[Congressional Record Volume 149, Number 102 (Friday, July 11, 2003)]
[Senate]
[Pages S9295-S9298]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




         PRESCRIPTION DRUG AND MEDICARE IMPROVEMENT ACT OF 2003

  Mrs. LINCOLN. Mr. President, I rise today to reflect on the recently 
passed Prescription Drug and Medicare Improvement Act of 2003, S.1. I 
am pleased to support this bipartisan effort both in the Senate Finance 
Committee and here on the floor. I believe this bill represents a 
positive compromise and a good start for America's senior citizens and 
individuals with disabilities who have relied on the Medicare Program 
for generations. I hope that the conferees act deliberately and fairly 
in the coming weeks to embrace what is good about this bill and to 
retain its bipartisan spirit. This process has been a long road for 
many of us who have worked on this issue for years but it has been an 
even longer road for America's seniors, who have watched drug prices 
escalate while Washington failed to act. Like all legislative products, 
this bill is not perfect. I have worked to improve this bill for 
Arkansas seniors in many ways, and I am committed to correcting any 
problems with it as it is implemented.
  Despite its shortcomings, which I will detail later, S. 1 is much 
better for Arkansans than the plan President Bush proposed earlier this 
year. First and foremost, S. 1 gives all Medicare beneficiaries access 
to a prescription drug benefit. Under President Bush's

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proposal, Arkansas seniors who wanted a drug benefit would have been 
forced to drop out of traditional Medicare and enroll in a private HMO 
instead, even though such a plan may not have been available in their 
area. Under the President's plan, seniors who remained in traditional 
Medicare would have received nominal discounts on prescriptions and a 
limited catastrophic benefit if they had extremely high drug expenses. 
I have said all along that it is simply unfair to deny a prescription 
drug benefit to beneficiaries in traditional Medicare. All 442,000 
Medicare beneficiaries in Arkansas are currently enrolled in 
traditional Medicare with no access to Medicare + Choice because 
private insurance companies found the profit margin of health care 
insurance in rural areas to be too small. That is why Medicare needs to 
be there as a safety net. That is why prescription drug coverage must 
be a part of traditional Medicare. That is why the guarantee in S. 1 
that traditional Medicare will pick up the slack where private insurers 
decline to operate needs to remain in the final version of this new 
policy.
  Second, I helped ensure that S. 1 provides special assistance to our 
State's most vulnerable seniors--those with low incomes. Over 40 
percent of Medicare beneficiaries in Arkansas have incomes below 160 
percent of the Federal Poverty Level--in 2003, $14,368 for a single and 
$19,392 for a couple--and simply cannot afford to fill their 
prescriptions. These are the seniors who struggle to pay for food, 
heat, and other necessities in order to afford their lifesaving drugs, 
and I hear from them often. I fought in the Senate Finance Committee to 
ensure that seniors under 160 percent of poverty would get special 
assistance with their premiums, deductibles, and cost-sharing. Those 
with very low incomes who also qualify for an assets test would receive 
more generous help. I helped improve the low-income provisions even 
more on the Senate floor by working with Senators Bingaman and Domenici 
to increase the asset test levels from $4,000 to $10,000, adjust these 
levels yearly for inflation, and reduce the paperwork burden for 
eligible seniors. Because this amendment passed, many more seniors in 
Arkansas will receive help with the cost-sharing imposed under this 
bill. Today, lower income seniors only fill about 20 prescriptions per 
year, compared to an average of 32 for those with prescription drug 
insurance. These provisions will help ensure that lower-income 
beneficiaries will be able to afford to fill their prescriptions, 
keeping them healthier and helping them live longer.
  I succeeded in including in S. 1 a number of other provisions that 
will improve the Medicare Program for Arkansans for many years to come. 
Two such provisions are based on legislation I introduced earlier this 
year, the Geriatric Care Act, S. 387. My first provision would provide 
for a 3-year demonstration project in Arkansas and five other sites on 
complex, chronic care management. Once this demonstration project is 
completed, S. 1 allows the Secretary of Health and Human Services, HHS, 
to use its findings to add this service as a part of traditional 
Medicare from 2009 to 2013 as long as it costs no more than $6 billion.
  More than 80 percent of Medicare dollars are spent on Medicare 
beneficiaries with three or more chronic conditions like Alzheimer's 
disease, cancer, or diabetes. Better care management for these seniors 
should improve patients' overall quality of life and reduce the need 
for expensive hospitalizations for chronic conditions. It is my hope 
that this further, more extensive study of chronic care management 
provided by geriatricians and their health care teams will prove this. 
We in Arkansas are blessed to have the Donald W. Reynolds Department of 
Geriatrics and the Center on Aging at the University of Arkansas for 
Medical Sciences, whose geriatric specialists have vastly improved the 
care for seniors across our State. These provisions will make it easier 
for our medical school and others across the country to better care for 
patients with chronic conditions while also training more physicians in 
geriatrics. The other provision included in S. 1 provides the Secretary 
of HHS with the authority to clarify that geriatric training programs 
are eligible for 2 years of fellowship support under Medicare. This 
change would help maintain incentives for fellows to continue into 
second-year training, a critical pathway to careers in academics and 
geriatric research.
  S. 1 also allows the Secretary of HHS to cover preventive benefits 
that aren't currently covered under traditional Medicare between the 
years 2009 to 2013. I have long fought to add new preventive services 
to Medicare, such as cholesterol screening, medical nutrition therapy 
services for beneficiaries with cardiovascular disease, counseling for 
cessation of tobacco use, and diabetes screening. These benefits are 
especially important for women, who are the majority of Medicare 
recipients and who make up 71 percent of the Medicare population over 
85 years of age. By encouraging women to get screened for diseases like 
heart disease, osteoporosis, and breast cancer, we can save and improve 
lives.

