[Congressional Record Volume 148, Number 136 (Wednesday, October 16, 2002)]
[Senate]
[Pages S10531-S10546]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
UNANIMOUS CONSENT REQUEST--S. 3018
Mr. BAUCUS. Mr. President, on October 1, Senator Grassley and I
introduced a bipartisan Medicare package, the Beneficiary Access to
Care and Medicare Equity Act. Our bill would address a number of
Medicare payment changes--primarily reductions--that went into effect
at the start of the fiscal year. At the beginning of the fiscal year,
Medicare payment reductions automatically went into effect in many
areas. What were they? Cuts to home health services. Cuts to nursing
homes. Cuts to hospitals. One of the most damaging cuts of all, for
Medicare physician payments, is scheduled to take place beginning
January 1, 2003. This is the second year in a row such physician
payment cuts would occur. Mr. President, these cuts threaten access to
care for tens of millions of seniors across America.
Sadly, since this bill was introduced, the Administration has
indicated that preventing these cuts from going into effect is simply
not a priority.
Tom Scully, the administrator of the Center for Medicare and Medicaid
Services made this clear last Tuesday. He said:
It would be fine with the Bush administration if Congress
does not pass Medicare provider payment legislation this
year.
If I had to guess right now--I guess there won't be any
give-back bill.
The White House Office of Management and Budget Director, Mitch
Daniels, also said he thinks ``the Federal Government cannot afford to
pass a Medicare provider give-back bill.''
Mr. President, the Administration says it cannot afford, after all
the billions that have been spent elsewhere, to restore some of the
cuts that have already gone into effect.
The chairman of the House Ways and Means Committee has been equally
unenthusiastic about addressing these cuts.
The Administration and the chairman of the House Ways and Means
Committee may believe this legislation is not a priority. I
respectfully disagree. This bill is a priority. It is a priority for
every senior who receives home health care. It is a priority for every
senior who receives nursing home care. It is a priority for all
Americans of all ages who depend on our teaching hospitals. And it is a
priority to anyone who cares about ensuring our seniors receive access
to physician services.
Again, a large cut goes into effect for physician services after
January 1. Last January, physicians saw their payments cut by 5.4
percent. Already some doctors are talking about leaving Medicare. Why?
Because they are concerned that Medicare payments may not be enough to
allow them to pay for the costs of caring for seniors.
If this legislation I have introduced with Senator Grassley does not
pass, physician payments will be cut again by over 4 percent. This must
be changed.
Our bill also is a priority for our children. Under current law,
funds for the Children's Health Insurance Program that have not yet
been spent are scheduled to be returned to the Federal Treasury. I
think this money should remain where it belongs--with the States,
helping children. It is helping children who need health insurance
benefits. We have about 9,500 Montana kids, and many more children in
many other States, who are currently receiving coverage through CHIP.
If our bill does not pass, America's kids stand to lose as much as $2.8
billion.
This bill is also a priority for States. We have all heard about the
budget problems threatening States in every corner of our Nation, about
the possibility of deep cuts to important programs and services, such
as Medicaid. Our bill will send an extra $5 billion in fiscal relief to
the States to forestall these cuts.
This bill is a priority for rural America. From Montana to Maine, the
Medicare payment system continues to discriminate against rural
patients and rural providers. Our bill takes strong steps to address
these regional inequities.
This bill is a priority. I cannot imagine the administration saying
this is not a priority, given all the other areas where we spend
dollars. Defense, homeland security, and other issues are vitally
important. But our Nation's health is also important, and we should
invest in it accordingly.
I cannot believe this administration is saying it is not a priority
to prevent these cuts from taking effect. I cannot believe that.
Nevertheless, that is what they say. This legislation tries to address
that situation so those cuts do not go into effect.
I said this bill is a priority. It is a priority for our seniors. It
is a priority for our children. It is a priority for our State
governments and rural areas in our country, for anyone who cares about
preserving access to quality care in America.
I might add, this is a bipartisan bill. Senator Grassley and I have
worked very hard on this legislation. Senator Grassley is the ranking
member of the Finance Committee. We worked together at every point to
craft this bill. We sought input from our colleagues on both sides of
the aisle. We met with our respective caucuses. We worked closely with
members of the Finance Committee.
When the Senator from Oklahoma objected to my unanimous consent
request almost two weeks ago, he suggested this bill appeared out of
nowhere on the Senate floor. That could not be further from the truth.
The Senator also objected to this bill because we lack official CBO
scoring. That issue has been cleared, as we received an official
estimate of the bill on Friday. CBO estimates this bill would cost
about $43.8 billion over 10 years. We guessed it would cost about $43
billion. CBO said our guess is pretty close; it is $43.8 billion.
I believe that is the minimum investment we should make to address
the priorities I mentioned. So today as the Medicare payment cuts go
into their 16th day, and as many more cuts loom on the horizon in
January, I will again ask unanimous consent to pass S. 3018.
Mr. President, I ask unanimous consent that the Senate proceed to the
consideration of S. 3018, a bill to amend title 18 of the Social
Security Act; that the bill be read a third time and passed; that the
motion to reconsider be laid upon the table; and that any statements
relating to the bill be printed in the Record.
The PRESIDING OFFICER. Is there objection? The Senator from Oklahoma.
Mr. NICKLES. Mr. President, reserving the right to object,
unfortunately this bill did not go through committee. I ask the Senator
if he would modify his request to refer the bill to the Finance
Committee to be reported out within 48 hours. Will he be willing to
modify his request?
Mr. BAUCUS. I am sorry, I was distracted.
Mr. NICKLES. Correct me if I am wrong, but the Senator is trying to
pass his bill which never had a markup in the Finance Committee. I
happen to be a member of the Finance Committee. I would like to offer
an amendment. I know Senator Snowe has an amendment she would like to
offer. Senator Sessions has an amendment he would like to offer, or
myself or someone else on the committee to offer on his behalf.
[[Page S10532]]
We would like other Members to have a chance to amend the bill. So
will the Senator be willing to modify his request to request this bill
be referred to the Finance Committee for 48 hours for a markup so all
members on the Finance Committee would have a chance to have input on
this particular bill?
Mr. BAUCUS. Mr. President, in responding to my good friend from
Oklahoma, I have a couple points. First, as my good friend well knows,
since he is a member of the committee, this issue, the Medicare
provider bill, has been discussed for many weeks. It was in the Finance
Committee informally, with several discussions and meetings.
In order to prevent the harm that these Medicare cuts represent, I
believe, and I think Senator Grassley believes--we should check with
him and make doubly certain--that we should pass this bill now. It
makes more sense to pass this consensus bill than to go back and try to
make it perfect in the view of some other Senators.
Second, there are very few days remaining in the session. There are
very few days remaining before the election occurs. What does that
mean? It means under the Senate rules, anybody who wants to frustrate
the will of the majority, frustrate the will of 99 Senators, can
essentially do so by objecting or by offering amendments.
The Senator knows this because we have had four separate votes on the
issues he is indirectly referring to. Any attempt to refer legislation
back to a committee for the purpose of offering amendments is really a
veto tactic. It is an indirect way of accomplishing the same objective
by objecting. As the Senator well knows, the amendments he is thinking
of will not pass the Finance Committee, will not pass the floor, and
will have the effect of preventing the Medicare provider bill from
being enacted.
So in good faith, in order to help millions of Americans,
particularly the millions of seniors who need help right away, I could
not agree to that modification. If there are other amendments on other
issues such as prescription drug benefits, which I know the Senator is
indirectly referring to, let us try at a later date to get that passed.
We have tried for months, almost a year, to get prescription drug
benefits passed, but there has been no breakthrough, there has been no
agreement.
But there has been agreement on this Medicare provider bill, basic
agreement within the committee and basic agreement between myself, the
chairman of the committee, and Senator Grassley, the ranking member of
the committee. Let's not let perfection be the enemy of the good.
Seniors need help. They need help right now. The cuts have already
started to take effect. So let's pass this legislation, and then we can
deal at a later date with the issues to which the Senator is referring.
Let us get this bill passed so the seniors can get some help.
The PRESIDING OFFICER. Is there objection?
Mr. NICKLES. Mr. President, I object.
The PRESIDING OFFICER. The objection is heard.
The Senator from Oklahoma.
Mr. NICKLES. Mr. President, I will repeat to my friend and colleague,
the chairman of the Finance Committee, I will work with him to try to
come up with a package that can pass this Congress this year. I want it
to pass, and I want it to be signed into law. To come up with a package
that the administration is opposed to means it will not become law.
Some of us want to alleviate some of the problems. This particular
bill the Senator has asked to pass by unanimous consent, which means no
Senator gets to offer any amendment, flies in the face of Senate
tradition.
Senate tradition has always been--I did a little homework on
Medicare. Twenty-two of twenty-three significant Medicare changes
passed the Finance Committee in a bipartisan fashion and passed the
Senate usually with overwhelming numbers--not all the time but usually
with overwhelming numbers. So I was sincere in saying let us refer it
back to committee, let us have some amendments, let us have some votes,
and maybe we can come up with a bipartisan package that then will have
momentum to pass on the floor.
I might remind my friend and colleague from Montana, my suggestion
was that is the way we should do the prescription drug bill. We did not
do that on prescription drugs, and we ended up with no bill. Seniors
got zero, and I am afraid if we continue going down this path on the
so-called Medicare adjustment give-back bill, they will end up getting
zero. I would like for us to provide some assistance by passing
something that could become law.
When I objected to this previously--I believe it was a week ago
Friday, October 4--there was not a Congressional Budget Office scoring.
The bill was just introduced, and I said: How much is it going to cost?
To my colleague's credit, he said about forty-some-odd billion dollars,
and it was forty-some-odd billions dollars. I said: How much will it
cost the first 2 years? Because sometimes these 10-year estimates do
not mean a lot but the first year or two does.
He said that over the first 2 years it would be $10 billion. We did
get CBO's estimate, and the first year's cost, 2003, was $10.1 billion.
The second year's cost, 2004, was $11.8 billion. So the total cost is
almost $22 billion the first 2 years, so it is twice as much as it was
estimated in the original 2 years. That is real money. Can we do this
right?
We have a letter from AARP, and I ask unanimous consent that this
letter be printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:
AARP,
Washington, DC, October 9, 2002.
Hon. Charles Grassley,
U.S. Senate,
Washington, DC.
Dear Senator Grassley: The legislative session is drawing
to a close with no Medicare drug coverage in sight. Once
again, after years of waiting and with drug costs soaring,
beneficiaries and their families find that they get no help
from Congress. What they face instead is yet another round of
provider ``givebacks'' that will raise their Part B premiums.
The provider pay hikes enacted in the Balanced Budget
Refinement Act of 1999 (BBRA) and the Medicare, Medicaid, and
SCHIP Benefits Improvement and Protection Act of 2000 (BIPA)
are already costing beneficiaries $14 billion over ten years
in higher Part B premiums. The over $40 billion givebacks
package being considered by the Senate will raise Part B
premiums even higher--$6 billion in the first five years
alone. Less than 10 percent of that package would directly
benefit Medicare beneficiaries--the people the program is
supposed to be serving.
These added costs to beneficiaries come in addition to
double-digit hikes in prescription drug costs for older and
disabled Americans, many of whom have little or no options
for drug coverage. Employers continue to reduce or eliminate
health care coverage. Medigap premiums continue to rise. And
now, nine more Medicare+Choice plans are pulling out of
Medicare.
AARP opposes giveback provisions without drug coverage in
Medicare, and our 35 million members will not understand how
the Senate can take this course of action. Our members want
providers who treat Medicare patients to be paid fairly.
Errors or miscalculations in Medicare payment formulas should
be corrected. Fiscal relief to states to avoid drastic
Medicaid cuts should be addressed. Those can be done for much
less than $40 billion. And it must be done at a far smaller
cost to the millions of Medicare beneficiaries still waiting
for the Senate to fulfill its long overdue promise of
affordable prescription drug coverage.
Sincerely,
William D. Novelli.
Mr. NICKLES. AARP, which I do not always agree with, basically says--
I will read this one sentence:
AARP opposes give-back provisions without drug coverage in
Medicare, and our 35 million members will not understand how
the Senate can take this course of action.
They have stated they are opposed to doing a give-back bill on a
stand-alone basis.
The House passed a Medicare adjustment bill, or give-back bill, in
addition to passing prescription drugs. I know the Senator from Maine
has indicated an interest in trying to do that. Asking unanimous
consent to pass it without amendment would deny the Senator from Maine
the opportunity to offer an amendment either in committee or on the
floor. It would deny the Senator from Alabama the chance to do more for
a rural provider wage adjustment, which I know Senator Sessions has
repeatedly said he wanted to address. He should at least have that
opportunity, either in committee and/or on the floor. To do something
strictly by unanimous consent denies them that opportunity.
