[Congressional Record Volume 149, Number 128 (Wednesday, September 17, 2003)]
[House]
[Pages H8361-H8366]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




MOTION TO INSTRUCT CONFEREES ON H.R. 1, MEDICARE PRESCRIPTION DRUG AND 
                       MODERNIZATION ACT OF 2003

  Mr. STENHOLM. Mr. Speaker, I offer a motion to instruct.
  The SPEAKER pro tempore. The Clerk will report the motion.
  The Clerk read as follows:

       Mr. Stenholm moves that the managers on the part of the 
     House at the conference on the disagreeing votes of the two 
     Houses on the Senate amendment to the bill H.R. 1 be 
     instructed as follows:
       (1) The House recede to the Senate on the provisions to 
     guarantee access to prescription drug coverage under section 
     1860D-13(e) of the Social Security Act, as added by section 
     101(a) of the Senate amendment.
       (2) To reject the provisions of section 501 of the House 
     bill.
       (3) The House recede to the Senate on the following 
     provisions of the Senate amendment to improve rural health 
     care:
       (A) Section 403 (relating to inpatient hospital adjustment 
     for low volume hospitals).
       (B) Section 404 (relating to medicare disproportionate 
     share adjustment for rural areas), but with the effective 
     date applicable under section 401(b) of the House bill.
       (C) Section 404A (relating to MedPAC report on medicare 
     disproportionate share hospital adjustment payments).
       (D) The following provisions of section 405 (relating to 
     critical access hospital improvements):
       (i) Subsection (a), but with the effective date applicable 
     under section 405(f)(4) of the House bill.
       (ii) Subsection (b), but with the effective date applicable 
     under section 405(c)(2) of the House bill.
       (iii) Subsections (e), (f), and (g).
       (E) Section 414 (relating to rural community hospital 
     demonstration program).
       (F) Section 415 (relating to critical access hospital 
     improvement demonstration program).
       (G) Section 417 (relating to treatment of certain entities 
     for purposes of payment under the medicare program).
       (H) Section 420 (relating to conforming changes relating to 
     Federally qualified health centers).
       (I) Section 420A (relating to increase for hospitals with 
     disproportionate indigent care revenues).
       (J) Section 421 (relating to establishment of floor on 
     geographic adjustments of payments for physicians' services).
       (K) Section 425 (relating to temporary increase for ground 
     ambulance services), but with the effective date applicable 
     under the amendment made by section 410(2) of the House bill.
       (L) Section 426 (relating to appropriate coverage of air 
     ambulance services under ambulance fee schedule).
       (M) Section 427 (relating to treatment of certain clinical 
     diagnostic laboratory tests furnished by a sole community 
     hospital).
       (N) Section 428 (relating to improvement in rural health 
     clinic reimbursement).
       (O) Section 444 (relating to GAO study of geographic 
     differences in payments for physicians' services).
       (P) Section 450C (relating to authorization of 
     reimbursement for all medicare part B services furnished by 
     Indian hospitals and clinics).
       (Q) Section 452 (relating to limitation on reduction in 
     area wage adjustment factors under the prospective payment 
     system for home health services).
       (R) Section 455 (relating to MedPAC study on medicare 
     payments and efficiencies in the health care system).
       (S) Section 459 (relating to increase in medicare payment 
     for certain home health services).
       (T) Section 601 (Increase in medicaid DSH allotments for 
     fiscal years 2004 and 2005).
       (4) The House insist upon the following provisions of the 
     House bill:
       (A) Section 402 (relating to immediate establishment of 
     uniform standardized amount in rural and small urban areas).
       (B) Section 403 (relating to establishment of essential 
     rural hospital classification).
       (C) Subsections (a), (b), (d), and (e) of section 405 
     (relating to improvements to critical access hospital 
     program).
       (D) Section 416 (relating to revision of labor-related 
     share of hospital inpatient pps wage index).
       (E) Section 417 (relating to medicare incentive payment 
     program improvements).
       (F) Section 504 (relating to wage index classification 
     reform).
       (G) Section 601 (relating to revision of updates for 
     physician services).
       (H) Section 1001 (relating to medicaid disproportionate 
     share hospital (DSH) payments).

