[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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