I make those points, but I am still willing to work with our
colleagues to see if we can do an affordable bill, one
[[Page S10533]]
that can pass both the House and the Senate and be signed by the
President this year. Maybe that is this week, maybe it is next week,
maybe it is the week after election, but I am willing to do that this
year. I am willing to try to get all parties together so we can
actually not make campaign statements but we can change the law and
have that law changed by a signature of the President. I think that is
doable, but we are going to have to get all parties together, and to my
knowledge that has not happened at this point.
I yield the floor.
Mr. HATCH. Mr. President, today I rise to join my colleagues on the
Senate Finance Committee in cosponsoring S. 3018, the Beneficiary
Access to Care and Medicare Equity Act of 2002. Although this bill does
not include all that I would have wanted, and indeed includes some
provisions with which I disagree, on balance, I believe it is necessary
to pass such a bill this year in order to provide needed assistance to
both Medicare providers and beneficiaries.
I would like to take this opportunity to express my strong support
for provisions contained in S. 3018 which increase reimbursement rates
for physicians, skilled nursing facilities and home health agencies.
Physicians' Medicare reimbursements were reduced by approximately 5
percent in 2002. Unfortunately, the estimates used by the Centers for
Medicare and Medicaid Services, CMS, when calculating the physician
payment formula were erroneous in some cases, and, regrettably,
physicians will continue to be subjected to large cuts in future years
if Congress does not take appropriate action. This is simply not fair
to physicians or their patients.
Doctors in Utah have been calling me about this issue since late last
year and have explained to me over and over again that these reductions
will have a lasting, negative impact on patient care. Some Utah
physicians have told me that they will no longer accept Medicare
patients or, even worse, are thinking about dropping out of the
Medicare program all together. And what impact does that have on
patients, especially those in rural areas? In my opinion, there is no
question it could lead to reductions in the number of Medicare
providers in rural areas. And, for those who are left, it will be
virtually impossible to spend quality time with patients.
Is this our goal? I do not think so. And I will be doing everything
possible to increase reimbursement rates to physicians to help them
continue to provide the high quality care that patients so deserve.
Another important component of S. 3018 is the valuable assistance
this bill provides to rural states, such as my home state of Utah. S.
3018 incorporates many of the recommendations included in the Medicare
Payment Advisory Commission's, MedPAC, 2001 report on rural health
care. This report found that beneficiaries living in rural areas
encounter more obstacles when receiving health care than those who live
in urban areas, primarily due to cost barriers. In addition, the MedPAC
report stated that rural hospitals have had lower Medicare inpatient
margins than urban hospitals throughout the 1990s. This gap has widened
from less than a percentage point in 1992 to 10 percentage points in
1999. These statistics not only apply to inpatient care, but also to
most Medicare services in rural regions of our country. In the end, the
report states the obvious, current Medicare payment policy places rural
communities at a distinct disadvantage and changes are necessary. S.
3018 takes steps toward addressing these important concerns and
attempts to provide equity between rural and urban Medicare providers
and patients. In my book, this is sorely needed.
In addition, it is important to me that Medicare funding for Skilled
Nursing Facilities, SNFs, is included in S. 3018. I have heard from
facilities across my State about the dire financial situation many SNFs
are facing due to reduced Medicare spending in fiscal year 2003. SNFs
care for our nation's most vulnerable seniors and provide valuable
medical assistance to these Medicare beneficiaries and their families.
I have been working with both Finance Committee Chairman Senator Max
Baucus and Ranking Republican Chuck Grassley on this important matter.
While I am pleased that the Senate Medicare provider give-back bill
provides more money to SNFs than the House-passed bill, I believe that
the funding level for SNFs should be even higher. I intend to continue
to work with my House and Senate colleagues on improving the Medicare
reimbursement rates for SNFs.
I also am pleased that S. 3018 includes provisions that will
eliminate the 15 percent reduction in home health payments. There is no
question in my mind that home health services are among the most
valuable Medicare provides. Home health agencies are providing
compassionate, caring services which, quite simply, help keep
beneficiaries out of more costly institutional settings. Home health
agencies across my State have urged me to support the elimination of
this cut. They have shown me how these potential cuts could cause many
home health providers in Utah to go out of business. Over my Senate
career, I have been extremely supportive of home health services, and
will continue my advocacy for this important program.
The preceding things having been said, one great concern that I have
with S. 3018 is the impact that this legislation could have on small
durable equipment manufacturers in Utah. The bill contains provisions
on competitive bidding which my constituents believe could drive them
out of business. On the one hand, I do recognize the need to ensure
efficiency in spending for scarce Medicare dollars. On the other hand,
though, I am deeply concerned about the effect this legislation could
have on these companies. I am working with CMS officials and my Utah
manufacturers to resolve concerns that have been raised about the
competitive bidding program included in this bill and will do
everything possible to protect small durable medical equipment
companies in Utah and across the country.
Let me also mention the Medicaid program. There is no secret that the
majority of States are running deficits in this program, expected to
reach $58 billion during this fiscal year. Adding to the urgency is the
fact that States have also used up two-thirds of their cash and their
``rainy day'' funds. According to a recent survey by the National
Conference of State Legislatures, more than 40 States had instituted
some kind of spending freeze or an across-the-board cut and 22 states
have cut Medicaid funds.
Included in the Baucus-Grassley legislation is a provision that would
direct some funds back to the States for their Medicaid programs. This
legislation increases the Federal medical assistance percentage by 1.3
pecent for 12 months. Additionally, it directs $1 billion in state
fiscal relief grants for Fiscal Year 2003.
In a perfect world, this is not the approach I would have preferred
we take to address the issue of fiscal relief for States. I have doubts
about the advisability of using an entitlement program to address a
shortfall in State funds. The precedence for linking an entitlement
program to the economy is unsound policy, in my opinion. If we had
adopted that policy years ago and were consistent in following it in
good times as well as bad, FMAP rates would have been lowered in the
1990s when States were experiencing surpluses, resulting in the current
FMAP rates being much lower than they are now. I am also very concerned
that this ``temporary fix'' will end up becoming permanent. Both the
Federal Government and the States do not have the best record when it
comes to cutting off a funding source we may have come to rely upon.
However, I do recognize that States are being forced to cut back
essential services to low and middle income individuals and families as
a result of States' considerable budget deficits.
Additionally, this legislation includes a much-needed fix for the
Children's Health Insurance Program, CHIP. Without this provision, some
$2.8 billion of unspent CHIP funds are scheduled to revert back to the
Treasury. It is critical that States are able to access these funds.
Some States experienced significant challenges when implementing their
CHIP programs. However, they are meeting that challenge and have
``ramped up'' considerably. They now are in a position to draw down
these dollars. Given these uncertain economic times, we should not
deprive states of funding to help finance the social safety net.
[[Page S10534]]
I also believe the provision prohibiting States from using their CHIP
monies to cover childless adults is wise policy. While I am extremely
sympathetic to the needs of the uninsured, it is important to note that
Senator Kennedy and I worked very hard to pass the CHIP program as a
way of helping the 10 million uninsured children in the country. As the
title reflects, the bill was solely directed at ``Children.'' Indeed,
it was not the health insurance program, HIP, nor the Adult Health
Insurance Program, AHIP, but the Children's Health Insurance Program,
CHIP.
If we would like to help needy, uninsured adults, by all means, let's
look at how we can accomplish that. In fact, Senator Wyden and I have
recently introduced a bill to jump-start that discussion. However, in
the meantime, we should not distort the focus of a program that is
working well to help its intended participants and lose the sense of
mission that has made it so effective.
Finally, I have serious concerns about the provisions in S. 3018 on
the Section 1115 waiver process for Medicaid and CHIP waivers. I will
be submitting a separate statement for the record which will outline my
thoughts on this issue in more detail.
In conclusion, I believe that passage of S. 3018, the Beneficiary
Access to Care and Medicare Equity Act, is critical for both Medicare
providers and beneficiaries. This legislation, while not perfect, will
provide access to quality and affordable health care to Medicare
beneficiaries across the country. I urge my colleagues to support this
bill and, in my opinion, we must pass this legislation before we
adjourn. Partisan politics needs to be put aside because this issue is
much too important to both Medicare beneficiaries and providers.
Medicare providers, and most importantly, the beneficiaries they serve,
are depending on us to get this job done, once and for all. Let's not
let them down.
The PRESIDING OFFICER. The Senator from North Dakota.
Mr. DORGAN. Mr. President, the two most powerful words in the Senate
are ``I object.'' The Senator from Oklahoma has demonstrated the power
of that by just objecting to the request by the Senator from Montana to
bring up the Medicare provider reimbursement legislation.
Some seem to believe there is no urgency about this issue. The
Senator from Montana has described bipartisan legislation that I
support very strongly and that I think it is urgent we pass. This is
bipartisan legislation addressing an urgent, serious, and difficult
problem. Let me describe it from the standpoints of two different types
of health care providers.
First of all, with respect to nursing homes, on October 1, long-term
care facilities experienced a cliff, or a sharp drop, in their Medicare
reimbursement. As of October 1, skilled nursing homes face a 10-
percent, or $1.7 billion, reduction in their payment rates for the
current fiscal year, and a 19-percent cut in 2004 unless Congress acts
to respond to it.
We can talk about numbers, this can all be about finances, but my
colleagues know what it really is about. It is about the quality of
care for people in our nursing homes. If the decision is made not to
reverse these cuts for long-term care, the quality of care is going to
be diminished for those folks who are in nursing homes.
I suppose one of the saddest days of my life was when I took my
father to a nursing home some months after my mother had been killed. I
will never forget the moment we decided he had to go to a nursing home
and then when I took him there. He did not want to go. The time he
spent in that nursing home meant I spent a lot of time there as well,
and I came to understand what long-term care was all about and what the
quality of care for our senior citizens was about. I have deep
admiration for the people who ran that nursing home. I do not know what
my father would have done without the care he received in that
facility.
In my State, we rank right near the top in this country with respect
to the number of nursing home beds per resident in the State are
concerned. Yet, on October 1, at a time when nursing homes are already
struggling and do not have the money they need, we find this cliff
exists where they get a reduction in reimbursement--and a pretty
substantial one at that.
Now we are nearing the last few days of this session and my colleague
Mr. Baucus brings to the floor legislation that I think makes great
sense. It is bipartisan. The chairman and the ranking member of the
Finance Committee are sponsors of this legislation. They say we need to
get this done, it is urgent, but we have people who stand up and say, I
object.
There are a thousand reasons to object, but there is only one good
reason to do what we need to do here to protect the quality of care for
vulnerable seniors in nursing homes, and that is because it is our
responsibility.
I have talked about nursing homes and how important they are. The
same is true with hospitals. For hospitals in my State, and I suspect
the States of Montana, Iowa, and many other States, the level of
Medicare reimbursement is going to determine whether we have hospitals
that are available to people who need acute care, who need emergency
care, in the future.
Now, we have the opportunity to do something to provide decent
payment to these hospitals.
Under the 1997 Balanced Budget Act, everyone in this Chamber
understands we cut too deeply. We understand that. The fact is, we have
hospitals and nursing homes on the brink of going out of business or
cutting back services. Rural hospitals, just about all of the hospitals
in my State, are disadvantaged by lower reimbursement rates. In my
State, and many others, rural and small urban hospitals receive a
standard payment that is woefully inadequate. We have to fix that. When
you take a look at the standardized payment for hospital payments, you
realize the standardized payment is not standard at all. This
legislation fixes that concern.
I know it is the eleventh hour. The fact is that Senator Baucus and
Senator Grassley have offered a piece of legislation that everyone in
this Chamber knows must be done. Yet we have people walking around as
if to say this is not an urgent problem. Check yourself into a nursing
home and tell me it is not an urgent problem. Check into a rural
hospital and check the financial records as you walk through the front
door and tell me it is not an urgent problem.
We spend a lot of time in the Senate during the year on things not so
serious. But there is a serious problem with Medicare reimbursement. We
often treat the light too seriously and the serious too lightly. This
is serious. We have a responsibility now to deal with this issue.
I hope the Senator from Montana will come to the floor every single
day we are in session and make the same unanimous consent request until
at some point we will not see people standing up to object. I hope he
will come tomorrow and I hope next week. At some point we will see this
Senate and the other body on the other side of this Capitol say: Yes,
let's do this. We have a responsibility to get this done for nursing
homes, for hospitals, and for other providers.
