[Congressional Record Volume 146, Number 124 (Friday, October 6, 2000)]
[Senate]
[Pages S10083-S10089]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




          STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS

      Mr. BINGAMAN (for himself, Mr. Domenici and Mr. Conrad):
  S. 3176. A bill to conduct a demonstration program to show that 
physician shortage, recruitment, and retention problems may be 
ameliorated in rural states by developing a comprehensive program that 
will result in statewide physician population growth; to the Committee 
on Finance.


 rural states physician recruitment and retention demonstration act of 
                                  2000

  Mr. BINGAMAN. Mr. President, I rise today with my colleague Senator 
Domenici of New Mexico to introduce legislation that is intended 
address a significant problem facing some rural states today--a serious 
shortage of physicians. The bills we are introducing are intended to 
demonstrate that physician shortages, and recruitment and retention 
problems can be ameliorated in some rural states by a multifaceted 
approach, including providing incentives for physicians in training to 
practice in areas where they are most likely to be needed.
  The Council on Graduate Medical Education (COGME) has for some time 
held the position that the U.S., in the aggregate, has enough, if not 
too many, physicians. However, COGME's most recent report, published in 
March 1999, documented that almost half of the counties in our country 
are designated as Health Professional Shortage Areas--a remarkable 
finding, given almost three decades of Federal government efforts to 
address the geographic maldistribution of physicians.
  In our State of New Mexico we have physician shortages that are 
worsening, with certain types of speciality physicians being in the 
shortest supply. According to 1998 data from the American Medical 
Association, New Mexico is 20 percent below the U.S. national average 
of 224 patient care physicians per 100,000 persons. In 15 New Mexico 
counties, there is no more than 1 physician or less per 1000 
population, and 1 New Mexico county has no physician at all to care for 
its population.
  And, Mr. President, New Mexico is not alone. Other rural states are 
also suffering.
  A recent Health Care Finance Administration report showed that there 
has been a decline over the past 5 years in certain types of specialty 
physicians either practicing medicine or participating in the Medicare 
program in many rural states. The worst loss for New Mexico has 
occurred in thoracic surgery with a 35 percent decline. Several other 
specialities, such as urology, ophthalmology, and psychiatry, are not 
that far behind.
  The only significant physician growth that can be seen is in primary 
care and that's still not adequate. With losses occurring in certain 
physician specialties, problems for all physicians' practices are 
continuing to worsen--they can't refer patients to specialists without 
great difficulty. For example, in New Mexico, there have been accounts 
of patients being referred to ear, nose and throat doctors having to 
wait up to 9 months for a non-emergency consultation. Without a timely 
in-state consultation, the patient's primary care physician may have to 
refer the patient to an out of state speciality physician for care. 
This is frustrating for the physician, and costly and time consuming 
for the patient.

  As many of you know, New Mexico is one of the nation's poorest 
states, with a large uninsured population. In 1998, it ranked 48th in 
the amount of personal income per capita. For many physicians, this 
means they may never get paid for much of the work they do.
  The physician shortage is becoming so severe in our state that last 
year the New Mexico Medical Society conducted a survey of our 
physicians to try to find out about how doctors are faring in the 
state. The response from New Mexico physicians was shocking--42 percent 
of the physicians surveyed said that they are seriously or somewhat 
seriously considering leaving their medical practice, and 40 percent 
said that reimbursement rates are a significant problem. Comments 
offered by physicians in this survey were very clear--``I make a good 
income, but to do that I have to work 65-70 hours a week, in, and week 
out. The reimbursement rates are such that I could move to a lot of 
nice places and maintain my income and work three-quarters as much. 
Family life is important.''
  Almost weekly, New Mexico newspapers report about problems caused by 
provider shortages. On September 7th, the Albuquerque Journal carried a 
story about a women who had fallen, bruised her spinal cord, and 
rapidly developed paralysis of both hands and arms. She had to wait 18 
hours to be seen on an emergency basis because of a critical shortage 
of neurosurgeons in Albuquerque, New Mexico's largest city. Stories 
like this one are becoming more and more common. There are many 
accounts of New Mexicans having to wait up to 9 months for an 
appointment to be seen by a specialist, and of newborns having to be 
transported out of state because the neonatal intensive care unit does 
not have adequate physician coverage.
  My offices in Washington, DC, and New Mexico are constantly receiving 
letters and phone calls, and visits from constituents who want to tell 
us about physician shortages, physicians leaving the State of New 
Mexico, and the loss of their individual providers. They can't 
understand why this happening in a country with the greatest healthcare 
system in the world.
  All of these problems clearly show that New Mexico's health care 
system

[[Page S10084]]

