements I am making on the issue of providing a prescription drug 
benefit for senior Americans. This continues the discussion I began 
last Thursday on the subject of how to modernize the Medicare program 
into one which will meet the needs of 21st century seniors in America.
  Last week, we discussed the need to fundamentally reform the Medicare 
program by shifting its focus from treating acute illness to promoting 
and maintaining wellness, essentially converting the Medicare program 
from one which has an orientation towards dealing with the disease or 
the results of an accident after they have occurred--a sickness 
system--to one that attempts to maintain the highest quality of 
health--a wellness system.
  We discussed the fact that access to affordable prescription 
medications is crucial to the success of a health care system based on 
keeping seniors healthy, well, and active. And virtually every modality 
that is established to maintain the highest state of good health for 
seniors involves access to prescription drugs.
  Additionally, we discussed that, in the long run, providing seniors 
with access to those components of an effective wellness system, such 
as preventive screening, medical procedures, and appropriate 
prescription drug therapies, can yield significant savings for the 
Medicare program and thus for the American taxpayer as well as 
providing the enormous benefits to the senior of good health and the 
active lifestyle that that will allow.
  Let's look at the case of osteoporosis. Osteoporosis is a disease 
characterized by low bone mass, deterioration of bone tissue, leading 
to bone fragility and increased susceptibility to fractures, 
particularly of the hip, spine, and wrist.
  Osteoporosis is a major public health threat for 28 million 
Americans. Eighty percent of those 28 million Americans are women. 
Osteoporosis is responsible for more than 1.5 million fractures 
annually in the United States. Included in this 1.5 million are 300,000 
hip fractures, 700,000 vertebra fractures, 250,000 wrist fractures, and 
more than 300,000 fractures in other parts of the anatomy. Estimated 
national direct expenditures, including those for hospitals and nursing 
homes, for osteoporosis and related fractures is $14 billion a year.
  The National Academy of Sciences and the National Institutes of 
Health agree that osteoporosis is highly preventable. A combination of 
a healthy lifestyle, with no smoking or excessive alcohol use, and bone 
density testing and medication and hormone therapies can keep men and 
women prone to this disease well and free of the debilitating, 
sometimes fatal, effects of fractures. Seniors and near seniors must 
have access to screening, counseling, and appropriate medication to 
keep this ``silent killer'' at bay.
  One of the most common prescriptions for osteoporosis prevention is a 
treatment referred to as Fosamax. The annual cost of Fosamax is 
approximately $750. Contrast that with a hip replacement where the 
surgery and followup therapy will cost the Medicare program and 
taxpayers over $8,000.
  It makes both programmatic and economic sense that these preventive 
interventions be included under the big tent of Medicare. They should 
be treated as all of the other benefits that 98 percent of those 
eligible for Medicare enjoy today.
  Let me restate the fact that Part B of Medicare--that is the part 
that, among other things, covers physicians and outpatient services--is 
a voluntary program that seniors must elect to get the benefits and to 
pay the monthly premiums for participation in Part B. How many seniors 
in America who are eligible for that component of Medicare in fact make 
that election and pay that monthly fee to get those benefits? The 
answer: 98 percent of eligible seniors voluntarily elect to participate 
in Part B of Medicare.
  Seniors trust and rely on Medicare. As a result, virtually all who 
are eligible to join voluntarily elect to do so. When the Federal 
Government decides that it should participate in providing a 
prescription drug benefit for American seniors, that benefit is best 
placed under the same big tent of the Medicare program.
  Now, this is not a unanimous opinion. Some of my Senate colleagues 
believe that a prescription drug benefit should be left outside the 
tent, left to a sideshow status, if you will. In order to determine 
which way is truly the best way, the main tent of Medicare or a 
sideshow, it is important to answer some key questions.
  Question 1 is what do the customers, the seniors and the people who 
live with disabilities, what do they want? How would they prefer this 
program to be organized and administered? We all know the old saying 
that the customer is always right. This will surely be true for the new 
drug benefit that we will offer to Medicare beneficiaries. Congress 
must learn to ask and to listen--in health care terminology, to first 
diagnose before we proceed to prescribe.
  This should have been the lesson learned from Congress' ill-
considered decision to add catastrophic coverage to Medicare in the 
late 1980s. We prescribed before we listened. When we listen, seniors 
tell us they like the Medicare program. Ninety-eight percent of them 
voluntarily elect to participate. In 1998, the Kaiser Family Foundation 
found that 74 percent of seniors surveyed believed that Medicare was 
doing a good job serving their interests.
  Seniors tell us that while Medicare is not perfect, it is convenient, 
affordable, and dependable. They never worry that the benefits will 
suddenly disappear or become too expensive. They like the universality 
of the Medicare program. No matter where they are--in Kansas, in Utah, 
or in Florida--the benefits are available and affordable. They don't 
want to worry, as they would in some plans, that an income of $16,000 a 
year would make them ``too wealthy'' to qualify for help.
  Including the prescription drug benefit in Medicare would offer peace 
of mind. But don't take my word for it. Another recent poll conducted 
by the Kaiser Family Foundation and Harvard University showed that when 
seniors are given the choice of having the Federal Government 
administer a Medicare prescription drug benefit versus the alternative 
of having the Government help to pay for private insurance plans, 36 
percent chose the private option; 57 percent of the respondents 
preferred to have the benefit as part of an expanded Medicare program.
  We hear over and over in statements on the Senate floor and 
occasionally even in political ads that Americans will be better off if 
prescription drug benefits are not made part of the Medicare program. 
But when we listen to the people, not to just political rhetoric, what 
we find is that Medicare beneficiaries do not complain about Medicare. 
Rather, we hear a desire to expand Medicare to include real 
prescription drug benefits. We should listen to these voices of the 
customers.
  Question 2: Will a true Medicare benefit or a program that relies on 
private and State insurers be the most reliable? Predictability, 
sustainability, reliability are important qualities for America's 
seniors. The bill I have introduced with Senators Robb, Bryan, Conrad, 
Chafee, and Jeffords assures that all beneficiaries, including those in 
underserved and rural areas, would be guaranteed a defined, accessible, 
affordable, and stable benefit for the same monthly premium nationwide. 
Medicare would subsidize benefits directly and pay for prescription 
drug costs as any other Medicare benefit.
  In contrast, the plan that is being proposed by Governor George W. 
Bush and by House Republicans and by some