I did not mention physician reimbursement. I will mention that when I
talk tomorrow about this subject.
I appreciate the leadership of the Senator from Montana and the
leadership of Senator Grassley. This legislation is the right thing for
right now. Not next year, not the year after, but right now. It will
have an impact on the quality of care for the American people in
hospitals and nursing homes across this country.
I yield the floor.
The PRESIDING OFFICER. The Senator from Maine.
Mrs. SNOWE. Mr. President, I am deeply disheartened by what I am
hearing today, the refusal to refer the Medicare provider give-back
legislation to the Finance Committee for the deliberation and the
consideration it deserves. Time and again this Senate has circumvented
the traditional and conventional procedures to undermine the
possibility of enacting a prescription drug benefit for our Nation's
seniors.
It is clear to me if my colleague from the other side of the aisle
wish to achieve and accomplish a victory for our Nation's seniors, they
will work with me and others--the Senator from Oklahoma, those of us
who worked on this legislation in the committee--who crafted a
tripartisan package to provide comprehensive prescription drug
[[Page S10535]]
coverage for our Nation's seniors. The Senator from Vermont, Senator
Jeffords, Senator Breaux from Louisiana, Senator Grassley from Iowa,
the ranking member of the committee, worked together. We could make it
possible.
I am deeply disappointed by what I am hearing today. Again, it gets
back to the all-or-nothing proposition. Some have said, we have already
had votes on this issue. What does that have to do with our Nation's
seniors who are denied the possibility of having a prescription drug
benefit included in their Medicare package? That is who we should be
talking about today. It is not an all-or-nothing proposition. We can do
both. It is possible to do the Medicare provider give-back package the
Senator from Montana is referring to.
It is also possible to do a prescription drug benefit for our
Nation's seniors and include it in one package. There is no reason we
have to be in any other situation than including and considering these
issues in tandem. That is the desire of the Senator from Oklahoma,
Senator Nickles. That is my desire. That is the desire of our Nation's
seniors. In fact, it is the desire of the largest organization that
represent our Nation's seniors, AARP.
I know the letter has already been printed in the Record, but I will
read it. It is important to read.
The legislative session is drawing to a close with no
Medicare drug coverage in sight. Once again, after years of
waiting and with drug costs soaring, beneficiaries and their
families find that they get no help from Congress. What they
face instead is yet another round of provider ``givebacks''
that will raise their Part B premiums.
The provider pay hikes enacted in the Balanced Budget
Refinement Act of 1999 (BBRA) and the Medicare, Medicaid, and
SCHIP Benefits Improvement and Protection Act of 2000 (BIPA)
are already costing beneficiaries $14 billion over ten years
in higher Part B premiums. The over $40 billion givebacks
package being considered by the Senate will raise Part B
premiums even higher--$6 billion in the first five years
alone. Less than 10 percent of that package would directly
benefit Medicare beneficiaries--the people the program is
supposed to be serving.
These added costs to beneficiaries come in addition to
double-digit hikes in prescription drug costs for older and
disabled Americans, many of whom have little or no options
for drug coverage. Employers continue to reduce or eliminate
health care coverage. Medigap premiums continue to rise. And
now, nine more Medicare+Choice plans are pulling out of
Medicare.
AARP opposes giveback provisions without drug coverage in
Medicare, and our 35 million members will not understand how
the Senate can take this course of action. Our members want
providers who treat Medicare patients to be paid fairly.
Errors of miscalculations in Medicare payment formulas should
be corrected. Fiscal relief to states to avoid drastic
Medicaid cuts should be addressed. Those can be done for much
less than $40 billion.
The fact is AARP, our Nation's largest organization that represents
the seniors' interest, is opposed to passing a give-back program
without including a prescription drug benefit for our Nation's seniors.
Mr. President, we have the opportunity. Yes, we have the time. Over
the last month, there have been a number of hearings and markups that
have been scheduled in the Finance Committee. They have then been
canceled on a variety of pieces of legislation, including the Medicare
give-back. I and others in the committee, and Senator Breaux, were
planning to offer an amendment to the Medicare provider give-back more
than a month ago again when that legislation was scheduled for markup
in the Finance Committee which is appropriate because that is the
committee of jurisdiction. We intended to offer an amendment to that
legislation. Then the markup was canceled. There were a variety of
other markups that were scheduled in the Finance Committee over this
last month on various issues.
Again, we were saying if we can have time to consider these other
important pieces of legislation, clearly we should have the opportunity
and we have the time to consider a prescription drug package.
Now, you might say, we had votes in July on this issue in the Senate.
That is true. Did the Finance Committee have a markup on the
prescription drug bill? The answer is an unequivocal no. I can't state
why. The Finance Committee, the committee of jurisdiction, did not have
a markup on a bill I think virtually everybody in this Chamber would
agree is one of our Nation's top domestic priorities. Everyone would
agree with that. So you might ask, why didn't the committee have a
markup, going through the conventional procedures, so that both sides
have the chance to deliberate, to amend, debate, and vote upon a
package? It is a very good question, a question to which I do not have
an answer. Yet I have never had an answer. This is close to a $400
billion package that would provide prescription drug coverage to our
Nation's seniors. Yet we did not have a markup. That clearly undermined
our ability to achieve a consensus on this legislation.
You could take the tax-cut legislation in the year 2001. No one knew
what the end result of that bill would be when it came before the
Finance Committee. We had the ability over several days to amend it,
debate it, and vote upon the various issues the Members had presented
to the committee. Ultimately we voted on a package. It came to the
floor. We had more amendments. We had more than 50 amendments to the
tax cut bill because we had the right and the prerogative to express
our positions and our views of the States that we represent. During the
natural course of the legislative procedure, we had the ability to
express ourselves on that very important piece of legislation and then
ultimately vote for its enactment.
The same was not true when it came to this significant issue that
affects most of our Nation's seniors. So it became an either/or
approach. What I am saying today is let's take the Medicare provider
give-back legislation and let's have the opportunity to also consider
an amendment--amendments to that legislation that would include a
prescription drug package. I will make a unanimous consent request
shortly on that issue.
But I think we have the time, we have the ability to do both in this
Chamber right now. The question is, Do we have the political will? Some
people, as I said earlier, say we have voted on this issue. It is not
about us. It is not about us. The last time I checked, Members of the
Senate had health care coverage that included prescription drug
coverage. It is about our Nation's seniors, and it is making this
institution work on behalf of the people we represent. Each of us have
an individual and collective responsibility to make that happen.
It is a true failure on our part that we did not make this possible.
We worked a year and a half ago--the Senator from Vermont is here, Mr.
Jeffords, and Senator Breaux from Louisiana, Senator Grassley and I
worked--more than a year and a half ago to begin the process of shaping
a comprehensive package so we could include this significant benefit in
the Medicare Program to avoid political collisions, to avoid the
scenario that has now manifested itself in this institution on this
particular issue.
But what we got instead was denial and obstruction and circumvention
of the conventional processes of this Senate--No. 1, because we did not
have a markup in the Finance Committee; and, No. 2, it was an up-or-
down vote in the Senate floor on two packages, no amendments. So we did
not have the ability to work through our differences, work through the
concerns that each of us might have in terms of how do we shape this
most significant benefit that nobody denies the seniors deserve and
desperately need. No one is denying that. So what is impossible about
doing it right here and now?
If we have had time over the last few months to schedule markups in
the committee on various initiatives, including the Medicare provider
give-back, then why don't we have the time to also include, in
conjunction with those bills, a prescription drug coverage?
How can we fulfill our commitment to our Nation's seniors if we fail
to do that in this session of this Congress? And to provide a provider
give-back bill that I certainly support, but also one that raises Part
B premiums? It raises Part B premiums. And that is not my estimate.
That is the estimate of the Congressional Budget Office.
What we are saying is, recognizing the impact that will have on our
Nation's seniors and the costs to them directly, when you raise Part B
premiums, you are obviously going to have to pay more of their out-of-
pocket costs for their Medicare coverage. So why then are we not also
considering a
[[Page S10536]]
prescription drug benefit to ease the impact of the cost to our
Nation's seniors, if they can even pay? Even if they can afford to pay
out-of-pocket costs for their drugs. But most, as we know, are forced
to choose between food and paying for their prescription drugs
prescribed by their doctors.
I believe we have a greater obligation. We have a greater obligation
to build upon the support of both goals here today. I hope we will be
able to do that. That is why I think it is so clear that we do not have
to end this session this way. If we had the ability to consider a $43
billion package that provides reimbursements to our rural hospitals and
home health care, to medical providers--and they, too, will acknowledge
how imperative this benefit is to our Nation's seniors--they certainly
would welcome the Senate's action on both pieces of legislation in
tandem.
The House of Representatives passed, months ago, both a prescription
drug bill and a Medicare provider give-back. While some may have
differences in this Chamber with what direction and what provisions
they included in that package, they ultimately passed a package that
included both initiatives. I happen to believe that we have a greater
obligation to do the same.
I don't think we can use the rationale that we are here at this point
in time and that we do not have the time anymore. Let's send this back
to committee. I regret the Senator from Montana objected to the request
made by the Senator from Oklahoma to refer this back to the committee.
We have the next couple of days. We are going to be here. We may be
here next week. We have the ability to mark up this legislation, both
the provider give-back and the prescription drug bill--we have the
time--and then report it back to the floor so each of us have the
opportunity again to debate and amend, if at all possible, on various
issues, and have a final vote.
I think we should try to work together to advance a viable,
comprehensive prescription drug plan that warrants strong bipartisan
support. We developed a tripartisan package beginning more than a year
and a half ago. We announced our principles a year ago July, setting
out the framework so we would avoid the political collisions and the
polarization and partisanship that seem to be the monkey wrenches
grinding this legislative process to a halt.
But again, I guess it was not sufficient to overcome those
impediments. Those negotiations we did have during the course of the
summer, even in the aftermath of the votes that were taken, the up-or-
down votes on the two packages--one by Senator Graham, one that was
offered by those of us who represented the tripartisan plan--we even
had negotiations this fall. We all felt a breakthrough compromise was
near.
The foundation of that compromise was going to be, in fact, the
tripartisan package. In fact, we had one of the meetings that was
chaired by the Senator from Montana that included more than 14
Senators, almost equally divided across the political aisle. We were
really focusing on the several issues that really did represent the
areas of disagreement. Somehow the meetings were canceled.
No explanation was given. This is all the more unfortunate and
disappointing because I think we did have a sense of agreement.
The bottom line is we have never been closer than we were in
September of providing this package--a universal, comprehensive
Medicaid benefit for our Nation's seniors. The basis of a consensus
package exists today.
I hope we can agree today to do both. I am committed to doing that.
I know there are others here who are committed in this Senate to do
what is right for our Nation's seniors. We can argue about not having
the time. Tell that to our Nation's seniors--that we just didn't have
time. We have time for other issues, but we don't have time for our
Nation's seniors when it comes to this vital benefit that can make the
difference between life and death.
We have all heard the traumatic stories and circumstances that many
of our Nation's seniors have been placed in because they do not have
the kind of coverage that is extended to each of us here in this
institution.
I happened to come across a poll not too long ago. It says when
asked, Should senior Americans have the right to choose between
different health care plans with different benefits just like Members
of Congress and Federal employees? Of course 90 percent said, yes, they
want to have that choice. They want to be able to choose in their
Medicare benefit package prescription drug coverage. They would have a
choice under the tripartisan package. They could choose the traditional
Medicare Program, the new enhanced fee-for-service program, or the
Medicare+Choice. But whichever program they would choose, they would
have the option of a prescription drug benefit. That is the way it
should be.
We all know the Medicare Program was developed almost 40 years ago.
It needs to be reformed and overhauled in a way that modernizes and
reflects the kind of health care that seniors are getting today. But
some say the traditional program works, and they should have that
option and benefit. If they want a new, enhanced fee-for-service that
also includes prescription drug coverage, they should have that
benefit. But the fact is they should have a choice.
We are told, ``the next Congress.'' I have been hearing that every
Congress. As far as I can check, we have been talking about this for
almost the last 4 years or more--the next Congress; the next year. It
is here and now that we have an obligation. We have an obligation to do
it now.
AARP is right in saying that you can't do one without the other--
especially because it has the impact on increasing our Nation's
seniors' Part B premiums. That, of course, has been underscored by the
Congressional Budget Office as well--that it will raise the cost of
Part B premiums as a result of this give-back bill. If we are going to
do the give-back--and I wholeheartedly support that--then we also have
a responsibility to provide this most critical coverage to our Nation's
seniors.