has broken down. However, it is not only New Mexico that is 
experiencing these problems. Other rural states are experiencing 
similar problems--they have become states that are being avoided by 
physicians entering practice. With the population in these states 
continuing to grow, the problem just gets worse. If this situation is 
not addressed right now, it will result in a complete breakdown of an 
already fragile health care delivery system.
  This is why we are each introducing this package of legislation 
today. These two bills, the ``Rural States Physician Recruitment and 
Retention Demonstration Act of 2000, will together, when enacted, 
demonstrate that physician shortages and recruitment and retention 
problems can be ameliorated in rural states by instituting a 
comprehensive plan that provides for a proper physician speciality mix 
that will address the needs of a rural state's population.
  My legislation will require the Secretary of the Department of Health 
and Human Services to establish a demonstration program that will:
  Target up to a 15 percent increase in physician residency slots 
identified to be in short supply in demonstration states. These 
expanded residency slots would carry with them a legally binding 
commitment to practice in the demonstration state on a year of training 
for year of service basis.
  Establish a loan repayment program to provide incentives for 
physicians in identified shortage specialities to locate their 
practices in demonstration states. This program will help physicians 
repay their educational loans on a year of service for a year of loan 
repayment basis in return for a commitment to practice in the 
demonstration state.
  Develop a demonstration state health professional data base to 
capture and track the practice characteristics and distribution of 
licensed health care providers. This data will be used to develop a 
baseline and track changes in a demonstration state's health 
professions workforce, target this demonstration program to identified 
physician specialities and determine a state's need for other types of 
supportive health professionals.
  Provide for an evaluation of each element of our comprehensive 
demonstration by the Council on Graduate Medical Education (COGME) for 
physician workforce issues, and by Medicare Payment Advisory Commission 
(Medpac) for Medicare reimbursement and Medicare funded graduate 
medical education positions.
  As I mentioned earlier, one of the primary reason physicians report 
they are leaving New Mexico is because reimbursement is too low, 
particularly when combined with other factors like long work days, 
inability to recruit speciality physicians, and provide comprehensive 
patient care in a reasonable period of time.
  That's why the second part of this package, the Physician Recruitment 
and Retention Act of 2000, consists of legislation that will provide 
physicians that are practicing in demonstration states with a special 5 
percent Medicare part B reimbursement rate increase. This increase will 
provide a financial incentive to physicians to continue to practice in 
the underserved states and also to continue to participate in the 
Medicare program.
  Both Senator Domenici and I anticipate that by the end of this 
demonstration program, physician shortages, particularly in specific 
physician specialities, will be greatly diminished or even have 
disappeared.
  Mr. President, the health care system in New Mexico is near collapse 
for reasons too numerous and complex to get into here. These bills we 
are introducing today, in combination with the fixes we are making to 
the problems resulting from the BBA of 1997, may stave off disaster for 
a while. I certainly hope they will.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 3176

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

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Rural 
     States Physician Recruitment and Retention Demonstration Act 
     of 2000''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.
Sec. 2. Definitions.
Sec. 3. Rural States Physician Recruitment and Retention Demonstration 
              Program.
Sec. 4. Establishment of the Health Professions Database.
Sec. 5. Evaluation and reports.
Sec. 6. Contracting flexibility.

     SEC. 2. DEFINITIONS.

       In this Act:
       (1) COGME.--The term ``COGME'' means the Council on 
     Graduate Medical Education established under section 762 of 
     the Public Health Service Act (42 U.S.C. 294o).
       (2) Demonstration program.--The term ``demonstration 
     program'' means the Rural States Physician Recruitment and 
     Retention Demonstration Program established by the Secretary 
     under section 3(a).
       (3) Demonstration states.--The term ``demonstration 
     States'' means the 2 States selected by the Secretary that, 
     based upon 1998 data, have--
       (A) an uninsured population above 20 percent (as determined 
     by the Bureau of the Census);
       (B) a population eligible for medical assistance under the 
     medicaid program under title XIX of the Social Security Act 
     (42 U.S.C. 1396 et seq.) above 17 percent (as determined by 
     the Health Care Financing Administration);
       (C) an unemployment rate above 4.8 percent (as determined 
     by the Bureau of Labor Statistics);
       (D) an average per capita income below $21,200 (as 
     determined by the Bureau of Economic Analysis); and
       (E) a geographic practice cost indices component of the 
     reimbursement rate for physicians under the medicare program 
     that is below the national average (as determined by the 
     Health Care Financing Administration).
       (4) Eligible residency or fellowship graduate.--The term 
     ``eligible residency or fellowship graduate'' means a 
     graduate of an approved medical residency training program 
     (as defined in section 1886(h)(5)(A) of the Social Security 
     Act (42 U.S.C. 1395ww(h)(5)(A))) in a shortage physician 
     specialty.
       (5) Health professions database.--The term ``Health 
     Professions Database'' means the database established under 
     section 4(a).
       (6) Medicare program.--The term ``medicare program'' means 
     the health benefits program under title XVIII of the Social 
     Security Act (42 U.S.C. 1395 et seq.).
       (7) Medpac.--The term ``MedPAC'' means the Medicare Payment 
     Advisory Commission established under section 1805 of the 
     Social Security Act (42 U.S.C. 1395b-6).
       (8) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (9) Shortage physician specialties.--The term ``shortage 
     physician specialty'' means a medical or surgical specialty 
     identified in a demonstration State by the Secretary based 
     on--
       (A) an analysis and comparison of National data and 
     demonstration State data; and
       (B) recommendations from appropriate Federal, State, and 
     private commissions, centers, councils, medical and surgical 
     physician specialty boards, and medical societies or 
     associations involved in physician workforce, education and 
     training, and payment issues.

     SEC. 3. RURAL STATES PHYSICIAN RECRUITMENT AND RETENTION 
                   DEMONSTRATION PROGRAM.