  Mr. STENHOLM (during the reading). Mr. Speaker, I ask unanimous 
consent that the motion to instruct be considered as read and printed 
in the Record.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Texas?
  There was no objection.
  The SPEAKER pro tempore. Pursuant to clause 7 of rule XXII, the 
gentleman from Texas (Mr. Stenholm) and the gentleman from Illinois 
(Mr. Shimkus) each will control 30 minutes.
  The Chair recognizes the gentleman from Texas (Mr. Stenholm).
  Mr. STENHOLM. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, all of us in this body have an enormous responsibility 
to the American people as we put together a bill that will shape the 
lives of 40 million current Medicare recipients and the millions more 
that will be retiring in the near future. This bill will make changes 
that will have profound effects on all Medicare beneficiaries and 
particularly on the one in four who live in rural America. Rural 
beneficiaries have different health care needs and delivery systems 
than those living in urban areas and Congress has a responsibility to 
pass a Medicare prescription drug reform bill that is responsive to 
their needs.
  The motion to instruct conferees that I am offering today will put 
the House on record in support of a conference report that addresses 
the unique challenges facing seniors and health care providers in rural 
areas as much as possible. The motion would instruct conferees to agree 
to the following:
  Guaranteed prescription drug coverage through a Medicare fallback 
option in areas where private drug plans are not available.
  The best provisions improving Medicare payments to health care 
providers in rural areas that were included in the Senate bill or the 
House bill.
  Reject the cut in payments to hospitals in the House bill which will 
adversely affect hospitals in rural areas and undercut the benefits of 
the rural health care improvements.
  Rural beneficiaries have consistently had less access to Medicare 
managed care plans. Since 2000, rural beneficiaries have been four 
times more likely than urban beneficiaries to lack a private plan 
option. This problem of low market penetration in rural areas by 
private insurance plans may be even more pronounced for a drug-only 
insurance plan. This motion would address this problem by calling on 
the conferees to accept a guaranteed fallback plan be offered through 
traditional Medicare that would be offered in areas where fewer than 
two private plans have entered to ensure that all seniors have access 
to this benefit.
  The House bill does not include a fallback provision to ensure that 
seniors have prescription drug coverage in areas where private plans 
choose to not participate. Instead, the House bill allows the Secretary 
to pay the drug-only plans whatever it takes to entice them to offer 
plans. Because premiums for prescription drug coverage are based on 
what the plans are paid, plans that take the bribe to participate may 
have significantly higher premiums than those operating in more 
competitive areas. With one in four seniors residing in rural areas, it 
is extremely important that we not exclude rural seniors from having a 
prescription drug benefit, which is a very real risk if we do not 
provide a guaranteed fallback plan for seniors in areas where private 
plans are not available. To deny seniors in rural America the 
prescription

[[Page H8362]]

drug benefit option is to deny them access to quality health care.
  The motion also calls on conferees to provide the strongest package 
possible for rural health care by taking the best of the House and 
Senate bills. Because of the very high proportion of elderly in rural 
areas, Medicare is a very large and critical source of payment for 
rural health care providers. Both the House and Senate bills would 
provide many important improvements in payments to rural health care 
providers. Unfortunately, there have been reports that assistance to 
rural health care providers is being held hostage in conference 
negotiations for leverage on other issues. This motion will send a 
clear message that the health care needs of rural America should not be 
used as leverage to advance an agenda on Medicare.
  The House bill offers assistance to health care providers in rural 
areas with one hand but takes away that assistance with the other hand 
through a reduction in payments to hospitals, which will be 
particularly harmful to rural hospitals. I am sure that all of us in 
this body who have talked to our local hospitals as I have done have 
heard about the challenges that our hospitals face, higher medical 
malpractice premiums, an increase in the uninsured population, and 
uncompensated care and cutbacks at the State and local levels. Reducing 
payments to hospitals could jeopardize the financial life of rural 
providers and undercut the benefits of the rural health care 
improvements in the bill. The benefits of improving payments to rural 
health care providers and increasing access to health care in rural 
areas will be negated if the hospital in a rural community is forced to 
close its doors. We must provide equal access to care for all Medicare 
beneficiaries, regardless of where they live. A vote for this motion is 
a vote to make sure that seniors and health care providers in rural 
America are treated fairly by the current Medicare system and the new 
prescription drug benefit.
  Mr. Speaker, I reserve the balance of my time.
  Mr. SHIMKUS. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, this motion would allow the Department of Health and 
Human Services to offer a Medicare prescription drug plan. There is no 
need for this type of government-run fallback because the House-passed 
legislation already guarantees that every Medicare beneficiary will 
have a choice of at least two Medicare prescription drug plans. My 
colleague represents rural Texas. I represent rural Illinois. We know 
that one of the problems in the past was Medicare plans leaving rural 
areas. I think the benefit of what we have crafted is that it broadens 
the scope of the region, so it brings in urban and suburban and rural 
areas.
  The motion also instructs conferees to recede to the Senate and 
remove the hospital market basket update adjustment contained in the 
House bill.