It would be a terrible oversight if we fail to do what is right. This
action is warranted. Seniors cannot put off their illnesses, and we
must not put off a solution.
I come to the floor to offer a proposal that we consider not only
Senator Baucus' legislation and provide for his legislation but also
the tripartisan prescription drug package. I made a commitment to our
Nation's seniors that I would protect their interests and do everything
possible to pass the Medicare prescription drug benefit this year.
Now is the time to be giving that consideration. To say that we don't
have time is really failing our Nation's seniors. We do have time. We
have time because we are considering the Medicare-provided give-back.
We have time because a number of markups were scheduled before the
Senate Finance Committee, and they were canceled. But there was
obviously time that was included on the schedule for the members of the
committees to consider other pieces of legislation for markup in
committee. I don't object to that. But what I object to is denying our
Nation's seniors the ability to have a prescription drug benefit
because we are denied the ability to give voice to that benefit and to
express our will through the traditional procedures of the committee
and here on the floor of the Senate.
I regret that the majority leader will not allow a vote and a vote on
an amendment and consideration on both issues in tandem. We could do it
in the committee and bring it to the floor. That is certainly what I
would prefer. But if not, we ought to be able to consider both of these
initiatives before the full Senate. We should let the process work the
way it is designed because our Nation's seniors deserve at least that.
Unanimous Consent Request
I ask unanimous consent that the Senate immediately turn to the
consideration of S. 2; that following the reporting by the clerk, a
substitute amendment at the desk which contains the text of S. 3018,
the Beneficiary Access to Care and Medicare Equity Act of 2002, and S.
2, the 21st Century Medicare Act, be considered and agreed to, the
motion to reconsider be laid upon the table, and the bill then be open
to further amendment and debate.
The PRESIDING OFFICER. Is there objection?
Mr. REID. Mr. President, reserving the right to object, I say to my
friend from Maine, the distinguished senior Senator, that maybe she
protesteth too much.
[[Page S10537]]
The fact is the prescription drug package that she talks about did
not get a majority vote in the Senate. The one that received a majority
vote of 51 Senators was the Gramm-Miller amendment prescription drug
plan. That received a majority vote of the Senate.
I think her idea is a good idea--that we go ahead and adopt what the
Senator from Montana, the chairman of the Finance Committee, has come
to the floor twice today and talked about doing the Medicare give-
back--have that and have the prescription drug bill have a majority
vote. Graham of Florida and Miller--51 votes.
That would let the will of the Senate work where the majority of the
Senate determines what happens. The problem was we didn't get 60 votes.
We had 51 votes.
I also say my friend from Maine talks about protecting the interests
of seniors. I know she wishes to protect the interests of seniors. I
think the best way to do that is with the best prescription drug
package that has surfaced in the Senate--the one that received the
majority vote of the Senate. Let us pass that. That would protect the
interests of seniors.
I would also say this: I say it with a smile on my face. To have the
minority talk about us having enough time to do things is about as
close to being ridiculous as anything I have heard. I have sat on this
floor--not for minutes but hours, days--I have sat here for weeks while
the minority has prevented us from doing anything. We can't pass our
appropriations bills because they won't let us. We can't pass homeland
defense because they won't let us. We can't pass the conference report
on terrorism insurance because they won't let us. We can't pass the
prescription drug bill because they won't let us. We can't pass the
generic drug bill because they won't let us. I could go on and on.
So don't tell me that we do not have enough time to do things. We are
not having enough time to do things because the minority won't let us.
So I object, unless my amendment is accepted.
I move to amend the unanimous consent request to accept the
language----
The PRESIDING OFFICER. Objection is heard.
The Senator from Maine has the floor.
Ms. SNOWE. Thank you, Mr. President.
In response to what the majority whip mentioned, the fact is that we
had the opportunity and the time. The motion that I offered with
respect to the Medicare-provided give-back legislation and the
prescription drug benefit is including further amendments and debate.
That is all we are asking, to have the opportunity to debate and
amend a package on the floor of the Senate that gives our Nation's
seniors the option of having a prescription drug benefit in the
Medicare program. It is not a question of whether I protest too much. I
can assure you, our Nation's seniors will protest when they learn about
the failure of this institution to pass any prescription drug benefit.
We were close to working out our differences on the few issues that
really did separate us on the two packages that were before the Senate
back in July. It really came down to several different issues. We had
ongoing negotiations, even including additional Members who had been
working on this issue before, because we were reaching out. We were
close to reaching an agreement, whether it was on the cost or the
fallback, to ensure every senior had the option and the access to a
prescription drug benefit that was designed in that program, regardless
of where they lived in America, so no one would be denied.
We were close to reaching that consensus. But for some unexplainable
reason, further negotiations were suspended. That was regrettable
because we could have been at a point where we could have enacted a
prescription drug benefit in the Medicare program.
When I asked for this unanimous consent, it was to also include the
opportunity for the Senate to amend and debate this legislation. We do
have the time. If we have the time to bring up Medicare provider give-
back legislation of more than $43 billion, then clearly we also have
the time to consider a prescription drug bill. Then, I would argue, we
are even further along in this institution in examining all of the
components and provisions and the issues surrounding the development of
a comprehensive universal package. We are much further ahead because we
did have debate on the two proposals on the floor, but we didn't have
the opportunity to amend our various packages. It was up or down, all
or nothing, either/or, take it or leave it, get the 60 votes or not--
not expressing our will through the conventional procedures of this
institution.
I cite again the example of the tax-cut measure we ultimately adopted
in the Senate back in May of 2001. It required several days. In that
case, there were 50 amendments. But we expressed ourselves. We had the
opportunity to offer amendments and then ultimately vote on a final
package, yes or no. That is not the same opportunity that has been
given to this issue.
Our Nation's seniors deserve to know that. They also deserve to
consider both of these initiatives in tandem. I have yet to hear a
reasonable argument as to why we can't do that, why we cannot include
both of these initiatives in one package, similar to what the House of
Representatives did months ago. We should be able to do the same thing
in the Senate, send the package to the conference, and work out the
issues.
Believe me, there is great urgency to obviously resolve both of these
initiatives to reach a final conclusion. I think there is genuine
interest on both sides of the political aisle here in this institution
and on the other side to work these issues out in the final and
remaining days of this Congress. But to say it can't be done, tell that
to our Nation's seniors.
Voting on an issue means nothing unless you produce results. Results
means taking final action on a piece of legislation that is sent to the
President of the United States. The President is eager to have
legislation that can be signed into law to give this much-needed
benefit to our senior citizens.
We can do it. I hope the Senate will recognize it is a very
reasonable unanimous consent request. I hope they will reconsider their
objection to this request.
Mr. REID. Would the Senator repeat herself? I was speaking to one of
my staff.
Ms. SNOWE. I hope the Senator would reconsider his objection to my
unanimous consent request because this motion really is asking to
include both issues in one package in tandem and to be able to further
amend and debate. I think it is a reasonable request, and it is one
that should not be denied.
Mr. REID. Will the Senator allow me to respond?
Ms. SNOWE. I am glad to have the Senator respond.
Mr. REID. The Senator has asked if I would respond or reconsider. I
have the greatest respect for the Senator from Maine. We have worked
together on many issues. She is a fine legislator, but she is simply
wrong.
It seems somewhat unusual to me that in the waning hours of this
congressional session, suddenly we want to have a debate on Medicare
give-backs and prescription drugs. We have fought the minority all year
long on many issues. On the list, of course, is prescription drugs.
That is the second one we have here. We were forced to pass something
that is good, but certainly not what we wanted with the generic drug
bill. It is buried in the dark hole of the Republican-led House of
Representatives because they will not go to conference.
We have the Medicare give-backs, which is so important for the people
of the State of Nevada and Maine and Vermont, West Virginia and
Montana, any State in the Union, a very important piece of legislation.
That is ready to move. We could pass that in a matter of minutes.
The prescription drug bill I referenced, the Graham-Miller
legislation, had extended debate on the floor. We have heard enough
about that. People understand the issue. It got a majority vote. We
don't need another amendable item on which we have, frankly, your side
stall, stall, stall, as you have done all year long.
I have reconsidered. The only thing I would suggest we do is adopt
the proposal of the Senator from Montana, the proposal of the Chairman
of the Finance Committee, on Medicare give-backs and stick in that, if
we have so
[[Page S10538]]
many on the other side who suddenly found religion and want to do
something to help seniors with prescription drugs; that we pass, as a
majority of the Senate has already said we should do, the Graham-Miller
prescription drug bill.
The PRESIDING OFFICER (Mr. Feingold). The Senator from Maine.
Ms. SNOWE. Mr. President, in response to the points made by the
Senator from Nevada, obviously the minority do not design the floor
schedule. That is the prerogative of the majority. The minority did not
preclude the Finance Committee from marking up this legislation. We did
not choose to postpone the consideration of a prescription drug package
in the Finance Committee. The Senator from Nevada would acknowledge a
markup in the Finance Committee was important and essential to
achieving the consensus that is so critical in passing any significant
piece of legislation.
In this instance, we are discussing a package that represents more
than $400 billion over the next 10 years.
Mr. President, I think everybody would agree the Finance Committee
should have had the opportunity to consider that initiative. I cannot
think of the last time that creating a new benefit, a new package, or a
new program that represents close to $400 billion over the next 10
years, has not had the benefit of a markup in the committee--at least,
if you are thinking about enhancing the ability to create the consensus
for the final passage of that legislation. So the process was
circumvented, for whatever reason, I do not know.
But what I do know is what is possible today. I do know if we had the
political will, we could resolve the few differences between the
positions that were offered on the floor back in July that,
regrettably, we didn't have the opportunity to amend or further amend.
It was, again, as I said, up or down, either/or, all or nothing. Well,
you cannot achieve cooperation and consensus on a major package of this
kind without working through the various issues.
So all I am asking is we have the opportunity to consider a
prescription drug benefit in tandem with the Medicare provider give-
back. If we have time to provide $43 billion in additional assistance
to Medicare providers--and I would wholeheartedly support that, but I
also would support providing prescription drug coverage to our Nation's
seniors. How can we do one without the other? I have not heard an
explanation I think would be acceptable to the senior citizens of this
country.
We didn't have time? Well, where have we been over the last 2 years?
We didn't have time, Mr. President? I don't think that is acceptable.
How does anybody go home and say to their constituents we didn't have
time--especially because that has been the rationale given for the last
4 years: we will put it on to the next Congress.
We are elected to do what is important here and now. That is our
obligation. If we have to stay here day and night, through the weekend,
what greater obligation do we have than to do what is important to the
people we represent? This is an issue that has been acknowledged by
both sides to be one of our top domestic priorities, and we are saying
we don't have time. We don't have time in the committee. We didn't have
time in the committee last July. We didn't have time in the committee
last spring. We have not had time. When do we have time around here,
Mr. President? When do we have time to do what is right in this
institution? When do we have time? How do we do it?
We had a tripartisan group from the Senate Finance Committee begin to
work on this issue a year ago--I would say in June, and we announced
our principles a year ago July--to avoid this type of political
showdown, to avoid the all-or-nothing confrontation that seems to
pervade this institution. Guess what. We are denied the ability to mark
up this bill in the Senate Finance Committee.
Well, I might be protesting too much, but, frankly, I think our
Nation's seniors deserve better. I know they are protesting. Tell them
we don't have time. Explain to them why we didn't have a markup in the
committee that would have increased the likelihood of the passage of
this legislation.
Now we are hearing we should have this Medicare provider give-back. I
endorse that, but I don't believe these are mutually exclusive issues.
I want to make that clear. These are not mutually exclusive items.
Obviously, AARP agrees because of the letter they sent to the
legislative leadership, the committee leadership, and the ranking
member of the Finance Committee, that you should not do one without the
other. I am speaking on behalf of the seniors I represent in my State
of Maine. They deserve better.
I hope the Senator from Nevada will reconsider, so we have the
ability here and now to consider the provider give-back benefit, and if
the Senator indicates there is general unanimous agreement to provide
that, then we can focus on the prescription drug benefit and on the few
areas we have identified to be the issues in disagreement between what
was offered by Senator Graham and the tripartisan package offered by
the Senator from Iowa, Senator Breaux from Louisiana, Senator Jeffords
from Vermont, and myself. We can do that. I hope I will hear that
message today. Let's begin here and now.
Mr. REID. Mr. President, I try to be very patient; sometimes I am and
sometimes I am not. But I have to tell you the statement of my dear
friend, the senior Senator from Maine, is really trying my patience.