       (a) Establishment.--
       (1) In general.--The Secretary shall establish a Rural 
     States Physician Recruitment and Retention Demonstration 
     Program for the purpose of ameliorating physician shortage, 
     recruitment, and retention problems in rural states in 
     accordance with the requirements of this section.
       (2) Consultation.--For purposes of establishing the 
     demonstration program, the Secretary shall consult with--
       (A) COGME;
       (B) MedPAC;
       (C) a representative of each demonstration State medical 
     society or association;
       (D) the health workforce planning and physician training 
     authority of each demonstration State; and
       (E) any other entity described in section 2(9)(B).
       (b) Duration.--The Secretary shall conduct the 
     demonstration program for a period of 10 years.
       (c) Conduct of Program.--
       (1) Funding of additional residency and fellowship 
     positions.--
       (A) In general.--As part of the demonstration program, the 
     Secretary (acting through the Administrator of the Health 
     Care Financing Administration) shall--
       (i) waive any limitation under section 1886 of the Social 
     Security Act (42 U.S.C. 1395ww) with respect to the number of 
     residency and fellowship positions;
       (ii) increase by up to 15 percent of the total number 
     residency and fellowship positions approved at each medical 
     residency training program in each demonstration State the 
     number of residency and fellowships in each shortage 
     physician specialty; and
       (iii) subject to subparagraph (C), provide funding for such 
     additional positions under subsections (d)(5)(B) and (h) of 
     section 1886 of the Social Security Act (42 U.S.C. 1395ww).
       (B) Establishment of additional positions.--

[[Page S10085]]

       (i) Identification.--The Secretary shall identify each 
     additional residency and fellowship position created as a 
     result of the application of subparagraph (A).
       (ii) Negotiation and consultation.--The Secretary shall 
     negotiate and consult with representatives of each approved 
     medical residency training program in a demonstration State 
     at which a position identified under clause (i) is created 
     for purposes of supporting such position.
       (C) Contracts with residents and fellows.--
       (i) In general.--The Secretary shall condition the 
     availability of funding for each residency and fellowship 
     position identified under subparagraph (B)(i) on the 
     execution of a contract containing the provisions described 
     in clause (ii) by each individual accepting such a residency 
     or fellowship position.
       (ii) Provisions described.--The provisions described in 
     this clause provide that, upon completion of the residency or 
     fellowship, the individual completing such residency or 
     fellowship will practice in the demonstration State in which 
     such residency or fellowship was completed that is designated 
     by the contract for 1 year for each year of training under 
     the residency or fellowship in the demonstration State.
       (iii) Construction.--The period that the individual 
     practices in the area designated by the contract shall be in 
     addition to any period that such individual practices in an 
     area designated under a contract executed pursuant to 
     paragraph (2)(C).
       (D) Limitations.--
       (i) Period of payment.--The Secretary may not fund any 
     residency of fellowship position identified under 
     subparagraph (B)(i) for a period of more than 5 years.
       (ii) Phase-out of program.--The Secretary may not enter 
     into any contract under subparagraph (C) after the date that 
     is 5 years after the date on which the Secretary establishes 
     the demonstration program.
       (2) Loan repayment and forgiveness program.--
       (A) In general.--As part of the demonstration program, the 
     Secretary (acting through the Administrator of Health 
     Resources and Services Administration) shall establish a loan 
     repayment and forgiveness program, through the holder of the 
     loan, under which the Secretary assumes the obligation to 
     repay a qualified loan amount for an educational loan of an 
     eligible residency or fellowship graduate--
       (i) for which the Secretary has approved an application 
     submitted under subparagraph (D); and
       (ii) with which the Secretary has entered into a contract 
     under subparagraph (C).
       (B) Qualified loan amount.--
       (i) In general.--Subject to clause (ii), the Secretary 
     shall repay not more than $25,000 per graduate per year of 
     the loan obligation on a loan that is outstanding during the 
     period that the eligible residency or fellowship graduate 
     practices in the area designated by the contract entered into 
     under subparagraph (C).
       (ii) Limitation.--The aggregate amount under this 
     subparagraph shall not exceed $125,000 for any graduate and 
     the Secretary may not repay or forgive more than 30 loans per 
     year in each demonstration State under this paragraph.
       (C) Contracts with residents and fellows.--
       (i) In general.--Each eligible residency or fellowship 
     graduate desiring repayment of a loan under this paragraph 
     shall execute a contract containing the provisions described 
     in clause (ii).
       (ii) Provisions.--The provisions described in this clause 
     are provisions that require the eligible residency or 
     fellowship graduate to practice in a demonstration State 
     during the period in which a loan is being repaid or forgiven 
     under this section.
       (D) Application.--
       (i) In general.--Each eligible residency or fellowship 
     graduate desiring repayment of a loan under this paragraph 
     shall submit an application to the Secretary at such time, in 
     such manner, and accompanied by such information as the 
     Secretary may reasonably require.
       (ii) Phase-out of loan repayment and forgiveness program.--
     The Secretary may not accept an application for repayment of 
     any loan under this paragraph after the date that is 5 years 
     after the date on which the demonstration program is 
     established.
       (E) Construction.--Nothing in the section shall be 
     construed to authorize any refunding of any repayment of a 
     loan.
       (F) Prevention of double benefits.--No borrower may, for 
     the same service, receive a benefit under both this paragraph 
     and any loan repayment or forgiveness program under title VII 
     of the Public Health Service Act (42 U.S.C. 292 et seq.).
       (d) Waiver of Medicare Requirements.--The Secretary is 
     authorized to waive any requirement of the medicare program, 
     or approve equivalent or alternative ways of meeting such a 
     requirement, if such waiver is necessary to carry out the 
     demonstration program, including the waiver of any limitation 
     on the amount of payment or number of residents under section 
     1886 of the Social Security Act (42 U.S.C. 1395ww).
       (e) Appropriations.--
       (1) Funding of additional residency and fellowship 
     positions.--Any expenditures resulting from the establishment 
     of the funding of additional residency and fellowship 
     positions under subsection (c)(1) shall be made from the 
     Federal Hospital Insurance Trust Fund under section 1817 of 
     the Social Security Act (42 U.S.C. 1395i).
       (2) Loan repayment and forgiveness program.--There are 
     authorized to be appropriated such sums as may be necessary 
     to carry out the loan repayment and forgiveness program 
     established under subsection (c)(2).