  I also succeeded in including my legislation, S. 1114, to provide 
Medicare coverage for kidney disease education services. Each year, 
some 80,000 people are diagnosed with chronic kidney failure--also 
known as end-stage renal disease (ESRD). Patients with ESRD require 
regular kidney dialysis treatments or a transplant to survive, and most 
are entitled to have this care paid for by the Medicare Program. 
Unfortunately, many of these renal patients are never informed that, 
prior to kidney failure, there are a number of steps they can take to 
improve their chances of having better outcomes with dialysis. Medicare 
currently requires that ESRD patients receive education on treatment 
options--but not until after the patient is already under the care of a 
dialysis clinic. Unfortunately, by then it is essentially too late to 
take advantage of much of the information. My provision makes 
counseling available to patients before dialysis is initiated to help 
patients understand all the therapies available for the treatment of 
ESRD. My amendment will save money and improve patient care.
  I also succeeded in including an important amendment to ensure 
Medicare coverage for insulin syringes. Before my amendment, S. 1 
provided no coverage for insulin syringes although it did provide 
coverage for insulin. Roughly 40 percent of the senior population with 
diabetes, or 1.8 million seniors, use syringes to inject insulin into 
their bodies to control their diabetes every day. Without coverage, 
syringe purchases--which can be especially expensive for seniors on 
fixed incomes--would not count towards cost-sharing and yearly maximum 
out-of-pocket expenses. My amendment changed that. Now, the bill 
ensures coverage for syringes and other necessary medical supplies 
associated with administering insulin as determined by HHS. Providing 
coverage for insulin syringes will help diabetic seniors who take 
insulin keep their disease under control. Syringe coverage will help 
seniors manage or prevent long-term complications of diabetes like 
kidney failure, blindness, and amputations by helping to keep blood 
glucose levels in a normal range.
  I was also able to include a 3-year, 5-site demonstration project to 
determine the merits of allowing Medicare beneficiaries direct access 
to physical therapists' services within the Medicare Program, as 
authorized by State law. Currently, some 37 States, including Arkansas, 
allow direct access to physical therapist services. While non-Medicare 
patients can directly access such services in these States, Medicare 
beneficiaries are restricted from such access by the requirement that 
they obtain a referral from another practitioner. Requiring a referral 
is unnecessary and limits access to timely and medically necessary 
physical therapist services. This demonstration, which is designed to 
be budget neutral, will determine if direct access does in fact improve 
patient care and save Medicare money.
  I also worked with Senator Craig Thomas to include a bill we 
sponsored together, S. 310, to provide Medicare coverage of licensed 
professional counselors and marriage and family therapist services. 
Although the rate of suicide among seniors is higher than for any other 
age group, fewer than 3 percent of seniors report seeing mental health 
professionals for treatment. Lack of access to mental health providers 
is one of the primary reasons why older Americans don't get the