She has stated numerous times she likes the tripartisan piece of
legislation. More power to her. The fact is, it could not get a
majority vote in the Senate. We had a piece of legislation that got a
majority, but she refuses to talk about that. She talks about
committee, committee, committee. We recognize how the Senate works. The
committee structure, I support. I have great respect for the traditions
of the Senate. But there are times when the committees don't have full
hearings on pieces of legislation.
The minority should become consistent because, on the one hand, they
are telling us if the committee works and they don't like what the
committee does, the matter should come to the floor anyway. Let's see
how that would work here. If something happens in the Senate Judiciary
Committee and they make a determination and the minority doesn't like
what happens in the committee, then it should come to the floor anyway.
It would seem to me if you are consistent, you have to recognize we
have a situation where we have had extensive debate that took place
over a period of many weeks on prescription drugs. The only one that
got a majority vote is the one I talked about--on two separate
occasions--by Senators Graham and Miller. Let's pass that now. I think
that is fine.
I see the Senator from Michigan, who spent weeks of her time working
on prescription drugs. We didn't get a prescription drug bill because
we could not get 60 votes. But we had a majority. We passed a generic
drug bill--not a perfect bill but a good one--that would lower the cost
of drugs in America, not only for seniors but for everybody. It allows
reimportation from Canada.
Where is that bill? It's buried over in the dark hole of the
conferences of the Republican-led House of Representatives. They won't
even let us do that. Here we have somebody telling us we have lots of
time. Let's do another prescription drug bill, but we want to start
this one in the committee. When it comes to the floor, we want to have
a lot of amendments, or a few amendments.
We know that is a prime-time word for the big stall. That is all this
is. I have great respect for the AARP. It is a great organization, but
they don't run the Senate or this country. There are many people in the
State of Nevada, and all over the country, who badly need this Medicare
give-back. So I am willing to take my chances with AARP because the
Republicans would not let us pass a prescription drug bill, a generic
drug bill. I will take my chances with AARP and go with the Senator
from Montana. Let's pass the Medicare give-back bill to help millions
of people in America--rural America and urban America--people who badly
need this. I am going to have convalescent centers going broke in
Nevada, filing bankruptcy.
Is that what we want? We had a convalescent center in rural Nevada.
They had all kinds of problems. They did not know what to do with the
people in the
[[Page S10539]]
center because they were going broke. What do they do with them? It was
the only center in town. This legislation would direct money to that
situation.
AARP is a great organization, but they can take that letter and
carpet floors with it because that is not how we run the Senate. We do
what is best for the people of our States, and the best for our States
is to do what the Senator from Montana said to do. We tried to pass all
kinds of legislation, and we have had the big stall. So do not have
anyone lecture me on enough time to do things. I have spent days,
weeks, and probably months of my life sitting here doing nothing
because they would not let us do anything.
The PRESIDING OFFICER. The Senator from Montana.
Mr. BAUCUS. Mr. President, I am thankful the Senator from Maine is
still on the floor. I wish to respond to a couple points she made.
I do not know that there is anybody in the Senate who wants to get a
prescription drug benefit for seniors more than the Senator from Maine.
Believe me, I understand that. I have been at many meetings with the
senior Senator from Maine where she has made that very clear.
There is also no one on the floor who wants to pass a prescription
drug bill more than the senior Senator from Montana. The same is true
of the Senator from Michigan, the Senator from Nebraska, and the
Senator from West Virginia, as well as the current occupant of the
chair, the Senator from Wisconsin. We all want to get a prescription
drug benefit passed.
On the one hand, there is the so-called tripartisan bill, which the
Senator from Maine supports, and which is basically the insurance
company model. On the other hand, there is the bill that would use
pharmacy benefit managers, or PBMs, to administer a drug benefit. This
is essentially the Medicare model. Reducing it to its basic simplicity,
that is the argument.
The Senator says she wants a prescription drug benefit passed, but
she slyly indicates she wants hers passed. But her bill did not get a
majority vote in the Senate. There are others who want to get
prescription drug benefits passed who have a different view of what a
prescription drug benefit should be, and that is the problem. Neither
side wants to give in. Both sides think they are right.
We just witnessed a good example of that. The Senator from Maine
says: Bring up a prescription drug bill, but bring up hers, the way she
wants it. She does not agree to bring up the other bill, apparently,
that the Senator from Nevada suggested, the one that received a
majority vote. That is the problem. Neither side agrees. Each side
wants its bill passed.
I say to my good friend--and she well knows this--I have worked so
hard with her to get a prescription drug benefit passed. I called the
meeting in my office with the Senator from Maine and with other
Senators who were key Senators on this subject as a last-ditch effort
to get a bill passed because I share with her the view we owe it to our
seniors to get a prescription drug benefit bill passed. I understand
that.
But the Senator knows well that there are huge differences of
agreement. The issue is basically, should we have a more privatized
system or not? That is basically the argument.
The Senator from Maine suggests the approach that privatizes
prescription drugs to seniors with insurance companies. That is
basically her bill. There are others who say: No, do not do that; that
is wrong because insurance companies will take too much for themselves;
the insurance companies will not give the benefits to the seniors, and
besides that, insurance companies are not sure they want to do it,
anyway.
It is very easy for a Senator to stand up and say: Let's do
prescription drug benefits. The hard part is actually coming up with a
compromise so we can reach a solution and pass a bill that does give
benefits to our seniors.
To be frank, I have not heard the Senator from Maine come forth to me
or anybody with a reasonable compromise. She has been pushing for this
insurance company model, and she is not coming up with a compromise. I
say that because that indicates the degree of separation and the
division in this Senate over how to get prescription drug benefits to
seniors.
But while we all want to pass a benefit, we also want to make sure it
is done right. If we are going to pass legislation on the order of $400
billion over 10 years, we have to make sure it is done right and that
it works for seniors. It does not make sense just to pass a bill. It
makes sense to pass a bill that works.
I could not agree more with the Senator that we should pass a bill,
but in all candor, at this late moment, coming up to the Chamber
without first suggesting an honest-to-goodness compromise sounds as if
this is obfuscation. On the surface, it sounds good: Let's pass a
prescription drug benefit. I know she means well, but there are others
on her side of the aisle for whom this is an obfuscation, a desire not
to get an underlying give-back bill passed.
The reason the Medicare give-back bill is here is because there is
agreement. There is agreement on almost all of the provisions: an
agreement that we should not allow the home health cut go into effect;
agreement on what the restoration for physicians should be; agreement
on hospital payments, the so-called standardized amount. There is
agreement.
But there is not agreement on how to provide prescription drug
benefits, and the Senator from Maine well knows that. Her argument is:
Let's just try; let's try it.
Sometimes we have to tell it like it is. The fact is, both sides are
so stuck in their ways that I have made the judgment that it is nearly
impossible in the remaining days to reach agreement because we are in
such a political season.
If the Senator from Maine wants to come forth and give me a
legitimate compromise, then maybe we can get a bill passed. She says
she wants the tripartisan bill up for consideration. She does not say:
let's sit down and work out a legitimate agreement and see if we can
put something together.
I would like to sit down with the Senator from Maine and see if we
can reach agreement. I know the Senator from Maine would like to do so.
To be honest, she has not suggested anything except the tripartisan
insurance company model. And that plan did not even get a majority vote
in the Senate. The approach by Senator Graham received a majority of
votes in the Senate.
Mr. President, if we don't pass this bill to restore Medicare
payments, we should consider all of the seniors who may get less care
in nursing homes, and seniors who may get less care because doctors
will no longer provide Medicare services to patients.
My good friend from Maine points out that the Medicare payment bill
will increase costs to seniors. She does not tell us that of the
increased cost to seniors 90 percent is caused by a restoration of
payments to physicians. This restoration is needed to ensure that
physicians will still provide care to seniors.
If she wants doctors to continue to withdraw from Medicare, that is
her right, that is her choice, when she complains about the amount of
the increase seniors will have to pay. It is true that they will have
to pay a little more. We have to figure out a solution to that. I am
hopeful we can do it next year, and I am hopeful there will be more of
a bipartisan mood around here.
I know the Senator's motives are pure. Hers are pure, but I cannot
say that for the majority of the Members on the other side of the aisle
on this issue at this moment. I have been around here a while and know
how this place works. I have the utmost respect for the Senator from
Maine. She has pure motives, but her offering this unanimous consent
request at this time is clearly an effort on the part of others--not
her--on the part of others to try to slow down and prevent the Medicare
give-back bill from passing.
Mr. HATCH. Mr. President, as my colleagues are aware, I have agreed
to cosponsor S. 3018, the Beneficiary Access to Care and Medicare
Equity Act of 2002, because I believe it is imperative we act this year
to correct deficiencies in Medicare payment levels that are certain to
create hardships for providers and those they serve, beneficiaries.
I want to take this opportunity to underscore concerns I have with
Section 706 which deals with the process for development and
implementation of Medicaid and CHIP waivers.
[[Page S10540]]
I am sympathetic to the underlying concerns expressed by the sponsors
of this provision, especially as they relate to coverage of childless
adults under the CHIP program. CHIP was designed to address the needs
of children of working parents who made too much money to qualify for
Medicaid, but, many times, could not afford private health insurance. I
believe that the integrity of the CHIP program must be maintained. For
this reason, I have even opposed attempts to expand CHIP to cover
pregnant women, because I believe funding should be devoted to
providing coverage to uninsured children, preserving the original
intent of this legislation. It should come as no surprise to my
colleagues that I oppose expanding CHIP under a waiver to cover
childless adults.
However, there are those who do not share my views on this issue and
I believe that they should be heard. There are those who believe that
CHIP enrollment is not as high as it could be because parents are not
covered by the program. They believe that one way to capture children
under CHIP is to offer family coverage. I do not agree with that
approach, but I do believe that there should be a debate on the issue.
Before Congress adopts provisions which could limit both the Federal
and State governments' ability to adopt innovative approaches to
address the problem of the uninsured, we ought to have a thorough and
comprehensive debate. The Senate Finance Committee should hold hearings
on these important waiver issues prior to enacting legislation which
could be detrimental to State flexibility and innovation. I strongly
object to including a provision which is opposed by the Secretary of
Health and Human Services and the National Governors Association in an
attractive package of Medicare reimbursements and fiscal relief for the
states. Both HHS and NGA have concerns with this provision because it
limits a State's flexibility to provide expanded health coverage
tailored to the specific needs of its residents.
I believe that, as drafted, Section 706 would deter a state's attempt
to provide health insurance coverage to those who are currently
uninsured. Additionally, it is my view that Section 706 would not
improve the waiver process, but would actually function as a
disincentive for States to undergo an open dialogue with stakeholders
as they go through the process of securing a Medicaid or CHIP waiver.
Section 706 would require that 60 days prior to the date that a state
submits a waiver or amendment application to the Secretary, the state
must publish, for written comment, a notice of the proposed waiver that
contains at least the following: projections regarding the likely
effect and impact of the proposed waiver on any individuals who are
eligible for receiving medical assistance or health benefits coverage.
In addition, a State must make a statement regarding the likely effect
and impact of the proposed waiver on any provider or suppliers of items
or services for which payment may be made under the Medicaid or CHIP
program.
It would seem to me, that we are putting the cart before the horse
here. Isn't it the purpose of a public comment period to determine the
effects and impacts on individuals and providers? Aren't we setting the
States up to be criticized for coming to pre-determined conclusions
about the effects of a proposed waiver by requiring them to effectively
develop these conclusions before the public has had a chance to weigh
in on the matter?
Section 706 goes on to require that the State must have one meeting
with the state's medical care advisory committee and two public
hearings on the waiver. I am somewhat confused by these provisions. It
seems to me that rather than encouraging an open and comprehensive
dialogue in the state over a proposed waiver, Section 706, if enacted,
would curtail and truncate the process, effectively limiting input from
the very individuals and groups which would be affected by the waiver.
In short, to comply with Section 706, a State could conclude what the
effects of the waiver would be prior to public comment, hold two
perfunctory public hearings and be done.
Officials in my State of Utah, in developing their waiver, did not
need the Federal Government to come in and tell them how to reach out
to stakeholders on this issue. I am informed that the state held
meetings for 10 months prior to getting approval for their waiver with
low-income advocates, providers, insurance companies, employers and
state legislators. The state held a series of work conferences and
community meetings on issues associated with Utah's waiver. The State
had several legislative task force meetings which were open to the
public as well as several budget hearings, also open to the public.
Officials from my State who were overseeing the waiver process attended
monthly meeting of advocate groups and met repeatedly with their
medical care advisory committee.