     SEC. 4. ESTABLISHMENT OF THE HEALTH PROFESSIONS DATABASE.

       (a) Establishment of the Health Professions Database.--
       (1) In general.--Not later than 7 months after the date of 
     enactment of this Act, the Secretary (acting through the 
     Administrator of Health Resources and Services 
     Administration) shall establish a State-specific health 
     professions database to track health professionals in each 
     demonstration State with respect to specialty certifications, 
     practice characteristics, professional licensure, practice 
     types, locations, education, training, as well as obligations 
     under the demonstration program as a result of the execution 
     of a contract under paragraph (1)(C) or (2)(C) of section 
     3(c).
       (2) Data sources.--In establishing the Health Professions 
     Database, the Secretary shall use the latest available data 
     from existing health workforce files, including the AMA 
     Master File, State databases, specialty medical society data 
     sources and information, and such other data points as may be 
     recommended by COGME, MedPAC, the National Center for 
     Workforce Information and Analysis, or the medical society of 
     the respective demonstration State.
       (b) Availability.--
       (1) During the program.--During the demonstration program, 
     data from the Health Professions Database shall be made 
     available to the Secretary, each demonstration State, and the 
     public for the purposes of--
       (A) developing a baseline and to track changes in a 
     demonstration State's health professions workforce;
       (B) tracking direct and indirect graduate medical education 
     payments to hospitals;
       (C) tracking the forgiveness and repayment of loans for 
     educating physicians; and
       (D) tracking commitments by physicians under the 
     demonstration program.
       (2) Following the program.--Following the termination of 
     the demonstration program, a demonstration State may elect to 
     maintain the Health Professions Database for such State at 
     its expense.
       (c) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as may be necessary for the 
     purpose of carrying out this section.

     SEC. 5. EVALUATION AND REPORTS.

       (a) Evaluation.--
       (1) In general.--COGME and MedPAC shall jointly conduct a 
     comprehensive evaluation of the demonstration program 
     established under section 3.
       (2) Matters evaluated.--The evaluation conducted under 
     paragraph (1) shall include an analysis of the effectiveness 
     of the funding of additional residency and fellowship 
     positions and the loan repayment and forgiveness program on 
     physician recruitment, retention, and specialty mix in each 
     demonstration State.
       (b) Progress Reports.--
       (1) COGME.--COGME shall submit a report on the progress of 
     the demonstration program to the Secretary and Congress 1 
     year after the date on which the Secretary establishes the 
     demonstration program, 5 years after such date, and 10 years 
     after such date.
       (2) Medpac.--MedPAC shall submit biennial reports on the 
     progress of the demonstration program to the Secretary and 
     Congress.
       (c) Final Report.--Not later than 1 year after the date on 
     which the demonstration program terminates, COGME and MedPAC 
     shall submit a final report to the President, Congress, and 
     the Secretary which shall contain a detailed statement of the 
     findings and conclusions of COGME and MedPAC, together with 
     such recommendations for such legislation and administrative 
     actions as COGME and MedPAC consider appropriate.
       (d) Authorization of appropriations.--There are authorized 
     to be appropriated to COGME such sums as may be necessary for 
     the purpose of carrying out this section.

     SEC. 6. CONTRACTING FLEXIBILITY.

       For purposes of conducting the demonstration program and 
     establishing and administering the Health Professions 
     Database, the Secretary may procure temporary and 
     intermittent services under section 3109(b) of title 5, 
     United States Code.
                                 ______
                                 
      By Mr. GRASSLEY (for himself, Mr. Breaux, and Mr. Reed):
  S. 3177. A bill to require the Secretary of Health and Human Services 
to establish minimum nursing staff levels for nursing facilities, to 
provide for grants to improve the quality of care furnished in nursing 
facilities, and for other purposes; to the Committee on Finance.


               NURSING HOME STAFF IMPROVEMENT ACT OF 2000

  Mr. GRASSLEY. Mr. President, I am pleased to have the support of 
Senator Breaux in introducing The Nursing Home Staff Improvement Act of 
2000. This is an important piece of legislation for the 1.6 million 
frail elderly Americans who reside in nursing homes across the nation.
  A recently released and long overdue report from the Health Care 
Financing

[[Page S10086]]