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mental health treatment they need. Not surprisingly, this problem is 
exacerbated in rural areas. Licensed professional counselors are often 
the only mental health specialists available in rural communities. This 
is true in Arkansas, where 91 percent of Arkansans reside in a mental 
health professional shortage area. This provision will significantly 
increase the number of Medicare-eligible mental health providers in 
Arkansas, providing better access for patients.
  I was successful in working with Senator Cantwell on an amendment 
that will restrict pharmacy benefit managers (PBMs), and require the 
Department of Justice and the Health and Human Services Inspector 
General to review PBM financial practices for any potential collusion 
between PBMs and drug manufacturers on drug pricing and availability. I 
also supported an amendment with Senator Enzi to ensure that 
pharmacists have the option of offering 90-day prescriptions when they 
are also offered by mail order.
  I sponsored an amendment with Senator John Ensign to repeal the 
$1,590 cap on outpatient physical therapy, occupational therapy, and 
speech-language pathology. The current therapy cap discriminates 
against the most vulnerable of Medicare beneficiaries. While the 
majority of enrollees will not exceed an annual $1,590 limitation on 
rehabilitation services, approximately 13 percent of seniors and 
individuals with disabilities covered by Medicare will be forced to pay 
for medically necessary services out of pocket. This is a particularly 
burdensome situation for beneficiaries living in rural communities. 
Most likely to be harmed are beneficiaries who have experienced a 
stroke or hip fracture or who have Parkinson's disease or other 
conditions that require extensive rehabilitation following injury or 
illness. Before Senator Ensign and I withdrew our amendment to repeal 
this cap, we discussed the amendment on the floor with the chairman of 
the Finance Committee, Senator Grassley, who promised to work in the 
conference committee to enact a moratorium on the therapy cap.
  I also succeeded in including a number of my amendments during debate 
of the bill in the Senate Finance Committee. The committee adopted my 
amendment to waive temporarily the late enrollment penalty for military 
retirees and their spouses who sign up for Medicare Part B and to 
permit year-round enrollment so that retirees can access the new 
benefits immediately. Currently, military retirees and their spouses 
who do not join Medicare Part B when initially eligible can only do so 
during the annual open enrollment season. This amendment was needed 
because many retired beneficiaries previously saw no value in enrolling 
in Medicare Part B because they believed they were promised lifetime 
health care in military treatment facilities, many of which were 
subsequently closed due to base realignment and closure.
  The committee also adopted my amendment to establish an adult day 
services demonstration project for home health beneficiaries. A bill I 
introduced earlier this year, S. 1238, would give Medicare 
beneficiaries the option to receive their Medicare home health services 
in an adult day setting. This would be a substitution, not an 
expansion, of services and is designed to be budget neutral. The option 
of Medicare home health services in an adult day location has a number 
of important advantages for beneficiaries and their families, 
including: increased social interaction, therapeutic activities, 
nutrition, health monitoring, medication management, and enabling 
family caregivers to continue working, since care would be provided all 
day. More than 22 million families nationwide, or nearly one in four 
families, serve as caregivers for aging seniors, providing close to 80 
percent of the care to individuals requiring long-term care. Nearly 75 
percent of people providing care for aging family members are women who 
also maintain other responsibilities, such as working outside of the 
home and raising young children. The average loss of income to these 
caregivers has been shown to be over $650,000 in wages, pension, and 
Social Security benefits. The loss of productivity in U.S. businesses 
ranges from $11 to $29 billion a year. The services offered in adult 
day care facilities provide continuity of care and an important sense 
of community for both the senior and the caregiver. This important 
demonstration project will benefit women of all ages.

  The bill also includes my amendment to ensure that Medicare Quality 
Improvement Organizations (QIOs), can assist providers, practitioners, 
benefit administrators and plans to improve the quality of care under 
the new Medicare drug benefit system. This will be consistent with the 
role that QIOs already play in ensuring quality health care.
  These initiatives, among others, will dramatically improve the 
Medicare Program. I am also pleased that S. 1 includes a number of 
provisions that I have cosponsored over several years that will 
significantly help rural health care providers in Arkansas keep their 
doors open to Medicare beneficiaries. By correcting a disparity in the 
way the Medicare physician fee schedule values physician work, practice 
expenses, and professional liability insurance, Medicare will pay rural 
physicians more fairly for treating Medicare patients. Also, the bill 
contains several provisions contained in my bill with Senators Conrad 
and Thomas, S. 816, to correct the disparities in Medicare payments to 
rural hospitals. Rural physicians and hospitals in Arkansas will 
receive millions of dollars of extra Medicare reimbursements under this 
bill.
  And now that I have discussed some of the positive aspects of this 
bill, I would like to focus on some of my concerns regarding other 
provisions.
  I am concerned that private, drug-only plans may not provide the 
stability or predictability that seniors want and need. The insurance 
companies have told me they don't want to offer a prescription drug-
only plan. The administrator of the Centers for Medicare and Medicaid 
Services has said such a plan ``doesn't exist in nature.'' And, quite 
frankly, I believe we have proven through the Medicare, Medicaid, and 
Veteran's program that the Government can do it in a more cost-
effective manner.
  That is why I am glad the bill contains a Medicare guaranteed drug 
plan--or safety net--called the fallback. However, the fallback is that 
it is available for seniors for only 1 year at a time. That means if 
private insurers decide to test whether they want to offer the benefit 
in a community, seniors lose access to the fallback plan, even if the 
new plan is significantly more expensive for them or more restrictive. 
I offered an amendment to S. 1 that would have provided more stability 
for seniors by giving the fallback a 2-year contract instead of one. 
This would prevent seniors from having to switch plans from year to 
year with no end in sight. Although my amendment failed on a narrow 
margin, I will continue to try to improve the stability of the drug 
benefit by enacting this small, but important change to the fallback 
before the benefit starts in 2006.
  I am also concerned about the fact that drug plans will vary 
throughout the country, meaning that seniors in Arkansas may have 
different premiums, cost-sharing, and formularies than seniors in other 
States. And, even worse, these plans can change their premiums, cost-
sharing, and formularies every other year. I voted for many amendments 
to make the prescription drug benefit less volatile for seniors. For 
example, to reduce the variance in premiums across the country, I 
supported an amendment to limit variations in the amount seniors have 
to pay in premiums to only 10 percent above the national average, no 
matter where they live. I felt that we should give seniors some 
assurance that their premiums will not vary or increase unreasonably. 
Currently, all Medicare beneficiaries pay a $58.70 premium for 
physician services no matter where they live. Seniors should have this 
same stability in the drug benefit. I am concerned that under S.1, 
seniors in rural areas, who are often older and sicker, will pay higher 
premiums than seniors in urban areas. Unfortunately, this amendment to 
stabilize the premium was defeated. However, I succeeded in the Senate 
Finance Committee in passing an amendment with Senator Snowe to 
encourage the Secretary of Health and Human Services to geographically 
adjust payments to plans to account for differences in drug utilization 
across service areas so that premiums wouldn't vary as much.