Now, it might be that other States contemplating a waiver might not
need such a comprehensive public outreach effort. Other states could
determine they should emulate such an approach. Is it really the role
of the Federal Government to micro-manage this process?
Section 706 would also require states to file copious records
documenting detailed descriptions of the public notice and input
process; copies of all notices, dates of meetings and hearings; a
summary of the public comments; and, a certification that the state
complied with any applicable notification requirements with respect to
Indian tribes.
If we are looking for ways to encourage unwilling states to reach out
to the public for input, one of the least effective ways to do so, in
my opinion, is to require States to jump through a bunch of
bureaucratic hoops. This will not foster open debate nor will it
encourage the states to try and draw a buy-in from stakeholders.
Instead, in my opinion, it will create an atmosphere where the state
will do the bare minimum in order to meet the requirements and no more.
This is not the way to promote outreach efforts and a free-flowing
exchange of ideas. In fact, I believe that if enacted, Section 706 will
stifle such an approach.
In considering the role of HHS relative to the waiver process, I am
informed that HHS Secretary Tommy Thompson has written in opposition to
Section 706. I share the Secretary's concerns that, as drafted, this
section would leave HHS vulnerable to costly and burdensome lawsuits. I
agree with Secretary Thompson that State and Federal resources should
be spent addressing the issue of the uninsured and should not go,
instead, to fending off legal challenges from every national advocacy
group who did not get exactly what they wanted.
Finally, one of the facts that gets overlooked in these waiver
discussions is that we have 41 million uninsured Americans and states
are trying to cover them. This is really the bottom line, here, the
states are trying to find ways to get some coverage to Americans who
would otherwise have no coverage. Rather than looking for ways to
inhibit the states from accomplishing this, we should be making it
easier for them.
I look forward to working with my colleagues on the Finance Committee
to accomplishing this important goal.
The PRESIDING OFFICER. The Senator from West Virginia.
Mr. ROCKEFELLER. Mr. President, I find myself in total agreement with
the Senator from Montana, sadly so but nevertheless very much so. But
this situation strikes me as ironic.
I support the position of the Senator from Montana and what he is
trying to do with the give-back. The Senator from Maine talked about
resolving a few minor differences, and the Senator from Montana said
they are not minor. They have to do with whether or not a State such as
West Virginia, which this Senator represents, will have any
prescription drug benefits at all because there are no insurance
companies that have any intention of coming into the State of West
Virginia and making those available.
I am not so sure that any would be willing to go to Maine. I do not
think they would be willing to go to Montana. I do not think they would
be willing to go to--well, I don't know. They probably would be willing
to go to Florida, probably Nevada a little bit, Michigan a little bit,
but Nebraska not very much; Wisconsin, I do not know.
Basically, all rural States--and 81 percent of all counties in the
United States of America are rural--will be shut out by this
prescription drug bill which the tripartite approach embraces. I hope
the Presiding Officer
[[Page S10541]]
does not think for one moment the Senator from West Virginia is going
to contemplate working out a compromise on the floor of the Senate,
with only a few days left, when we have been filibustered on every
single thing we have brought up, especially something as complicated as
a difference between a pharmacy benefit manager and an insurance model.
There is a lot of educating that has to go on on the Senate floor
that has taken place in the Finance Committee. There was a vote on the
floor. The vote said one thing and the Senator from Maine says she
wants something else.
I am extremely disappointed we are not able to get the unanimous
consent that was sought to proceed to the Beneficiary Access to Care
and Medicare Equity Act of 2002.
I have heard nonstop from those in my State concerning the effects of
the declining Medicare reimbursement on access to critical care
services. The reality is we will also be unable to enact a Medicare
prescription drug benefit for this year. Why? Because of the huge
ideological gap which I have just finished describing.
People can describe it as a minor difference. It is the Grand Canyon
of difference, and it is the difference between whether people from
populated, wealthier areas get a prescription drug benefit and
everybody else does not.
If that is what one wants, fine; but that is not what the Senator
from West Virginia wants, and it is not what my people want. It is not
what the majority of the people in this country want. Yes, they want
something called a prescription drug benefit. But there is a question
of saying how do they get it and who gets it? The mechanism is
important.
I want a prescription drug benefit. I dare say the income of Medicare
beneficiaries in the State of West Virginia is lower--about $10,800--
than the Medicare beneficiaries in the State of Maine.
People spend $4,000, $5,000, to $6,000 out of their pockets on
prescription drugs. Do I want a prescription drug benefit? You better
believe I do, but I want one which will actually get to the people I
represent and which are represented across America in rural States.
We do not have a choice of being able to say let's do both. We cannot
finish that debate on this floor. We cannot reach agreement on this
floor. Not the Senator from Maine, but there are many on the other side
of the aisle who do not want to see that happen in some respects
because they do not want to see the Graham-Miller bill pass because
that would be deemed a victory for the wrong people, or something like
that.
However, one priority that cannot wait until next year is providing
States with fiscal relief. That would include the State that the
Presiding Officer is from.
On July 25, 75 members--talk about a consensus. The Senator from
Maine, Ms. Collins; the Senator from Nebraska, Mr. Nelson; and this
Senator put forward a compromise plan, and it got 75 votes. It got half
the Senators on the other side of the aisle to vote to provide States
with $9 billion in assistance. That has since been somewhat cut down in
an agreement with the Republican leader on the Finance Committee to $5
billion, but that is still substantial relief--$4 billion in Medicaid
and then $1 billion in Social Security's block grant. That is a lot of
money. It will help all States.
Since we passed that amendment by an overwhelming vote, the situation
in the States has, in fact, gotten much worse. The last time States
faced a budget crisis this bad was in 1983. I happen to remember that
because I was Governor of West Virginia and our unemployment rate was
about 21 or 22 percent. One does not forget those things quickly.
At least 46 States struggled to close a combined budget gap of $37
billion in the past fiscal year. This year's gap is even wider. This
year it is going to be a combined $58 billion deficit. Most States are
required by law to balance their budgets, something we did up until a
year and a half ago. Then a variety of things happened, and it is no
longer balanced. So they are being forced to slash their spending. The
Governors do not want to, but they have to.
This year coming up, 18 States are planning to cut families from
Medicaid coverage, and 15 States are eliminating important health care
benefits. Twenty-nine States are cutting or freezing provider payment,
further jeopardizing access to health care. As a result, thousands of
Americans, at the least, will join the ranks of the uninsured and
countless more will find access to needed benefits reduced or
eliminated altogether.
In this tough fiscal climate, a new survey of Medicaid programs shows
an increasing number of States are dropping certain groups of patients,
curtailing some services, requiring poor people to help pay for their
own care when they can, limiting access to expensive drugs and then
cutting or freezing payments to hospitals, doctors, nursing homes, and
other providers of care. Is that kind of important? You bet your bottom
dollar it is. Fundamental access to health care.
In Massachusetts, the legislature had to stop covering about 50,000
unemployed adults. In California, children spent longer in foster care
because of cuts in adoption services.
In New Jersey, the working poor will lose access to State-funded
health care. In Louisiana, there will not be future hospital beds
available for low-income patients. The Kaiser Commission on Medicaid
and the Uninsured, which nobody disputes, in a new study found that 18
States are planning to tighten their eligibility rules in the coming
fiscal year, compared with 8 States last year.
The most common strategy that States are using to cut costs is to
limit their expenditures on prescription drugs by reducing
pharmaceutical payments or making it more difficult for doctors and
patients to select expensive but necessary medicines. Forty States are
trying to cut costs by limiting their drug expenditures. In Illinois
last month, Medicaid officials began requiring patients who need the
popular antidepressant drug Zoloft to get tablets that are twice as
strong as they need and then break the pills in half. I do not know if
that makes a tragedy, but it sure is a lousy way to do business.
In a subtler strategy, some States are curtailing recent innovations
that were designed to find more people who are eligible for public
insurance and then make it easier for them to stay covered once
enrolled. Delaware stopped a very good initiative which had been paid
through an outside grant to publicize Medicaid and the Children's
Health Insurance Program and to help clients fill out applications.
They had to stop that because they had no money.
So the decision being made by Governors, legislators, and Medicaid
administrators underscores the pressure that States are confronting in
a weakened economy, which I dare say will stay weakened for some time.
Their revenues are plunging. Increases in unemployment and poverty are
prompting more people to sign up for government help. As a result,
States are reversing the trend that lasted nearly a decade when they
added money and changed rules so the public insurance programs could
help more Americans who lack health coverage and pay for more kinds of
care.
The fiscal crisis has a direct impact on the families in our States
but it also has a direct impact on local economies. Medicaid is the
largest purchase of maternity care in the United States of America. It
pays for half of all nursing home care which everybody faces at some
point in their life.
Medicaid provides significant support for local hospitals and for
nursing homes. Providers in some instances are struggling to stay in
business, and in many instances have stopped. Eight out of 10 hospitals
in West Virginia are losing money. How long can they continue in small
rural counties? The bottom line is that means Medicaid plays a critical
role in sustaining local economies as well as people's lives and health
care. For every dollar a State cuts from Medicaid--and that is what is
happening--it loses between $1 and $3.31 in Federal assistance. That is
one large loss. That loss would have otherwise gone to hospitals, to
home health services, nursing homes, and health clinics tied into our
local economy.
For this reason, the legislation introduced last week in the Senate
to increase payments to providers under Medicare, which we just failed
to get unanimous consent on, also includes a
[[Page S10542]]
billion dollars in fiscal relief for States. In many ways, States are
the largest providers of health care, and ensuring their stability is
the best way to maintain access.
If Congress does not act to provide a temporary boost to Medicaid
funding for States to help them meet their responsibility to protect
the most vulnerable citizens, and all citizens, since a great majority
of Medicare citizens are vulnerable, the situation will get worse.
We have made significant progress over the last 10 years in expanding
access to health insurance. This year, 50 million Americans are
expected to receive health insurance through two programs: Medicaid and
the Children's Health Insurance Program which was started in the Senate
Finance Committee. These programs provide health coverage to more than
10 percent of all Americans.
In closing, this coverage is now at risk unless, as the Senator from
Montana wants, the Congress refuses to act. This is one priority that
cannot wait until next year. We should pass the Senate's proposal to
reduce the current law cuts to critical Medicare providers. Even if we
fail to do that, we must enact a provision to provide additional relief
to the States that struggle to provide our Nation's people with the
crucial safety net.
I yield the floor.
The PRESIDING OFFICER. The Senator from Maine.
Ms. SNOWE. Mr. President, I respond to some of the issues raised by
the Senator from Montana, for whom I have a great deal of respect. It
is important to clarify some of the issues suggested by the Senator
regarding the legislation I and others have proposed, the tripartisan
legislation.
The Senator from Montana did schedule meetings in his office with
Senators from both sides of the political aisle, Senators who were very
concerned about the legislation. Obviously, there were differences
among all the Senators. We were trying to narrow the areas of
differences.
I was surprised by the characterization suggested by the Senator with
respect to those meetings. He had established the agenda. In fact, he
asked everyone at the meetings, what should be the basis for
negotiations? What should be the starting point for discussions? It was
agreed by those in the room, when he initiated the question, that the
tripartisan legislation should be the basis for the discussion and
negotiation. The staff had been given instructions to develop language
with respect to the three areas in which we had identified to be the
major areas in disagreement.
One was the assets test, one was the cost, and one was the fallback
provisions as to whether or not the provision included in the
tripartisan package was in and of itself sufficient to guarantee
prescription drug coverage to a senior, regardless of where they lived
in America. We thought our language certainly met the conditions for
ensuring that our Nation's seniors, regardless of whether they lived in
an urban or rural area, would have the benefit of a prescription drug
coverage as designed in our legislation. But we were certainly amenable
to additional language, additional protection in the legislation to
absolutely guarantee we would provide seamless coverage in the event
that an insurer was not providing the options for prescription drug
coverage to seniors in a particular area of the country for whatever
reason. So no matter what, a senior would have the benefit of the
coverage, regardless of where they lived, and they would have a choice
of at least two plans, so we were more than amenable. We were amenable
even on the price tag. We were considering language on the acid test.
The chairman did not reconvene meetings after assigning the staff
with the responsibility of drafting the new legislation. We were never
given reasons no additional meetings were scheduled.
In the meantime, markups were scheduled in the Finance Committee this
fall on various issues, including the provider give-back. We said we
intend to offer the tripartisan package because that had the support of
Senator Grassley, who worked on it a year and a half ago; Senator
Jeffords from Vermont, a member of the committee; Senator Breaux from
Louisiana; and myself as a member of the Finance Committee. We would
offer that as an amendment and see where the process takes us in
Finance Committee. The markups were canceled.