[[Page S8749]]

Members of this body asserts that prescription medications are a 
sideshow act and should not be included under the big tent of Medicare. 
They have outlined plans and introduced legislation to accomplish that 
objective.
  We have heard from our colleagues that seniors do not want big 
government involved in their prescription drug benefit. My colleagues 
have said that the Vice President's plan and even the plan that has 
been introduced by a bipartisan group of our colleagues is a one-size-
fits-all plan without adequate choice. Governor Bush attacks the Vice 
President's plan in his latest television ad entitled ``Compare,'' 
saying that ``Al Gore's prescription drug plan forces seniors into a 
government-run HMO.''
  I would like to quote from the New York Times of September 16, which 
analyzes this latest ad. This is what the New York Times has to say 
under the category of Accuracy:

       Health maintenance organizations are not popular, so it is 
     not surprising that the commercial links Mr. Gore's 
     prescription drug plans to HMOs. But to do so is to stretch 
     the facts.
       Mr. Gore does not force the elderly to accept his new 
     prescription drug benefit. It is voluntary. And Medicare 
     recipients can stay in traditional plans where they choose 
     their own doctors.
       Mr. Gore's plan does rely on private benefit managers to 
     manage the program--just like private insurers do--which 
     encourages use of generic drugs and less expensive brand 
     names. But these are not HMOs.