                              {time}  1615

  I would note for my colleagues that we are not cutting hospital 
reimbursement. We are reducing the increase they are going to receive. 
According to the Medicare Payment Advisory Commission, MedPAC, the 
nonpartisan panel of experts that advises Congress on Medicare policy, 
hospitals make a 10 percent profit for Medicare inpatient services and 
a 5 percent profit, on average, for all services provided to Medicare 
patients. MedPAC unanimously advised Congress to increase payments by 3 
percent, which is what the House bill does. This is often referred to 
as market basket minus 0.4 percent.
  Finally, this motion would instruct conferees to accept every rural 
provider increase contained in both bills. This budget-busting motion 
would mean the cost of the entire package would greatly exceed the $400 
billion allocated under the budget resolution for Medicare prescription 
drugs which would jeopardize our ever getting to a final bill. 
Obviously, in our budget resolution we passed a bill for prescription 
drugs at $400 billion. If we go above that amount, we will raise to a 
point of order, and really we will have no resolution to this.
  This motion is unnecessary. The House has already recognized the need 
to ensure that rural Medicare providers are paid fairly. In fact, the 
House-passed bill contains a $24.9 billion increase in payments to 
rural providers which would help rural hospitals and physicians, among 
others, continue to provide care to rural Americans. Let me just say 
that again. I traveled all through the August break to many of the 
rural hospitals. They do not have the numbers to be able to bring to 
bear all the benefits; so they really need this increase, and this 
rural increase of $24.9 billion is real dollars to rural hospitals, and 
I know my colleague knows the need for an increase in rural hospital 
coverage.
  I would also note that conferees have reached agreement in a 
bipartisan, bicameral basis on a number of issues that will be reopened 
under this motion. Do we really want to tell the conferees to start 
over all from scratch? I do not because we want to see success in this 
Medicare prescription drug bill, and we want to finally get help to the 
seniors who have asked for it.
  Mr. Speaker, we should allow the conferees to work out the 
differences between both bills. Since both Chambers have made a 
significant commitment on helping rural providers, I have every 
confidence that they will develop sound policy.
  Mr. Speaker, I reserve the balance of my time.
  Mr. STENHOLM. Mr. Speaker, I yield such time as he may consume to the 
gentleman from Texas (Mr. Sandlin).
  Mr. SANDLIN. Mr. Speaker, I thank the gentleman from Texas (Mr. 
Stenholm) for yielding me this time, a real hero and champion of rural 
health care, especially in west Texas.
  Mr. Speaker, I join my colleagues in instructing the Medicare 
prescription drug conferees to remember our Nation's 9.3 million rural 
Medicare beneficiaries as they continue their critical deliberations. 
The way this bill currently stands is nothing more than the old bait 
and switch. The Republican leadership has used smoke and mirrors to 
trick our seniors into thinking that they are getting a Medicare 
prescription drug plan, when in reality they are forcing them to seek 
medication from private insurance companies and HMOs that will set the 
price and set the benefits. This HMO enrichment plan does not even 
pretend to address the needs of rural America.
  Mr. Speaker, as my colleagues know, over 80 percent of rural health 
care beneficiaries today live in an area that insurance companies do 
not and will not serve, and it is worse than that in my district. Not 
one single insurance company in the United States of America has signed 
up for the plan that is being proposed by our friends on the other side 
of the aisle.
  Just what has history shown us about what happens when insurance 
companies get involved in Medicare? Medicare+Choice, the great managed 
care experiment of our Nation's seniors, should have been named 
Medicare Minus Choice. After all it has been a total disaster. Between 
1998 and 2003, the number of Medicare+Choice plans dropped in the 
United States by more than half. And in Texas, in our State, over 
313,000 Medicare+Choice seniors have been dropped by insurance 
companies since 1999 alone, dropped straight in the grease in Texas 
because they do not want to serve rural America. Rural seniors do not 
have access to private insurance plans, not the same as our urban 
seniors, and knowing this, we must include a Government fallback option 
for areas served by less than two plans. And there are no plans in east 
Texas, no plans in rural America.
  Mr. Speaker, we also need to eliminate the premium support provisions 
in H.R. 1 that are scheduled to take place in 2010. It is 
unconscionable to market this prescription drug bill as an equitable 
bill and universal, when these folks who stay in traditional fee-for-
service Medicare will see significant premium increases under the 
competition program. There is no competition in rural America, and 
there is no service in rural America.
  Rural seniors have not gotten a fair deal. On average, they are in 
poorer health, have lower incomes, face higher out-of-pocket medical 
spending than seniors in urban areas, and they are not addressed. They 
need our help, and yet, all we are doing with this bill is compounding 
the inequity rural seniors already endure.
  I implore my colleagues to join me in instructing the Medicare 
conferees to honor our rural seniors. Rural seniors need health care. 
Rural seniors need our representation. The HMOs already have all that 
covered.