Administration was the immediate impetus for our bill. This report was 
first mandated by Congress in 1990. It took the Department of Health 
and Human Services 10 years to complete Part I of the report. It will 
take almost another year to finish it. The first part of the study 
documented, to just about everyone's satisfaction, severe staffing 
shortages, severe staffing shortages in our nation's nursing homes. 
While we are waiting for the agency to complete the second and final 
part of the report, Senate Breaux and I want to begin to address the 
staffing crisis in long-term care. Therefore, we are introducing this 
legislation today.
  We have a long way to go in meeting the staffing needs of elderly 
nursing home residents. The bill we are introducing today is not the 
answer to the problem. It is only a first step. Yet, it is an extremely 
important step that Congress should take.
  Before describing the bill Senator Breaux and I are introducing 
today, I'd like to take a couple of minutes to go over the history of 
our committee's work on nursing home quality of care and HCFA oversight 
of the Nursing Home Reform Act of 1987. It's important for me to 
emphasize the scope and depth of the problem in order to give my fellow 
Senators an appreciation of the context out of which this legislation 
developed.
  In the fall of 1997, serious allegations were brought to my attention 
about the quality of care provided in California nursing homes. These 
allegations claimed that thousands of California nursing home residents 
had suffered and met with untimely and unnecessary deaths due to 
malnutrition, dehydration, decubitus ulcers, and urinary tract 
infections.
  In an effort to respond to these allegations, I asked the General 
Accounting Office [GAO] to conduct a thorough review of them and, more 
generally, of the quality of care in California nursing homes.
  This review culminated in a 2-day hearing held on July 27-28, 1998, 
entitled ``Betrayal: The Quality of Care in California Nursing Homes.'' 
At this hearing, the GAO released its report titled ``California 
Nursing Homes: Care Problems Persist Despite Federal and State 
Oversight.'' The findings of this report were explosive and disturbing, 
illustrating that residents in far too many California nursing homes 
were threatened by seriously substandard care.
  One week prior to this hearing, the Clinton administration announced 
a broad set of new nursing home initiatives to improve enforcement of 
the Nursing Home Reform Act and, hence, the quality of care in nursing 
facilities. The administration was acting in response to the impending 
release of the GAO's study before the scheduled Aging Committee 
hearing. It acted also in response to a congressionally mandated report 
by the Department of Health and Human Services on nursing home 
oversight that was completed just before the hearing. The Department's 
report uncovered weaknesses on the part of the federal government in 
its oversight of nursing home quality of care. As the Federal agency 
with regulatory oversight responsibility over our Nation's nursing 
homes, the Health Care Financing Administration [HCFA] is responsible 
for monitoring the compliance of nursing home facilities in meeting the 
requirements of the Nursing Home Reform Act. For facilities found to be 
noncompliant, HCFA is responsible for seeing that remedies or sanctions 
are imposed until the situation is corrected. The administration's 
report found shortcomings in HCFA's enforcement of the Nursing Home 
Reform Act of 1987. The agency's report was really a kind of self-
indictment. Up to that point, the agency had failed in its 
responsibility to protect nursing home residents.

  As part of its multistep initiative, the administration called for 
improvements in nursing home inspections, better and more timely 
enforcement against nursing homes that repeatedly violate safety rules, 
and more attention to quality of care for nursing home residents 
through prevention of bed sores, malnutrition and dehydration. HCFA was 
given the responsibility for carrying out this initiative. Under my 
chairmanship, the Senate Special Committee on Aging has taken an active 
role in overseeing the implementation of the President's nursing home 
initiative led by the Administrator of HCFA. At regular hearings and 
forums, 10 to be specific, I have heard from family members, health 
care professionals and other long-term care experts about the progress 
and obstacles in achieving improved nursing home quality of care.
  Anecdotally, we have heard from the very beginning of our work on 
nursing home quality of care that understaffing is a root cause of many 
of the problems facing nursing home residents. Because we desperately 
needed a more systematic, research-based analysis of this understaffing 
problem, I had persistently urged HCFA to finish the long delayed 
staffing report I mentioned earlier.
  On July 27, 2000, Part I of the report, entitled ``Appropriateness of 
Minimum Staffing Ratios in Nursing Homes'' was done, and our committee 
held a hearing to take testimony on it. The report and the hearing 
presented groundbreaking new information on nursing facility staffing. 
It was the first time that understaffing, and the consequences of 
understaffing, were described by a scientifically sound government 
report. Although a Part II of the report will be required to completely 
validate the findings of Part I and to analyze a number of other 
questions raised by Part I, the report showed for the first time what 
family members and resident advocates had been saying for years: that 
the majority of nursing homes in our country are dramatically 
understaffed. Specifically, the report concluded that more than half of 
nursing facilities around the country employ too few nurses and nurse 
aides to provide adequate care to residents.
  As a result of these report findings, I began working on legislation 
to address the serious problems of understaffing. I started by seeking 
input from interested parties, including the Administration, nursing 
home providers, health care professionals, and resident advocates. I 
finalized my proposal right around the same time the President 
announced the administration's initiative in this area. The two 
proposals are similar in their goal to start addressing the problems of 
understaffing in nursing facilities.
  As I said earlier, the impetus for my bill was the Report to Congress 
on the ``Appropriateness of Minimum Nurse Staffing Ratios in Nursing 
Homes''. The major conclusions of the report are outlined in the 
Findings section of our bill. The report found that 2.0 nurse aide 
hours per resident day is a threshold below which residents' lives are 
at risk, not a standard for the provision of appropriate care. The 
findings also showed that 2.9 nurse aide hours per resident day are 
necessary for a nurse aide to complete core resident care tasks, 
although, because of the very conservative estimates used in this part 
of the study, 2.9 hours probably significantly understates the staffing 
levels necessary for a nurse aide to complete these core tasks. Part I 
of the report also indicated that Part II will analyze and report on 
minimum staffing levels according to a facility's resident acuity 
level. I urge Congress and the Administration to be careful in 
accepting either the 2.0 or 2.9 nurse aide hours per resident day as a 
minimum goal for nursing facilities until these results are validated 
and case-mix is included in the equation. It is reasonable to expect 
that staffing requirements will be substantially higher for facilities 
that have residents with higher acuity.
  Our bill calls for the completion of phase two of the study. It 
requires the Secretary to complete the report not later than July 1, 
2001. It adds to the original authority a requirement that the study 
undertake several tasks that Part I of the report stated would be done 
in the second phase. Among other things, these tasks include a 
requirement that the case mix analysis of Part I of the report be 
further refined and related to appropriate minimum staffing levels. It 
also adds to the original authority a requirement that the report 
analyze ``optimal minimum'' caregiver to resident levels and ``optimal 
minimum'' supervisor to caregiver levels of skilled nursing facilities 
participating in the Medicare program and nursing facilities 
participating in the Medicaid program. We modified the original 
authority in this manner because we believed the public should know not 
just appropriate minimum