If our bill was not going anyplace, as the chairman suggests, then
why were the markups canceled? If our bill had no opportunity to go
anyplace, why were the markups canceled? Is it because these four
members of the Finance Committee had at least offered a basis for a
bipartisan--in this case a tripartisan--comprehensive prescription drug
package? We did not say it was all or nothing. We did not suggest
inflexibility or intransigence on our part. We say let's offer this as
a basis for amendment, further consideration, and debate and votes.
The same was true in the unanimous consent request I presented on the
floor that was ultimately rejected. It says ``be open to further
amendment and debate.'' That does not suggest inflexibility. I didn't
say take tripartisan package or nothing. I am saying the only way you
work things out is being able to bring up the bill and offer amendments
and debate and vote on the amendments and reach a final conclusion. Now
we are talking about July.
Mr. BAUCUS. To be honest, I think if all Members of the Senate were
like the Senator from Maine, we would have an agreement. The Senator
well knows there are a lot of other Senators in this body who were dug
in and who very much wanted their points of view.
We had the last meeting. We were working on five issues: Assets test,
benefit design, Medicare reforms, consumer protections, and how to
design a viable fallback mechanism, which would take effect in the
event of private plans not entering a particular market. Roughly
speaking, we were working off the basis of the so-called tripartisan
view, but is it not also true at that time that was very loose and
there were an awful lot of issues to work out?
Ms. SNOWE. I would like----
Mr. BAUCUS. It was my judgment after that meeting and checking with
Senators on both sides of the aisle, that discussions were going
backwards on prescription drugs. I basically made a decision that
Senators were digging in so much that they were not going to agree.
Ms. SNOWE. I would like to pose a question to the Senator from
Montana as to why we didn't have any additional meetings based on your
instructions to the staff to work out language in the various areas? I
didn't sense there was inability to reach a consensus. It might well
have been, after we considered and pondered the legislative language
they were drafting, language over the weekend. We didn't have the
opportunity to talk about those issues.
Mr. BAUCUS. That is correct.
Ms. SNOWE. We didn't have an opportunity to talk about the language
the staff was instructed to draft in these three areas.
Mr. BAUCUS. I might ask the question--the reason is because I checked
with Senators who were at that meeting and they said: No, sorry, I am
not going to agree with that. They are going backwards. They were going
in the other direction. They didn't want to meet. It is unfortunate, it
is so unfortunate. To be candid, Senator, you and I know you and I were
the last two standing on this issue. Basically you are the last one
standing on this issue trying to find agreement.
But it is clear there are not enough Senators in this body who also
want agreement at this time. That is why I think we cannot let the
Medicare provider legislation be held hostage to another bill which
does have an agreement.
It is very unfortunate we could not get agreement. But it is partly
because the Senate, as well as the House, is still a bit too partisan
on all matters--not all matters, but most matters. Particularly on this
issue, because it gets to a very fundamental question which this body
and the other body will have to address, the whole country is going to
have to address, and that is: What is the future of health care in this
country? To what degree is it going to be privatized, to what degree
not? That is a huge question. The prescription drug benefit debate is
really the opening shot of that larger debate.
I wish that were not so. I wish we could pass the prescription drug
benefit
[[Page S10543]]
quickly this year, but it is the judgment of this Senator, and I think
it is the judgment of virtually every other Senator in this body, that
it is not going to happen now. I wish that were not true.
Therefore, I think let discretion be the better part of valor and let
this Medicare payment bill pass.
Ms. SNOWE. In response to what the Senator from Montana indicated,
let me say this. Obviously I am not privy to his private conversations,
but we were sitting in those meetings in good faith, and I didn't hear
from anybody around that table--more than 14 Members--who resisted the
idea we should not proceed, that we should not work out these areas,
that it was impossible.
Maybe in the final analysis, it might have been impossible, but that
certainly was not the expression of the sentiment in that meeting
during that course of time. The fact is quite the contrary. I think
most of the Senators--as I said, it was equally divided between
Republicans and Democrats, including Senator Jeffords from Vermont.
There was an indication of strong interest to proceed to try to see if
we could work through and resolve the identified areas in disagreement.
Those are the ones I mentioned previously.
So I didn't hear any indication there was a ``can't do'' attitude. In
fact, just the contrary. They were suggesting we could proceed and
instructed the staff to work over the weekend on those various areas.
Suffice it to say we didn't have the process in the committee to work
these through. Obviously, for whatever reasons, it did not work out as
a result of those negotiations. But they were, I think, very close. I
think we were very close.
I know if those individuals sitting around the table had agreed in
these areas, we certainly could have overcome any political obstacles
and impediments here in the Chamber because I think there is virtually
unanimous desire to get something done on behalf of our Nation's
seniors.
I cannot imagine anybody here in the Senate would want to tell their
seniors that somehow it could not be done. We are elected to get things
done. We are responsible for ensuring this institution functions in a
way that does dignity to the process. Unfortunately, I think in this
instance we failed.
I happen to believe on the Medicare provider give-back, if we were
somehow to be able to resolve those differences behind closed doors,
without a markup and on the floor, then clearly we should be able to do
what has been deemed to be the impossible--the impossible in this
institution--in advancing this legislation in the interests of our
Nation's seniors. In fact, we invited the AARP to be part of our
negotiations this fall to talk about some of the issues.
Yes, they had concerns with the tripartisan bill, as they did with
the bill that had been offered by Senator Graham, in providing an
unfunded mandate on States. But the fact is, who is to say any
legislation is perfect? We certainly didn't indicate ours was. This is
the agreement we had reached. We were prepared to accept amendments and
to consider different ideas. That is where we were in these meetings
that were scheduled by the Senator from Montana in his office.
Ultimately, there were not additional meetings, even though the staff
had been instructed to draft language in the three areas I mentioned
originally. The fact is, this failure is at whose expense? It is at our
Nation's seniors' expense. As prescription drug prices go up each and
every year by more than 15 percent, it is 2\1/2\ times faster than the
cost of additional health care components. By 2011, the prescription
drug spending is expected to be 15 percent of all health care spending
in America. Rising prescription drug costs have made prescription drug
coverage for Medicare beneficiaries less available and more expensive.
We have seen employer-sponsored retiree health plans provide 28 percent
of Medicare beneficiaries with prescription drug coverage, more than
any other source. It is a major source of prescription drug coverage
for our Nation's seniors.
Now what are we finding? Far fewer employers are offering coverage to
their employees. Those employers who continue to do so are requiring
seniors to pick up a larger share of the costs. That is what we are
talking about. The proportion of larger employers offering retiree
health benefits dropped from 31 percent to 23 percent between the years
1997 to 2001. Those who were requiring Medicare-eligible retirees to
pay the full cost of their coverage rose from 27 percent to 31 percent.
Those are not my figures. Those are the figures that have been given
by the GAO, that have been certified. Certainly I think they underscore
the costs of prescription drugs to our Nation's seniors and, I think,
the challenges we face in this country if we fail to address this most
serious problem.
As AARP indicated in its own letter, the costs of prescription drugs
are going up, as was said, more than 15 percent on an annual basis.
These added costs to beneficiaries, as we have seen, because the
Medicare provider give-back is going to increase part B premiums. There
is no question about that. So that is going to raise the premium $6
billion in the first 5 years alone. These added costs, as they said in
their letter recently, come in addition to double-digit hikes in
prescription drug costs for older and disabled Americans, many of whom
have little or no options for drug coverage.
Employers continue to reduce or eliminate health care coverage.
Medigap premiums continue to rise. And now, nine more Medicare+Choice
plans are pulling out of Medicare.
So, you see, we do have an obligation to do what is right. I would
not be standing here today insisting on getting this done if I didn't
think it was possible. That is because I have had a number of
conversations with colleagues on both sides of the aisle, on different
sides of the issues, different philosophies. Many have indicated they
are prepared to make concessions and develop compromise and consensus
on this issue to get it done here and now.
I agree with the statement that was made by the Senator from West
Virginia with respect to the provider give-back legislation, I think it
is necessary for our Nation's hospitals and home health care. So is
this. They are not mutually exclusive. They go hand in glove for our
nation's seniors.
I have toured many of the hospitals in my State.
I have heard firsthand from seniors in my State about the plight of
some who have gone without prescription drug coverage.
I was told a story about a man who had diabetes and was supposed to
take his medication and couldn't take his medication. He knew what that
would lead to. He didn't have prescription drug coverage. So he was
unable to take the medication prescribed by his doctor after he was
released from the hospital. He had diabetes which ultimately led to
amputation and ultimately to his death.
Those are the kinds of tragic stories we hear over and over again.
Those are choices our seniors shouldn't have to make.
We have the time. We have the time to do what is right.
Mr. KYL. Mr. President, I rise in support of S. 3018, the Beneficiary
Access to Care and Medicare Equity Act, which was recently introduced
by the Chairman and Ranking member of the Finance Committee.
This act would provide more than $40 billion over the next 10 years
to improve benefits for Medicare beneficiaries, guarantee that Medicare
beneficiaries continue to receive the high quality health care they
deserve, and increase reimbursements to Medicare providers.
I would prefer that we address these issues as part of comprehensive
Medicare reform, reform that includes a new prescription-drug benefit.
Unfortunately, the process the Majority Leader used to bring a
prescription drug benefit to the Senate floor guaranteed its defeat,
and no drug proposal put forward won the 60 votes necessary for
passage. While the Senate was unable to pass a prescription drug bill,
we still have an opportunity to address other critical Medicare issues.
And it is critical. In 1997, Congress passed the Balanced Budget Act.
This act made significant cuts in Medicare provider reimbursements and
implemented new payment systems. In many cases, these cuts made sense.
However, in some cases they went too far. Moreover, the process of
implementing these new payment systems for home
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health care, hospital outpatient services and skilled nursing-facility
services has not been a smooth one.
One key area where we see this is in payments to physicians.
Physicians are reimbursed for providing services to Medicare
beneficiaries under a fee schedule. The fee schedule is updated
annually under a very complex formula. The formula considers the
sustainable growth rate which is based on four factors: the estimated
changes in fees; the estimated changes in the average number of
Medicare Part B enrollees, not including Medicare+Choice beneficiaries;
estimated projected growth in real gross domestic product growth per
capita; and estimated change in expenditures due to changes in law or
regulations.
On November 1, 2001, the Center for Medicare and Medicaid Services
(CMS) announced that the annual update of the fee schedule in 2002
would result in a 5.4 percent reduction in reimbursements. A number of
factors led to this decline, including the adjustment by the
sustainable growth rate. But the sustainable growth rate is flawed
because of mistakes made by CMS. In the late 1990's, CMS overestimated
the number of Medicare beneficiaries in the Medicare+Choice program and
underestimated gross domestic product growth. These errors resulted in
reimbursements greater than what they should been if CMS had not made
them. As more accurate data came about CMS has corrected its previous
errors. This correction has partially led to the -5.4 percent update
this year. Additionally, physicians are looking at future payment cuts
next year and the two years following that. Overall, physicians could
see a 17 percent reduction in reimbursements from Medicare over these
four years.
The key concern, of course, is really not so much Medicare
reimbursements for physicians, but Medicare beneficiaries' access to
medical care. There is increasing evidence that doctors are not taking
new Medicare beneficiaries, are retiring early or accepting
administrative positions. According to a report in the March 12, 2002
edition of the New York Times, 17 percent of family doctors are no
longer taking new Medicare patients. The Beneficiary Access to Care and
Medicare Equity Act would increase reimbursements to physicians over
the next three years, and, in turn, help stem the tide of doctors
refusing to treat new Medicare patients.
Of course, physicians are not the only health-care providers that
this legislation would help. The legislation would eliminate a 15
percent reduction in home health-care reimbursements mandated by the
Balanced Budget Act of 1997. As it turns out, the Balanced Budget Act's
original change in the payment system for home health care services
helped save money. But it is no longer necessary to implement the 15
percent cut. Additionally, this legislation would help smooth out the
transition to a new payment system for skilled nursing facilities. S.
3018 would also provide both urban and rural hospitals with increases
in reimbursements. It has many provisions to help alleviate the
reimbursement differences between rural and urban hospitals. Of
particular note, S. 3018 contains a technical change that will allow
publicly-funded safety net hospitals to negotiate for lower drug
prices. These hospitals bear a disproportionate burden in caring for
the uninsured in our country; allowing them to negotiate lower prices
will save them millions of dollars.