[[Page H8363]]

  Mr. SHIMKUS. Mr. Speaker, I yield myself such time as I may consume.
  Let me just respond to my colleague. The private sector already does 
manage the Medicare system. The private sector is already involved in 
Medicare. They have been doing the job now. They can do it again. If we 
mandate, as in our bill, that there would be two providers and, again, 
expand the area of coverage from cities to suburbs out to the rural 
areas, we will have coverage. I would remind folks $24.9 billion for 
rural hospitals is real money.
  Mr. SANDLIN. Mr. Speaker, will the gentleman yield?
  Mr. SHIMKUS. I yield to the gentleman from Texas.
  Mr. SANDLIN. Mr. Speaker, how can we assume that coverage would be 
available in my district or in rural America when it is not available 
now, and countrywide it is not available in 80 percent of rural 
districts covered where we have Medicare-covered folks?
  Mr. SHIMKUS. Mr. Speaker, reclaiming my time. Mr. Speaker, it is my 
time.
  The SPEAKER pro tempore (Mr. Linder). The gentleman from Illinois 
(Mr. Shimkus) controls the time.
  Mr. SHIMKUS. Mr. Speaker, reclaiming my time, it is because it is on 
a county-by-county basis. What this Medicare bill does is set up at 
least at a minimum two coverage areas that would cover the cities, the 
suburban areas, and out to the rural areas. That way we bring in a 
bigger pool. But I will also say again $24.9 billion to rural hospitals 
we jeopardize if we go off in an opportunity to start instructing 
conferees and distract from this debate.
  Let me say one other thing about this legislation. I know my good 
friends and colleagues are budget watchers, and the idea is that we 
have a budget that has $400 billion for prescription drug benefit 
coverage. Anything other than what we have going down the track would 
probably be risen to a point of order because what they are going to do 
is expand the cost structure.
  Mr. Speaker, I ask unanimous consent that the gentleman from Texas 
(Mr. Sam Johnson) be allowed to control the balance of my time.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Illinois?
  There was no objection.
  Mr. SAM JOHNSON of Texas. Mr. Speaker, I yield myself such time as I 
may consume.
  I cannot believe we are arguing over this because there are some 
misnomers here, I think. When they come up with this motion to 
instruct, we are asking to accept the Senate's position on a 
government-run prescription drug delivery structure, and the CBO has 
estimated that that government-run provision will lead to higher prices 
for beneficiaries and taxpayers in over $8 billion in higher costs. 
That is a giveaway to the pharmaceutical industry.
  This talk about seniors not having a benefit in rural areas is just 
not right. Both CBO and CMS agree that numerous drug plans will be 
available and more than 95 percent of the beneficiaries will 
voluntarily sign up for the benefit. These nonpartisan actuaries have 
no axe to grind and are in agreement on that point.
  Furthermore, any action to approve the other body's position provides 
unprecedented inflationary increases to hospitals and other health care 
providers which will force the conference, as my colleague has said, to 
exceed the $400 billion allocation in the budget resolution, thereby 
jeopardizing the whole program. It will also undo bicameral, bipartisan 
decisions that conferees have already resolved. The motion is 
completely unnecessary because both bills already require prescription 
drug plans to assume financial risk in delivering prescription benefits 
to provide a fallback to guarantee all seniors have access to 
prescription drug plans. It does not matter whether they live in a city 
or in a country. Both CBO and CMS, as I said, agree that more than 95 
percent of beneficiaries will voluntarily sign up.
  Mr. Speaker, I reserve the balance of my time.
  Mr. STENHOLM. Mr. Speaker, I yield myself 1 minute.
  To respond to my friend from Texas, this is not a budget-busting 
amendment. We fully expect the conferees to live within the $400 
billion. We have a different idea of the prioritization than what the 
majority party has, and we are just expressing that today. And also, 
when the House has a chance to vote, Members on both sides can see 
whether or not the priorities we believe are the most important should 
be considered by the conferees. And also with the emphasis on 
government-run, let me remind my friend from Texas that it is only if 
the private system fails in rural America, will we have a return to a 
Medicare plan. Only if it fails. We worry because of the past history 
of private plans in rural America. We worry that they may not work, and 
we think it would be irresponsible for us not to provide a fallback. 
That is our opinion. It is not government- mandated, and these little 
speech lines that keep flowing out, this is a different idea, a 
different opinion, and we just expressed it today.
  Mr. Speaker, I yield 4 minutes to the gentleman from Ohio (Mr. 
Brown).
  Mr. BROWN of Ohio. Mr. Speaker, I thank the gentleman from Texas for 
yielding me this time.
  The premise behind the Stenholm motion is simple. One fourth of all 
Medicare beneficiaries live in rural areas, and they are getting the 
short end of the stick. Rural hospitals are closing, and there are not 
enough rural hospitals to begin with. Twenty-five percent, as I said, 
25 percent of all Medicare beneficiaries live in rural areas; 90 
percent of all physician specialists practice in urban areas. Senior 
and disabled Americans who need care simply are not getting it in time. 
That is more than a problem. It is a tragedy. Because of the high 
proportion of elderly in rural areas, Medicare plays a particularly 
important role in those areas. Inadequate Medicare reimbursement means 
inadequate access. There is no cushion. Our responsibility to rural 
Medicare enrollees is the same as our responsibility to urban Medicare 
enrollees. They paid in Medicare throughout their working years in 
exchange for health care security during their retirement. It is the 
covenant between the Government and its people.
  Now that those people are retired, their health care should be 
reliable. It should be affordable. It should be easily accessible. To 
meet that responsibility, we need to pay rural providers enough to stay 
in business. It is that simple.
  Unfortunately, Mr. Speaker the House bill tries to have it both ways. 
It invests in rural hospitals. That is good. Then it squeezes blood 
from them by cutting reimbursement across the board. One cannot do it 
both ways. It makes no sense, no sense, to undermine our own efforts to 
help rural providers and by extension rural beneficiaries, the whole 
point, by simultaneously increasing and then cutting hospital 
reimbursement, not to mention the negative impact on urban and suburban 
hospitals.
  This motion, the Stenholm motion, simply instruct conferees to 
eliminate the hospital cut. This motion instruct conferees to ensure 
that no senior ends up without access to prescription drug benefits. 
That is what this whole exercise is all about. H.R. 1 sets the stage 
for two scenarios when it comes to areas traditionally underserved by 
HMOs. Neither of those scenarios is acceptable from a public health 
perspective or, as the gentleman from Texas (Mr. Stenholm) points out, 
a fiscal perspective.
  First, to lure an HMO to provide drug coverage in a rural or other 
underserved area, in a sense this Congress bribes them. Knowing the 
Federal Government is prepared to cover virtually all of an insurer's 
risk in order to attract them to a rural area, I wonder how many 
private plans will not hold out for this sweetheart deal? Of course 
they will.