[[Page S10087]]

staffing levels, but also what more optimal staffing levels should be 
in nursing facilities.
  My bill requires that minimum staffing levels be developed and 
enforced within one year of the completion of the Report. It requires 
the Secretary to make recommendations regarding appropriate minimum 
caregiver to resident levels and minimum supervisor to caregiver levels 
for skilled nursing facilities participating in the Medicare program 
and nursing facilities participating in the Medicaid program. The 
Secretary further shall require through the administrative rulemaking 
process compliance with appropriate minimum staffing levels as a 
condition for such facilities to receive payment under those programs. 
The Secretary would be required to promulgate a final rule not later 
than one year after completion of the report.
  The bill requires that the Secretary establish appropriate minimum 
staffing levels because we believed that a regulatory requirement 
should establish those staffing levels that will assure that residents 
receive the quality of care they have a right to receive under the 
terms of the Nursing Home Reform Act of 1987. We assume that the 
resident case mix of a facility will have an effect on the appropriate 
minimum staffing levels of the facility.
  In order to help States prepare for the minimum staffing levels that 
the Secretary will promulgate by July 1, 2002, my bill establishes a 
competitive state grant program. The purpose of the grant program will 
be to improve staffing levels in nursing facilities in order to improve 
the quality of care to residents of such facilities. A state that 
secures such a grant may provide technical or financial support to 
nursing facilities, labor organizations, nonprofit organizations, 
community colleges, or other organizations approved by the Secretary. 
Such support from the state shall be used for projects which will help 
to increase or improve recruitment and retention of direct care nursing 
staff. Projects supported by a state must be consistent with the 
requirements of sections 1818 and 1919 of the Social Security Act. No 
funds may be made available to county or state-owned nursing 
facilities. Funds used under a grant to a state may only be used to 
supplement, not supplant, other funds that the state extends to carry 
out the activities that may be supported by this grant program. The 
Secretary shall evaluate this grant program and report to the Congress 
on her findings not later than six months after completion of the grant 
program. Authorized to be appropriated are $500,000,000 for each of 
fiscal years 2001 and 2002.

  My bill includes a requirement for reporting of accurate information 
on staffing. Skilled nursing facilities participating in the Medicare 
program and nursing facilities participating in the Medicaid program 
would be required to submit staffing information to the Secretary in a 
form and manner determined by the Secretary. Such information must be 
attested to as accurate by the reporting facility. The Secretary shall 
periodically post and update such information on the Nursing Home 
Compare web site. Skilled nursing facilities participating in the 
Medicare program and nursing facilities participating in the Medicaid 
program shall submit to the Secretary a classification of all residents 
of the facility according to the resident classification system 
required under current law. My understanding is that nursing facilities 
should have data on hand and in a form that would be required by the 
Secretary for reporting to the Department, and, thus, the 
administrative burden of this requirement should be minimal.
  My bill includes a requirement for posting of facility staffing 
information. Facilities participating in the Medicare and Medicaid 
program would be required to post daily for each nursing unit and each 
work shift the current number of licensed and unlicensed nursing staff 
directly responsible for resident care together with the number of 
residents per unit and shift.
  Throughout my work and oversight activity of nursing facility quality 
of care, I have made it a point to stress that there are many good 
nursing facilities. When a family is in need of a facility for a loved 
one, it is critically important that individuals shop around and gather 
information in order to find the best nursing home to meet the needs of 
their loved ones. The provision in my bill calling for additional 
reporting of staffing and facility posting of staffing data will help 
families which need to find a good facility for a loved one's 
placement. It should also eventually have an effect on the overall 
quality of care in nursing facilities as families search out and choose 
better facilities.
  The information collected by HCFA will help it improve and maintain 
its Nursing Home Compare web site. This is a database which contains 
information on every Medicare and Medicaid certified nursing home in 
the country. You can locate nursing homes in your area and find 
information about compliance with Medicare and Medicaid regulations 
based on the facility's most recent survey by state inspectors. 
Additionally, the web site contains useful phone numbers for survey 
agencies and long term care ombudsmen on the web site's ``Phone 
Directory'' page.
  In closing, I plan to continue my work to improve quality of care and 
quality of life for nursing home residents. In my position as Chairman 
of the Special Committee on Aging, I will continue to monitor the 
quality of care provided to our nation's nursing home residents. With 
the assistance of the GAO, I will continually assess and monitor the 
Health Care Financing Administration's progress and commitment to 
improving the quality of care in nursing homes.
  Mr. BREAUX. Mr. President, I rise today as ranking member of the 
Special Committee on Aging and am proud to inform you that after the 
culmination of years of investigation and attention to the relationship 
between nursing home staff levels and quality of care, today Senator 
Grassley--my colleague on the Committee--and I are introducing 
legislation on this important issue. Our ``Nursing Facility Staff 
Improvement Act of 2000'' would encourage increased quantities of staff 
but also would improve the quality of those caring for our loved ones 
in nursing homes.
  Chairman Grassley and I have been committed to ensuring that our 
seniors are getting the best quality care possible in our nation's 
nursing homes, and the Aging Committee has held numerous hearings 
regarding the best way to reach this goal. We have been working with 
HCFA to determine the best way to ensure state surveyors are 
appropriately monitoring the quality of care their residents receive. 
Additionally, we held a hearing to learn from industry representatives 
about the links between nursing home bankruptcies and quality care. And 
we have continually and consistently sent the message that we will 
remain involved and committed to improvement for as long as it takes.
  The bill we introduce today--the Nursing Facility Staff Improvement 
Act of 2000--is the result of bipartisan efforts to put something on 
the books that will not only provide real incentives for nursing home 
staff to strive to do their jobs well but will also be a huge step 
toward defining what optional nursing home care should entail. I 
commend President Clinton for building on the Aging Committee's 
findings and making this very important issue one of his priorities.
  More specifically, this bill will:
  Call for the Secretary of HHS to establish a competitive grant 
program to the states to increase or improve the recruitment and 
retention of direct care nursing staff. Provide for $1 billion over two 
years. Require that HCFA complete Phase II of their Nursing Home 
Staffing study and report back not later than July 1, 2001. Appropriate 
use of grant monies would include: establishing career ladders for 
nurse aides; improving nursing management; providing additional 
training programs for staff.
  In conclusion, it is exciting for me to put forth a piece of 
legislation that offers tangible incentives to current and future staff 
and also directly encourages appropriate nursing home care for our 
loved ones. This effort has truly been one of joint cooperation between 
my Republican colleague on the Aging Committee and myself and I am 
proud to introduce it to you today.
  Mr. REED. Mr. President, I rise today to join my colleague from Iowa, 
the Chairman of the Special Senate Committee on Aging, to introduce 
legislation that we hope will begin to address an immediate and 
critical labor