[[Page S9298]]

  I voted for many other amendments to strengthen the drug benefit in 
this bill but they failed. I voted to make the drug benefit more 
attractive to seniors by closing the ``coverage gap'' that exists in S. 
1. This gap may penalize sick seniors. Once a senior's total drug 
spending reaches $4,500 for the year, the benefit shuts down until her 
total drug expenditures reach at least $5,813, unless the senior 
qualifies for low-income protections. I voted to allow employer-
sponsored retiree health plans contributions to count in this gap. I 
voted to eliminate the coverage gap altogether. I voted to prevent 
seniors from paying premiums when they are in the coverage gap. 
Unfortunately, all these amendments were defeated. I will seek to work 
with my colleagues to close this coverage gap before the benefit 
starts.
  I also voted for amendments to contain the skyrocketing costs of 
prescription drugs. One measure that I supported, which passed, seeks 
to increase access to more affordable and equally effective generic 
drugs. I also voted for an amendment, which failed, to help consumers 
better compare the cost-effectiveness of prescription drugs. Finally, I 
voted for a successful amendment to allow wholesalers and pharmacists 
to import prescription drugs from Canada, which will provide 
substantial savings to consumers while ensuring their safety.
  Another concern I have about S. 1 is its $6 billion experiment that 
starts in 2009 to test whether private insurance plans are more 
efficient and less costly than Medicare. To me and many others, the 
evidence we have already speaks to the fact that Medicare is more 
efficient. The Congressional Budget Office, the General Accounting 
Office, and outside experts all agree that private, preferred provider 
organizations and managed care plans cannot achieve the efficiencies 
Medicare can due to their need to make profits. Given these findings, I 
wonder how much of the ``savings'' this demonstration project seeks to 
achieve will come from privatization and how much will come from 
shifting more costs to seniors and health care providers? More 
importantly, I wonder why we couldn't have used the $6 billion to 
reduce drug costs to seniors by making the benefit better?
  Medicare provides health care for a special population of Americans--
millions of seniors, individuals with disabilities, and people with 
kidney failure--those who are uninsurable in the private market. 
Congress created Medicare in the first place because private insurance 
plans were failing to provide affordable health care coverage for this 
high-risk population. I wonder why we must turn back the clock and 
commit billions of taxpayer dollars to again test whether the private 
insurance market wants to insure this population.
  In conclusion, much has been accomplished but more needs to be done. 
I look forward to the deliberations of the conference committee and 
urge my colleagues to engage with me and others in the Senate who are 
eager to get a good bill signed into law. I hope my friends on the 
conference committee will retain the Senate low-income assistance 
provisions, for they are far superior to those in the House bill. This 
low-income assistance is of special importance to our nation's older 
women. Of the 19.5 million female Medicare beneficiaries over age 65, 
12.4 percent or 2.4 million enrollees live on incomes that are below 
100 percent of the Federal Poverty Level. Another 3.2 million, 16 
percent, live on incomes between 100 percent and 150 percent of 
poverty. Of senior men, on the other hand, only 7 percent are below 
poverty and another 11 percent are between 100 percent and 150 percent 
of poverty. Medicare seniors are disproportionately women and 
disproportionately poor, and will be far better served by the Senate's 
low-income provisions.
  Our parents and grandparents are depending on us, and we must not let 
them down once again. I hope that partisan politics do not stand in the 
way of a drug benefit that is available to all seniors under 
traditional Medicare.

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