                              {time}  1630

  Of course, they will. But if no plan takes the bait, then seniors in 
that area just do not get drug coverage.
  There are many provisions in H.R. 1 and S. 1 about which Members can 
reasonably disagree, but do any of us really want to pass a bill that 
plays that kind of game? The possibility that some seniors would not 
have access or they will have to shower almost unlimited tax dollars on 
HMOs to ensure that access, why would we ever think of going down that 
road?
  Fundamentally, the Stenholm motion instructs conferees to take the 
best of both bills when it comes to bolstering access to care and 
ensuring access to coverage in our Nation's rural

[[Page H8364]]

areas. It warns that the hospital cut included in H.R. 1 short-circuits 
the bill's provider provision, rural provider provisions, and the 
Federal fallback omitted from H.R. 1 is crucial if our goal truly is to 
fill the drug coverage gap in Medicare.
  Mr. Speaker, I urge my colleagues to vote for the Stenholm motion.
  Mr. SAM JOHNSON of Texas. Mr. Speaker, I yield myself such time as I 
may consume.
  Mr. Speaker, I am kind of getting worried about us wanting to spend 
more money. It seems like every time I turn around, we do that. This 
particular proposal spends more money. In fact, I think my colleagues 
forget over there that we put in $27 billion extra for rural, just for 
rural, and if you look at some of the statistics, Iowa, for instance, 
has a 5.5 percent increase and plus-up on Medicaid. I think Iowa is 
rural. Oklahoma has a 5.7 percent increase and a 5.9 percent increase 
on Medicaid. I think that is rural, for the most part.
  As I go through these notes, it seems to me that the States that you 
call rural and are not getting anything, they are getting more. Montana 
gets a 5.7 increase. It is impossible for me to figure out why you 
think the rural areas are getting stiffed. South Dakota, 5.4 percent 
increase; Tennessee, 5.3 percent, and so on. I can go on and on.
  But the thing is that the Senate provision, or the provision, that 
you are trying to affirm results in higher costs; and it is a complete 
and utter giveaway. I think that it is time that we got a little bit of 
fiscal responsibility in this House and stopped spending money.
  Mr. Speaker, I reserve the balance of my time.
  Mr. STENHOLM. Mr. Speaker, I yield 3\1/2\ minutes to the gentleman 
from Iowa (Mr. Boswell).
  (Mr. BOSWELL asked and was given permission to revise and extend his 
remarks.)
  Mr. BOSWELL. Mr. Speaker, I thank the gentleman for yielding me time.
  Mr. Speaker, it is my pleasure to be here. This is a very dear thing 
to people in my State. The gentleman made a reference to Iowa. I think 
if you get into the print though, you will find out that we give the 5-
whatever percent, but then we take a piece of it back in the market 
basket thing.
  So what happens here? When we are in the last position, it is a bad 
place to be. It is my understanding that no matter where you live, you 
pay the same as we go into this. We pay the same, but we do not get the 
same benefit.
  This is doing us a lot of harm. We understand the impact this has on 
the older folks. Everybody thinks that just applies to them, but it 
applies to the whole community. When you cannot recruit doctors, you 
cannot retain doctors; you cannot recruit nurses, you cannot retain 
nurses; you cannot get technicians, you cannot retain them. You just go 
right on down to the mess halls, as we used to say in the Army and the 
Air Force. It affects the whole community, from the oldest to the 
youngest. You cannot buy equipment. It does not cost any less in Iowa 
and the rural areas than somewhere else. It is a very serious matter, 
and it needs attention.
  So I hope that this will be accepted, that we will instruct to go and 
make sure that reimbursement rate is taken care of, and some equity, 
fairness, will take place. It is unfair discrimination, pure and 
simple, against States like mine, which rank last in the Nation in 
reimbursement, and many other areas throughout the Nation.
  I find out down in Texas, there are areas out there that are as bad 
as we are. Yet overall, as we put all the numbers together, we go to 
the bottom, a rate that is less than half what the top rate is in the 
Nation. Something is awry. Something is wrong. We pay the same, but we 
cannot have the same.
  Wait a minute, this is the United States of America. If we all pay 
the same, why do we not have the same treatment? That is not going on, 
and here is a chance to make that right.
  So I am very hopeful, I am very hopeful, that we will not pass up 
this opportunity. We get to the underlying bill, the prescription drug 
side, that is another argument, and it affects everybody across the 
country. It does not affect just those of us getting a very bad shake 
on the reimbursement rate for Medicare. It affects everybody. I think 
we will keep that out in front of us for some time. I do not think that 
is going to go away.