[[Page S10088]]

shortage facing nursing home facilities across the nation as well as 
the long term objective of establishing nursing home staffing 
thresholds.
  In late July, the Health Care Financing Administration, HCFA, 
released the first phase of its long awaited report on the feasibility 
and appropriateness of minimum nursing home staffing ratios. The 
initial phase of this report explored the relationship between staffing 
levels and quality of care. The HCFA study found a strong correlation 
between certain staffing thresholds and the quality of care provided to 
nursing home residents. The report also found that nursing homes are 
having great difficulty in recruiting and retaining qualified staff to 
work in their facilities. Clearly, we can and should be doing more to 
ensure that the care of our elderly and disabled is not being placed at 
risk.
  In my home state of Rhode Island, we have been dealing with a 
critical shortage in the number of Certified Nursing Assistants, CNAs, 
in particular. CNAs provide direct care in a skilled nursing setting to 
residents who need help with essential daily living tasks, such as 
dressing, feeding and bathing. A state task force comprised of long 
term care providers and nursing home consumer advocates found that over 
26,000 individuals were licensed as CNAs, but only 14,000 are currently 
working in the field. The task force also found that the turnover rate 
for CNAs rose to an unprecedented 82.6 percent in 1999.
  The two most important issues identified in the state report were 
wages and adequate staffing levels. In terms of wages, a person in my 
state can make more in starting salary as a hotel maid in Providence 
($9.50/hour) than they would as a licensed CNA ($7.69/hour). Those 
individuals who have dedicated their careers to caring for our most 
vulnerable citizens certainly deserve better and the legislation we are 
introducing today will help to restore respect and dignity to the 
caregiver profession.
  The Nursing Home Staff Improvement Act will address these problems in 
essentially two ways. First, the legislation requires the Secretary of 
Health and Human Services to complete the second phase of the nursing 
home staffing report by July 2001. The Secretary will then be called 
upon to use the findings and recommendations of the final report to 
develop appropriate caregiver to resident and supervisor to caregiver 
ratios for nursing facilities that participate in the Medicare and 
Medicaid programs. The second major component of the bill is the 
establishment of a grant program to States for the purpose of 
augmenting staffing levels. This provision, which is based on a 
initiative announced by President Clinton in mid-September, will 
support projects aimed at improving the recruitment and retention of 
direct nursing staff. The bill also requires nursing homes to post, on 
a daily basis, the number of staff and residents at the facility as 
well as submit staffing information to the Secretary.
  As a member of the Special Senate Committee on Aging, I am pleased to 
be an original cosponsor of the Nursing Home Staff Improvement Act, a 
balanced piece of legislation that I believe will go a long way in 
stabilizing nursing home staffing levels nationwide. I look forward to 
working with Senator Grassley and my other colleagues to enact this 
important legislation.
                                 ______
                                 
      By Mrs. LINCOLN (for herself and Mr. Cleland):
  S. 3179. A bill to promote recreation on Federal lakes, to require 
Federal agencies responsible for managing Federal lakes to pursue 
strategies for enhancing recreational experiences of the public, and 
for other purposes; to the Committee on Energy and Natural Resources.