  Some critics argue that it is Mr. Bush's plan that would increase the 
number of older persons enrolling in managed care. Mr. Bush would give 
the people the ability to choose between the traditional Medicare 
program, including a new drug benefit and government-subsidized private 
insurance packages. A question is whether the premiums would rise for 
traditional Medicare, causing more people to choose managed care.
  Mr. President, I ask unanimous consent that the article from the New 
York Times of September 16 be printed in the Record immediately 
following my remarks.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (See Exhibit 1.)
  Mr. GRAHAM. Let's take another look at what Governor Bush and others 
in the House, as well as some of our colleagues, would offer to 
seniors. They would offer choice in their prescription drug plan, but 
the choice is not for seniors. It is for the private insurers, the 
States, and other entities that might choose to participate. HMOs which 
participate can choose to offer an affordable benefit or a 
prohibitively expensive one or no prescription drug benefit at all. 
According to the Health Care Maintenance Organization, this year some 
900,000 Medicare beneficiaries who had signed up with a Medicare+choice 
HMO have seen those benefits yanked away, as the HMO terminates 
coverage.
  Many others have seen their HMOs either eliminate the prescription 
drug benefit, as have many in my State of Florida, or they have seen 
that benefit substantially reduced.
  The House Republicans' plan looks to private insurance to offer 
prescription drug policies to seniors. We have discussed time after 
time that the private insurance industry has said it doesn't want to 
offer these plans. Maybe a reason for their disinclination to offer 
these plans can be provided through the window of a type of plan which 
is very similar to the Republican House proposal.
  Under the current law, there are various types of Medigap plans--
plans that are provided by private insurers to fill gaps in the 
Medicare program. Three of these Medigap plans cover prescription drug 
benefits. All three of these have a $250 deductible and a 50/50 cost 
sharing for coinsurance.
  Plans labeled ``H'' and ``I'' cover drugs up to $1,250 in total 
spending and plan ``J'' covers up to $3,000 in total spending. None of 
these three plans offer what is referred to as a stop-loss. There is 
never a point in the process where the beneficiary is not forced to 
continue to pay half of the cost of their drugs.
  Now, what does Medigap charge to get these programs which limit 
coverage, in two cases, to $1,250, and in a third, $3,000, without a 
stop-loss provision? The average cost of these plans nationwide, per 
month, is $136. In my State of Florida, the average cost per month is 
$167. This gives you some idea of what seniors are going to be asked to 
pay should we go to a private insurance model as the means of providing 
prescription medication. These costs are well beyond what is affordable 
for most low-income and many middle-income seniors.
  With the history of broad variation, high, and unpredictable premiums 
and sub-par benefit packages, it is unclear to me why a Medigap-like 
approach to designing a Medicare prescription drug benefit would be in 
the best interest of America's seniors.
  Finally, there is now before us a proposal for an ``immediate fix'' 
for low-income seniors with incomes up to 150 percent of poverty in the 
form of block grants to States. Not only would this plan cover only a 
fraction of Medicare beneficiaries, it would provide a patchwork quilt 
of coverage for those individuals who did qualify for the benefit.
  States could offer coverage consistent with their current Medicaid or 
State drug assistance programs, or could punt their programs to the 
Federal Government if they chose not to participate at all.
  Seniors in some States would have coverage, but when they move to 
another State, they might have no coverage, or different coverage. It 
would be like Forrest Gump and his box of chocolates--seniors would 
never know just what kind of coverage they would get.
  The reason that 98 percent of Medicare-eligible beneficiaries sign up 
for the Medicare program is that it provides reliable, quality coverage 
for everyone equally and everywhere in the United States of America. So 
why would we treat a prescription drug benefit differently than we do 
for the rest of Medicare benefits?
  A third question is who is eligible under the program and what will 
they get?
  There is a great deal of rhetoric about who will be eligible under 
the prescription drug plans being offered. For Mr. and Mrs. Jones, who 
make $11,000 a year--100 percent of poverty--both of the plans offered 
in the Senate and by Texas Governor Bush claim that their drug coverage 
will be completely paid for. But what will that coverage be?
  In Texas, the Medicaid program only covers three prescription drugs a 
month. So Mr. and Mrs. Jones would be out of luck if they required more 
than that. But if they moved to Illinois, the program might only cover 
drugs for certain conditions, as is the case with that State's current 
drug assistance program.
  A prescription drug benefit within Medicare, such as those proposed 
by my colleagues and myself in the Senate and the Vice President, would 
ensure coverage of all medically necessary prescription drugs based on 
need without a benefit cap. That is the kind of reliability that 
seniors need. And what of my own constituent, Elaine Kett.
  Elaine Kett is a 77-year-old woman from Vero Beach. She is a widow 
living on a fixed income of approximately $20,000 a year. Like many of 
my constituents, Mrs. Kett sent me a list of all the prescription drugs 
that she takes to keep herself active and well. Every year, Elaine Kett 
makes sacrifices to ensure that she takes the medications she needs to 
live a normal active life. There are millions of seniors like Mrs. Kett 
in the United States today. None of them would be covered by a low 
income block grant to the states.
  Question Four: The final question, which approach would ensure that 
seniors have access to an affordable drug benefit--one which could be 
most effective in holding down the escalating prices of prescription 
medications?
  Individuals like Mrs. Kett are not alone. We are all witnessing 
prescription drug prices climbing at record levels of over 17 percent 
per year. We are all aware of the fact that buying in bulk yields 
discounts. Those seniors without insurance plans that cover drugs are 
on their own in the market and are faced with the higher drug prices 
than those of us who have prescription drug coverage negotiated by a 
pharmacy benefit manager.
  Tomorrow, we will discuss the impact of the high cost of prescription 
drugs on seniors--and what can and should be done to make prescription 
medications more affordable for seniors.