  But this might be the chance, this might be the chance for some 
parity, some equity, an opportunity to have some fairness when it comes 
to Medicare reimbursement.
  I hope that those that have the last say on this when it comes back 
to us to either vote it up or vote it down will take this very, very 
seriously and try to treat all Americans alike. We need fairness. We 
pay the same, we ought to have the same result. It is a national 
program; it is not just for individual areas.
  It is kind of interesting, I would say to the gentleman from Texas 
(Mr. Stenholm), talking to you and realizing out in some of the rural 
areas in Texas, and I am sure it is the same in parts of your district 
as well, that, no, it is not so. But, anyway, it certainly is in some 
of the rural areas, and Texas is Texas.
  Mr. Speaker, it is time for fairness. We are all Americans. We are 50 
States, and we are not getting treated the same. Iowa would like to be 
treated as everybody else. We do not want anything extra. Just treat us 
the same. We stand up and pay the same; we ought to be treated the 
same.
  Mr. SAM JOHNSON of Texas. Mr. Speaker, I yield myself such time as I 
may consume.
  Mr. Speaker, I will tell you what: let us correct the record. You did 
get a market basket adjustment of minus 0.4 percent, but the number I 
quoted you was the number at the end, which was a 5.5 percent increase. 
That is 2.1 percent more than current law. That does not count the 5.5 
percent increase in additional allotments for Medicaid. Iowa is not 
being mistreated. When I hear talk about let us treat everybody equal, 
I think of Canada and their socialist program of medicine, which has 
not worked; and that is why Canadians come down here for medicine.
  Mr. Speaker, I reserve the balance of my time.
  Mr. STENHOLM. Mr. Speaker, I yield 2 minutes to the gentleman from 
New Jersey (Mr. Pallone).
  Mr. PALLONE. Mr. Speaker, I am just amazed when I listen to the 
Republican side, because they are just so bent on the ideology of this, 
and I think that the motion of the gentleman from Texas (Mr. Stenholm) 
and what the Democrats are saying is look at this situation 
practically.
  If you listen to what the gentleman from Texas (Mr. Stenholm) has 
said in the motion to instruct, it essentially says, look, we know 
those of us who are in rural areas, I am not, but we know these HMOs 
and these private plans are not working, for the most part, and if 
someone tries to get their prescription drugs through an HMO or managed 
care private plan, in many cases it is not going to be available, and 
they are not going to have access to it.
  It is the Republicans that basically are trying to impose an ideology 
and saying we must privatize, we must go this route, this is no 
alternative. All the gentleman from Texas (Mr. Stenholm) is saying is 
in a situation where the HMOs or the private plans are not available, 
we still have to guarantee drug coverage for those seniors in those 
rural areas that cannot get it through these private HMOs or other 
private plans. So let us have the Senate fallback that says you can get 
your prescription drugs through traditional Medicare.
  Now, I just do not understand why the Republicans keep insisting from 
an ideological point of view, well, we cannot do that; you have to 
privatize. They went so far as to suggest we have private contractors 
that provide Medicare services now, but that is the Federal Government 
as the ultimate insurer contract with some private company to provide 
the service.
  What you have done in this House bill is say that if you as an 
individual cannot find a private plan, you are out of luck. All the 
gentleman from Texas (Mr. Stenholm) is saying with this motion to 
instruct is let us have a fallback. Let us have an alternative for 
these people in rural areas when they cannot get the HMO to provide the 
service. What could make more sense?
  Mr. Speaker, it is the same thing as far as the reimbursement rate is 
concerned. I heard the colleagues on the