Another provision of note is section 805, which would provide $48
million annually for two years to States and other providers that offer
federally-required emergency medical treatment to illegal aliens. A
congressionally-commissioned study by the U.S.-Mexico Border Counties
Coalition estimates that the 24 counties along the southwest border
incur uncompensated costs of over $200 million per year in connection
with the provision of emergency health treatment to undocumented
aliens. The non-border counties in southwest States, and other states,
including New York, Florida, Illinois, New Jersey, Massachusetts,
Washington, Colorado, and Maryland, also incur tremendous costs. The
entire state of Arizona, for example, incurs unreimbursed costs of
approximately $100 million per year to provide such treatment.
These southwest States and counties, many of which have very small
tax bases and small annual budgets, and other States should not be
forced to bear the responsibility of providing emergency health
treatment to undocumented aliens. These unreimbursed costs have helped
put Arizona's and other States' affected hospitals in a state of dire
fiscal emergency. Many hospitals have closed, or are in danger of
closing, their emergency rooms either temporarily or permanently.
The Balanced Budget Act of 1997 provided funding to states to help
defray some of these uncompensated costs; however, this provision
expired at the end of fiscal year 2001. Section 805 would specifically
extend and refine the Balanced Budget Amendment Act of 1997 to provide
$32 million in each of fiscal year 2003 and fiscal year 2004 to the 17
States with the highest number of undocumented aliens, as defined by
the U.S. Department of Justice. Additionally, in fiscal year 2003 and
fiscal year 2004, $16 million would also be allotted to the six highest
undocumented alien apprehension States, as defined by the U.S.
Department of Justice.
Forty-eight million dollars per year is just a fraction of the
unreimbursed costs that the States incur each year, but this funding
will at least begin to defray some of the costs.
Although, I strongly support most of the provisions contained in S.
3018, I do have concerns about others. For instance, section 707 of S.
3018 provides States with a temporary 1.3 percent point increase in
their Federal Medical Assistance Percentage, FMAP, payments, the amount
that the Federal Government supplements States' Medicaid spending.
Under FMAP, Medicaid funds are distributed to States based upon a
formula designed to provide a higher Federal matching percentage to
those States with lower relative per capita income, and a lower Federal
matching percentage to those States with higher per capita income. This
formula, although not perfect, is justified because States cannot
manipulate it for their own gain; the data are periodically published
and can be estimated with reasonable accuracy. Additionally, the use of
per capita income is a proxy for state-tax capacity which, in turn,
relates to a State's ability to pay for medical services for needy
people. To put it simply: poorer States get more help than wealthier
States.
Unfortunately, S. 3018 ignores the Medicaid formula and gives each
State a 1.3 percent point increase. Under this section, States that
have been determined by the Medicaid formula to receive the lowest FMAP
of 50 percent receive the greatest percentage increase in FMAP. States
with the highest FMAP receive the lowest percentage increase. This is
the exact opposite of how the funds should be allocated. The Medicaid
formula, whatever its faults, does indicate a relative sense of need.
It would be wrong to give the least needy States the largest percentage
increase.
Even though I have concerns about how funds are distributed under
this section, I urge my colleagues to support S. 3018. It is vitally
important that Congress enact changes to Medicare payment policies
before we adjourn. I also support the passage of a Medicare
prescription-drug benefit, preferably the tripartisan modernization
proposal; but we should not allow our inability to reach a consensus on
that matter to stop us from making the appropriate changes to
Medicare's payment policies. Medicare beneficiaries need guaranteed
access to high quality care, and S. 3018 is a means to that end.
Mr. JEFFORDS. Mr. President, I first want to salute the Senator from
Montana, Mr. Baucus, as well as my good friend and colleague, Senator
Grassley, for their bipartisan effort and leadership in crafting S.
3018, the Beneficiary Access to Care and Medicare Equity Act of 2002.
As the chairman and the ranking member of the Senate Finance
Committee, they have worked long and hard on legislation that is
critically important to the future of health care for our citizens that
rely on Medicare. I am proud to be a cosponsor of S. 3018, and I urge
all of our colleagues to support its passage as soon as possible.
In the closing days of the 107th Congress, there will be many bills
that on their way to consideration and passage will enjoy the unanimous
consent of
[[Page S10545]]
the Senators. There are few of these many bills more worthy of our
consideration and unanimous consent than this measure.
Vermont, like so many of our States, has a healthcare system that is
facing reductions in levels of Medicare reimbursement that are
untenable. In some cases, these reductions took effect on October 1 and
others will occur at the end of this month. The cuts have already led
to fewer physicians and services being available to care for our
elders.
The list of cuts and reductions is long. Physicians and other
healthcare professionals, home health agencies, critical access
hospitals, skilled nursing facilities, sole community hospitals, and
others are being affected. And make no mistake, these cuts translate as
cuts in access to healthcare for our elders.
But it is not too late. We can pass this legislation, engage in a
conference with our colleagues in the other chamber, and have a bill
for the President to sign before the end of this Congress.
Once again, I want to commend Senator Baucus and Senator Grassley for
their work on this bill and for this chance to speak to its merits
today. It is needed legislation, it is balanced, and it is well
crafted. Our elders need it passed. Our providers need it passed.
Children depending on SCHIP need it passed, and our States need it
passed. We should not let this opportunity to enact this legislation go
by, and so I urge our colleagues to support its passage.
Also I want to commend the Senator from Maine for her statement with
which I agree and commend her.
The PRESIDING OFFICER. The Senator from Nebraska.
Mr. NELSON of Nebraska. Mr. President, the Senator from Maine has
told us what the Baucus-Grassley unanimous consent request to move the
legislation forward won't do, what it has been said is included, what
has not been included in it, and, therefore, as a result it shouldn't
be considered at this point.
I will concede the point to my friend from Maine that it is a
tremendous shame we didn't somehow pass a prescription drug benefit for
our seniors. I have worked with her. We even shared an amendment on the
Patients' Bill of Rights. I know of her passion for health care and for
the benefits for our seniors. I share those values, and I share the
concern we all have today everywhere that we don't have a prescription
drug benefit for our seniors.
I have to go back to Omaha and face George and Lee, who have spent so
much time telling me about the importance of having a prescription drug
benefit. But you know we had three shots at it this session. One was it
was too expensive, one was it didn't provide enough benefits, and the
one my friend from Maine supported--the insurance model--failed by
getting only 48 votes.
But I come from an insurance State. And not one insurer that I spoke
to told me they planned to offer this benefit anywhere, let alone in
the State of Nebraska.
There were a lot of reasons why that particular bill didn't make it.
There were reasons why the other two bills didn't make it.
I would like to have us pass a prescription drug benefit before we
leave, but I don't want to do it at the expense of this legislation
that is so necessary.
When I go back, if we don't pass it because we try to pass a
prescription drug benefit that causes the failure of this legislation
which I am going to describe in a minute, I will have to face George
and Lee. Not only will they tell me we didn't get a prescription drug
benefit, but their physician Medicare rates are down and their doctor
doesn't want to provide the care for them anymore. Or I have to go back
and find out the skilled nursing facilities are not going to be funded
or the State fiscal relief that Senators Rockefeller and Collins and I
worked so hard to get through is now cut back from $9 billion to $5
billion and that is not going to be available to the State.
I agree with the passion of the Senator from Maine and her concern
about the fact we didn't get a prescription drug benefit done yet this
session. But I don't agree we ought to pull this legislation which is
before us back into committee so they can attach to it a bill that
failed, only got 48 votes, and which I don't think will work. I think
we have to separate these two issues--and they have been separated.
Let us talk about the bill that is now before us, the Baucus-Grassley
bill, a bipartisan effort. The ranking Member from Iowa is pushing to
have this considered on the floor rather than to go back and be delayed
in committee.
Under current law, Medicare's physician payment rates are projected
to fall by 12 percent over the next 3 years. In Nebraska, physicians'
losses due to the 2003-2005 cuts will total about $63 million or
$17,230 per physician. This comes on top of a 5.4 percent payment cut
which cost Nebraska doctors a total of $12.9 million or about $3,875
per physician in 2002.
An AMA survey conducted earlier this year found that one in four
physicians either has restricted or plans to restrict the number or
type of Medicare patients treated. One in three has stopped or intends
to stop delivering certain services to Medicare beneficiaries.
Additional payment cuts of an extra year will only exacerbate these
problems and cause significant access problems in the State of
Nebraska--a State that is already challenged geographically to be able
to provide access to our residents.
Let us talk for just a moment about skilled nursing facilities and
what will happen there.
Our skilled nursing facilities are also in jeopardy. If action isn't
taken and if this legislation does not pass, then Nebraska's facilities
will lose $28.48 per patient per day next year, for a total of $10
million. There are just some that aren't going to make it. They are
going to be in small communities that will be left out when it comes to
skilled nursing facilities.
When it comes to State fiscal relief, my colleague from West Virginia
and I--both former Governors from our States--know very well what the
impact is going to be on the States of Nebraska and West Virginia, as
well as the rest of the States. Forty-nine out of 50 States must
balance their budgets by law.
It is no secret the economy is hurting. States are facing a number of
difficult decisions as a result of that. When States have to make
budget cuts, let me assure you it affects real people. There may be
line items in a budget, but there are faces associated in every case.
In a special session in Nebraska in August, the legislature made some
drastic cuts. It wasn't pretty. Thirteen thousand kids were cut from
Medicaid.
That is why we have been working so closely, Senators Rockefeller,
Collins, and I, to pass State fiscal relief, which is part of this
legislation. Seventy-five of our Senate colleagues agreed with us when
they supported our amendment in July. Senators Baucus and Grassley have
included State fiscal relief in this very important provider package,
and it is extremely important to the people in the State of Nebraska
and the States of every one of our colleagues here in the Senate.
If I were one of my residents of Nebraska, or one of my constituents
watching or listening to the debate today and heard about unanimous
consent requests, objections, sending this back to committee for
further consideration, trying to deal with what cloture is, how many
times, what person did what, and how many of us are all interested in
making sure we get not only this legislation through but also a
prescription drug benefit, they have to be confused.
Their only question is, Why don't you just get this legislation done
and work also on a prescription drug benefit? What has one got to do
with the other? Don't, for heaven's sake, deny us our prescription drug
benefit because you can't get it through, and at the same time now come
along and make sure our doctors aren't going to get reimbursed enough,
or our skilled nursing homes aren't going to have enough money, and our
States are going to continue to cut back on Medicaid benefits. Separate
the two issues and get them done.
Three tries, and I don't think we are out. That is true in baseball.
I don't think it is true here. I think we can dust off one of these
versions and make it work well.
I have met with Senator Snowe on a prescription drug benefit. I have
met with everybody I can in the interest of finding a prescription drug
benefit. I know it is possible. I also know it is
[[Page S10546]]
difficult. But I think it is extremely important for us to first
fulfill our obligations with the Baucus-Grassley effort. Let us let
this come to a vote. Let us stop the objections. Let us withdraw the
objection from the other side. Let us get a vote. Then let us see if a
bunch of us can come back together--and we should--and get a
prescription drug benefit.
But, for heaven's sake, even in the greatest and most sincere effort
in the world, we should not think about one bill here because we are
trying to save another, when we know very well it is not going to work.
We have not run out of time. We can do this. We should bifurcate them.
We should separate them, get the Baucus-Grassley bill done, withdraw
the amendment, and let us work on a prescription drug benefit so I can
go home and I can talk to Lee and George and tell them something more
than: Well, we tried.
I sure don't want to have to go back and say: Well, we didn't get
anything on prescription drugs. But that isn't where the bad news ends.
There is worse news. We also didn't get the give-back bill through, and
that means if you have to go to a nursing home, there may not be one.
Your doctor may decide he is not going to treat you because he has had
a reimbursement dropped or if, heaven forbid, they have to go on
Medicaid, there will not be any benefits to provide for seniors as
well.
I don't want to have to tell the children of Nebraska there are
further cuts coming because we could not get the State relief, the
FMAP, as it is called, back to the States to take care of the short
budgets so that people are not going to be further disadvantaged by
these unfortunate economic conditions in these times.
I agree with my friend from West Virginia, there is more passion in
this Senate body to pass a prescription drug benefit than you can
imagine. The problem is very simple. We just cannot agree on how to do
it. It cannot cost too much, the benefits cannot be too little, and we
cannot pass something that will not work.
I think we have the collective wisdom to find a way to do it, but it
is going to require the collective will to do it. But this mechanism is
not the mechanism on which to do it. And let's not sink it trying to do
something noble for those who are the most vulnerable among us, our
seniors. I think they can understand why we do not want to sink one
trying to do the other.
Mr. President, I yield the floor.
The PRESIDING OFFICER (Mr. Dayton). The Senator from West Virginia.
____________________