                      Recreation Lakes Act of 2000

  Mrs. LINCOLN. Mr. President, I rise today to introduce the Recreation 
Lakes Act of 2000--a bill that will recognize the benefits and value of 
recreation at federal lakes and give recreation a seat at the table in 
the management decisions of all our federal lakes. I am proud to be 
joined in this effort today by Senator Cleland.
  Recreation on our federal lakes has become a powerful tourist magnet, 
attracting some 900 million visitors annually and generating an 
estimated $44 billion in economic activity--mostly spent on privately-
provided goods and services. And by the middle of this century, our 
federal lakes are expected to host nearly two billion visitors per 
year.
  Yet, even with the millions of visitors each year to our lakes and 
reservoirs, recreation has suffered from a lack of unifying policy 
direction and leadership, as well as insufficient interagency and 
intergovernmental planning and coordination. Most federal agencies are 
focused on the traditional functions of man-made lakes and reservoirs; 
flood control, hydroelectric power, water supply, irrigation, and 
navigation. And often recreation is left out of the decision process.
  Mr. President, this legislation will reaffirm that recreation is also 
an authorized purpose at almost all federal lakes and direct the 
agencies managing these projects to take action to reemphasize 
recreation programs in their management plans. This legislation will 
emphasis partnerships between the federal government, local 
governments, and private groups to promote responsible recreation on 
all our federal lakes.
  It will establish a National Recreational Lakes Demonstration 
Program, comprised of up to 20 lakes across the nation. At each of 
these federal lakes, the managing agency will be empowered to develop 
creative agreements with private sector recreation providers as well as 
state land agencies to enhance recreation opportunities. Rather than 
just building new federal campgrounds with tax dollars, we need to 
create new partnerships to provide support for building recreation 
infrastructure that is in line with visitor and tourist desires for 
recreation. The National Recreation Lakes Demonstration Program will be 
a pilot project to test these creative agreements and management 
techniques on a small scale to demonstrate their effectiveness at 
promoting recreation on federal lakes.
  Second, this legislation will establish a Federal Recreation Lakes 
Leadership Council to coordinate the National Recreation Lakes 
Demonstration Program and coordinate efforts among federal agencies to 
promote recreation on federal lakes.
  It also will include the Bureau of Reclamation and the U.S. Army 
Corps of Engineers in the Recreation Fee Demonstration Program. The Fee 
Demo Program has had wide successes in Arkansas and across the country 
in allowing individual parks and recreation areas to keep more of their 
fee revenues on-site to reduce the often overwhelming maintenance 
backlog.

  The legislation will also provide for periodic review of the 
management of recreation at federal water projects--something long 
overdue. A great deal has changed since many of the water projects were 
authorized, yet the initial legislative direction from over 70 years 
ago continues to be the basis for the management practices now in the 
year 2000--and that is not right.
  Finally, the legislation will provide new opportunities to link the 
national recreation lakes initiative with other federal recreation 
assistance efforts, including the Wallop-Breaux program for boating and 
fishing.
  Mr. President, let me give you a little background on how this 
legislation was developed. In 1996, the U.S. Senate recognized that 
recreation was becoming more important on federal lakes and conceived 
the National Recreation Lakes Study Commission to review the current 
and anticipated demand for recreational opportunities on federally 
managed lakes and reservoirs. The National Recreation Lakes Study 
Commission was charged to ``review the current and anticipated demand 
for recreational opportunities at federally-managed man-made lakes and 
reservoirs'' and ``to develop alternatives for enhanced recreational 
use of such facilities.''
  The Commission released its long-awaited report confirming the impact 
of recreation on federally-managed, man-made lakes in June of last 
year. The Commission also recognized that we are far from realizing 
their full potential. The study documented that these lakes are 
powerful tourist magnets, attracting some 900 million visitors annually 
and generating an estimated $44 billion in economic activity--mostly 
spent on privately-provided goods and services.
  During the Energy and Natural Resources Committee's hearing last year

[[Page S10089]]

on the Recreation Lakes Study, the Chairman and I spent some time 
discussing how children today do not take full advantage of the outdoor 
opportunities that are available to them. It is so important that we 
encourage our children to enjoy the great outdoors that often times is 
less than an hour's drive away.
  As the mother of twin 4-year-old boys, I feel we need to encourage 
our children to be children, not to become adults too quickly, to learn 
how to enjoy the outdoors. The only way we can do that is by exposing 
them to it early and often.
  In this nation we have nearly 1,800 federally-managed lakes and 
reservoirs. There are 38 in my home state of Arkansas. With so many 
federal lakes spread throughout the country, there's no reason why we 
shouldn't do all we can to promote recreation on our federal lakes. I 
know that in Arkansas, we don't think twice about getting away to the 
lake for the weekend to go boating or fishing, or to just get away from 
the day-to-day grind. And that doesn't even begin to get into the 
tremendous economic impact from recreation on our federal lakes.
  Mr. President, this bill is not an attempt to completely rewrite how 
federal lakes in this country are managed or to put recreation in front 
of all other authorized purposes at federal lakes.
  The Recreation Lakes Act of 2000 will work with all current laws and 
regulations to ensure that recreation is merely given a seat at the 
table when the management decisions are made for our federal lakes.
  Mr. President, this is a good bill. In everything from the creation 
of jobs to the money that tourists like myself spend at the marinas and 
local stores surrounding the lake--our Federal lakes and reservoirs 
have an immense recreational value that can and does bring revenues 
into our local economies. The best way to encourage and expand this 
aspect is to ensure that recreation is given a higher priority in the 
management of our federal lakes.
  I encourage my colleagues to support this legislation and look 
forward to the debate on how we can promote recreation on our federal 
lakes.
                                 ______
                                 
      By Mr. EDWARDS:
  S. 3180. A bill to provide for the disclosure of the collection of 
information through computer software, and for other purposes; to the 
Committee on Commerce, Science, and Transportation.

                          ____________________