[[Page H8365]]

Republican side say there is no cutback effectively in the 
reimbursement rate. Certainly there is. Many of us went to meet with 
the oncologists today, the cancer doctors; and they were talking about 
the negative impact on cancer victims because of this reimbursement 
rate. We have got to change that as well. Just follow the gentleman 
from Texas (Mr. Stenholm). It is the practical way to do this, with 
this motion.
  Mr. SAM JOHNSON of Texas. Mr. Speaker, I reserve the balance of my 
time.
  Mr. STENHOLM. Mr. Speaker, I yield 3 minutes to the gentleman from 
Tennessee (Mr. Tanner).
  (Mr. TANNER asked and was given permission to revise and extend his 
remarks.)
  Mr. TANNER. Mr. Speaker, I thank the gentleman for yielding me time.
  Mr. Speaker, what we are talking about here is no less than a matter 
of life and death. All of the medical technology in the world is not 
going to help somebody who cannot access the system. When you are 
talking about Tennessee, you are talking about 47 percent of the acute 
care hospitals in rural Tennessee are losing money. In the House bill 
you cut the market basket to those hospitals.
  There is no way that one can deny the fact that somebody is going to 
die needlessly because they do not have a hospital or an emergency 
medical room within 50, 60 or 70 miles, simply because they live in a 
rural area. You can argue about it, but there is no denying that it 
will happen. Somebody will die in rural America, because if this House 
bill goes through, you are going to see acute care hospitals in rural 
areas close, not to mention the fact that there are people involved.
  I think my friend, the gentleman from New Jersey (Mr. Pallone), 
talked about the fallback provision. Because we live in a place where 
you do not need a blinker signal on your car because the guy behind you 
knows where you are going to turn off, we do not have a lot of choice. 
And that is what we are talking about here. We are talking about life 
and death in rural America.
  You may not live in rural America; but you have a cousin, an aunt or 
uncle, a brother, sister, or somebody that does; and these people are 
going to be irreversibly adversely affected if we do not accept the 
motion of the gentleman from Texas (Mr. Stenholm).
  Mr. SAM JOHNSON of Texas. Mr. Speaker, I yield myself such time as I 
may consume.
  Mr. Speaker, Tennessee is kind of an interesting State, because they 
get a 5.3 percent increase; and it does not include six Tennessee 
critical access hospitals which are rural which are paid exactly what 
their costs are. Now, this bill is all-encompassing. It takes care of 
people. It does not let people die, and it does not spend the Treasury 
of the United States to zero.
  Mr. Speaker, I reserve the balance of my time.
  Mr. STENHOLM. Mr. Speaker, I yield 1 minute to the gentleman from 
Texas (Mr. Rodriguez).
  Mr. RODRIGUEZ. Mr. Speaker, let me first of all say that what we have 
before us is two bills. Neither one is worth the paper they are written 
on, and they are not going to respond to the issues that confront us.
  The approach that the gentleman from Texas (Mr. Stenholm) is 
providing is to try to look at what is best and try to make something 
happen. The gentleman from Texas (Mr. Sam Johnson), I know he is from 
Texas also, and I am from Texas, and I have counties that right now do 
not have any access to any type of health care because they have chosen 
to leave, they were not making the profits they wanted, and we are 
having a rough time.
  That bill is not going to be responsive. You are saying you are 
concerned about being fiscally responsible. My God, you are taking 
money from cancer, which is kind of robbing Peter to pay Paul. You are 
taking money from people dying from cancer to try to fill another need. 
We are here to tell you there are needs on both sides. That bill does 
not meet those needs.
  So one of the things we have to come to grips with is we have a 
problem before us, and you are choosing not to deal with it directly, 
and you are choosing to play games with Americans.
  Mr. SAM JOHNSON of Texas. Mr. Speaker, I yield myself such time as I 
may consume.
  Mr. Speaker, let me just make a couple of observations. The 
hospitals' payments include some of the payments for beneficiaries. It 
is not just all hospital costs. I think that we have to consider the 
fact that the United States Senate, which according to what this 
proposal embodies, puts the government fully at risk.