[[Page S8750]]

  Mr. President, our families should be secure in the fact that 
prescription medications are included in the big tent of Medicare and 
are not treated as the bearded lady outside the big tent at the circus. 
For many seniors, prescription medications are the main event--and we 
should treat them as such. A prescription drug benefit in the Medicare 
program is not ``one size fits all,'' but rather one program for all. I 
look forward to discussing why a prescription drug benefit must not 
only be universal and accessible, but truly affordable.
  Mr. President, when I give my fourth statement on this topic, I will 
elaborate on the question of which of the options that are before us 
inside the ``main tent'' of Medicare or the ``side tent'' of a separate 
non-Medicare administered prescription drug benefit, and which one will 
have the best opportunity of assuring affordability for America's 
seniors.

                               Exhibit 1

               [From the New York Times, Sept. 16, 2000]

                      A Three-Part Attack on Gore

                          (By Alison Mitchell)

       The Republican campaign of Gov. George W. Bush and Dick 
     Cheney has begun broadcasting a commercial, ``Compare,'' in 
     18 states in its effort to take the offensive on the issues. 
     It takes aim at Vice President Al Gore's stands on a 
     prescription drug benefit in Medicare, on education and on 
     tax cuts.
       Producer Maverick Media.
       On the screen. The 30-second commercial features statements 
     about Mr. Gore's proposals in black on stark white 
     background, counterposed with color pictures of Mr. Bush. It 
     then shows pictures in color of Americans of different 
     ethnicity, as it speaks of people who will not get a tax cut 
     under Mr. Gore's $500 billion plan for tax relief.
       The script. A female announcer: ``Al Gore's prescription 
     plan forces seniors into a government-run H.M.O. Governor 
     Bush gives seniors a choice. Gore says he's for school 
     accountability, but requires no real testing. Governor Bush 
     requires tests and holds schools accountable for results. 
     Gore's targeted tax cuts leave out 50 million people--half of 
     all taxpayers. Under Bush, every taxpayer gets a tax cut and 
     no family pays more than a third of their income to 
     Washington. Governor Bush has real plans that work for real 
     people.''
       Accuracy. Health maintenance organizations are not popular, 
     so it is not surprising that the commercial links Mr. Gore's 
     prescription drug plan to H.M.O.'s. But to do so it has to 
     stretch the facts.
       Mr. Gore does not force the elderly to accept his new 
     prescription drug benefit. It is voluntary. And Medicare 
     recipients can stay in traditional plans where they choose 
     their own doctors. Mr. Gore's plan does rely on private 
     benefit managers to manage the program--just like private 
     insurers do--which encourages use of generic drugs and less 
     expensive brand names. But these are not H.M.O.'s.
       Some critics argue that it is Mr. Bush's plan that would 
     increase the number of older people enrolling in managed 
     care. Mr. Bush would give people the ability to choose 
     between the traditional Medicare program including a new drug 
     benefit and government-subsidized private insurance packages. 
     A question is whether the premiums would rise for traditional 
     Medicare, causing more people to choose managed care.
       On schools, Mr. Bush and Mr. Gore both propose testing and 
     different kinds of accountability measures, but Mr. Bush's 
     proposal calls for tests that would cover more grades and be 
     more frequent than does Mr. Gore's.
       It is true that Mr. Bush's $1.3 trillion 10-year tax-cut 
     plan would give a tax reduction to every income bracket while 
     Mr. Gore's plan for $500 million in targeted tax cuts would 
     give tax breaks only for purposes like college education or 
     child care.
       Score card. With its tag line, ``Governor Bush has real 
     plans that work for real people,'' the spot suggests that Mr. 
     Gore is not credible and neither are his programs. But Mr. 
     Bush has his work cut out for him. Many polls show that 
     voters trust the Democratic candidate more on health care and 
     education. And while Mr. Bush may have the Republican's 
     traditional advantage when it comes to tax-cutting, right now 
     tax cuts are not one of the top concerns of voters.

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