                              {time}  1645

  There is little incentive to control costs, and I think that the 
provisions have to lead to higher prices for beneficiaries and 
taxpayers, and it is a complete and utter giveaway. I think that we 
have to defeat this motion.
  Mr. Speaker, I yield back the balance of my time.
  Mr. STENHOLM. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, this motion to instruct conferees is not a budget 
buster. It is a red herring to suggest that we are going to bust the 
budget at $400 million. I support that, and those of us who support 
this resolution support that. It is a red herring.
  One of the things my friend from Texas does not seem to want to 
acknowledge is that there are many hospitals, as the gentleman from 
Iowa (Mr. Boswell) pointed out, there are many hospitals that have not 
enjoyed the increases that hospitals in the bigger towns have enjoyed 
over the last 20 years. And when you have not gotten the increases that 
some have gotten and you have gotten a lesser amount of reimbursement, 
you are hurting. That is why we believe the Senate provisions are 
fairer to those hospitals.
  The gentleman is totally correct when he says they get less of an 
increase, no one is getting cut; but when you have a baseline that is 
too low, it is important that you get a chance to compete on a level 
playing field with those hospitals who enjoy a little better situation. 
We have argued for that for years, but unsuccessfully. Now we notice 
that there is bipartisan support for acknowledging that rural hospitals 
and many inner city hospitals have the same problem and that we should, 
in fact, recognize and begin to correct that disparity.
  Regarding the pharmaceutical benefits and the going back to a 
government program, only if it fails will we go back to a Medicare 
government program. But some of us, myself included, are very skeptical 
that private businesses are going to be as interested in rural areas 
with less people as they are in urban areas; and, therefore, a fall-
back is critical to us. But it does not do what the gentleman said it 
did. It is only if it fails; only if it fails will we have a fall-back.
  Now, in conclusion, it is difficult for me, and I will not miss the 
opportunity to say that to be lectured by my friend from Texas on 
fiscal responsibility, I say to the gentleman, that is a joke. For the 
gentleman to have supported and continue to support the economic game 
plan of his side of the aisle that has given us the largest deficits in 
the history of our country, $689 billion and going up, and I know this 
because my friend from Texas voted for the last bill that increased the 
deficit another $12 billion. I did not, and I will get criticized. But 
I think it is time for us to be fiscally responsible, but I find that 
it is only when it is convenient. If it is a tax cut, it is great. But 
if it is being fair to rural hospitals, that is a no-no.
  As to the child tax credit, the debate that went on before this, let 
me point out that every single dime of tax dollars that have been 
collected on the Social Security system are being spent for current 
operating expenses. Really, we are borrowing, in addition to that, $560 
billion. Differentiating between Social Security taxes and income taxes 
is a joke, a joke. Just because it was done for 40 years is no longer 
reason for us to continue to do it.
  But do not lecture me on fiscal responsibility. Do not let staff feed 
the little notes in saying here is what it does and here is what it 
does not, because this motion does not bust the $400 million budget. We 
live within it. We only ask the conferees to make the changes. Yes, it 
will be difficult. Yes, you cannot do what you want to do. You cannot 
do the things that you want to do in total, but it is a reasonable 
compromise; and that is what conferences between the House and the 
Senate are all about. It is taking the differences and working them out 
in a

[[Page H8366]]

very, very good and concise way. But do not lecture us on budget. Go 
somewhere else. Argue the philosophical. That is a fair shot. The 
gentleman and I philosophically disagree apparently on the direction 
that this ought to be. That is a fair shot, and we will argue that. But 
this amendment does not bust the budget. It offers some, we hope, 
constructive suggestions; and I hope that the House will in an 
overwhelming vote say to the conferees, we believe this has merit, take 
a look at it, and let us pass it.
  Mr. Speaker, this amendment is not what is important. It is what 
comes back, because that is what is, in fact, going to be affecting 
lives. And in rural areas, this is a critical difference from a 
hospital's standpoint. If we cannot do what this amendment does, we are 
going to continue to have real problems in rural areas, and anybody 
that represents a rural area needs to take a good hard look and 
hopefully join in support of this amendment.
  Mr. Speaker, I yield back the balance of my time.
  The SPEAKER pro tempore (Mr. Linder). Without objection, the previous 
question is ordered on the motion.
  There was no objection.
  The SPEAKER pro tempore. The question is on the motion to instruct 
offered by the gentleman from Texas (Mr. Stenholm).
  The question was taken; and the Speaker pro tempore announced that 
the ayes appeared to have it.
  Mr. STENHOLM. Mr. Speaker, on that I demand the yeas and nays.
  The yeas and nays were ordered.
  The SPEAKER pro tempore. Pursuant to clause 8 of rule XX and the 
order of the House of earlier today, further proceedings on this motion 
will be postponed.

                          ____________________