[Congressional Record Volume 149, Number 137 (Wednesday, October 1, 2003)]
[House]
[Pages H9062-H9067]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
[[Page H9062]]
MOTION TO INSTRUCT CONFEREES ON H.R. 1, MEDICARE PRESCRIPTION DRUG AND
MODERNIZATION ACT OF 2003
Mr. CASE. Mr. Speaker, I offer a motion to instruct conferees on H.R.
1.
The Clerk read as follows:
Mr. Case 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. CASE (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 Hawaii?
There was no objection.
The SPEAKER pro tempore. Pursuant to clause 7 of rule XXII, the
gentleman from Hawaii (Mr. Case) and the gentleman from Florida (Mr.
Bilirakis) each will control 30 minutes.
The Chair recognizes the gentleman from Hawaii (Mr. Case).
Mr. CASE. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, by my calendar, we now have 16 days until the October
17th deadline announced by the President and the Senate majority leader
for completing the pending conference on the so-called Medicare reform
bill. And still before this House, before this Chamber and the Senate
and the country the unanswered question, in my mind, is: Does the
current administration and does the congressional majority really care
about health care for the American people?
Now, I know a lot of people around here really care about a lot of
people around here that make a lot of money off of health care. And I
know that a lot of people around here really care about spending money
on a lot of things other than health care. I have seen that in my time
here in Congress. And I have certainly heard a lot of talk, a lot of
talk about health care. I have certainly heard a lot of talk about
Medicare. But the question is: Do they really care? What do their
actions demonstrate? Do they care about the people at the end of this
food chain?
It is a long food chain from the halls of this Congress through the
Federal Government and out through the health care community and down
into the communities where people live, work and get sick. Do they
really care about the people at the end? All of us do not just want
affordable and available health care; we need it, and it has to be
available and affordable.
When we look at where the people of our country live, who most want
and most need health care, and when we look at where the assistance of
our Federal Government should go, it is in the rural areas of our
country, our small cities, our small towns, our hamlets, our isolated
outposts, out where people live away from these urban centers where we
live and do our work. And the reasons for that need are well
documented, and I do not think anybody else has to tell us any more.
We all know why health care is so important to the rural areas of our
country. First of all, we have less available preventive care
throughout life, so when people get sick younger, they get sick worse
in the rural part of our country. In the rural parts of our country
today and down the road, people are older than in the urban parts of
our country; they need health care more.
{time} 1245
In the rural parts of our country people have lower incomes, higher
unemployment, and when we have lower income and higher unemployment,
health care suffers.
In the rural parts of our country, it always has been true that there
has been less access to medical care and specialization, and that is
getting worse.
Finally, in the rural parts of our country, there is simply less
availability and coverage of health care insurance.
These are not just abstract thoughts. We can read about these in
Federal reports. We can debate them here in Congress, but let us talk
about real America, what happens out there in these communities, and
let me talk about my community, the community that I represent, because
I represent rural Hawaii. I do not represent downtown Honolulu. I
represent the rural parts of my State, islands all of them, islands
that are rural, islands with small cities, small towns, hamlets and
outposts every bit as rural as the rest of our rural country, every bit
as prone to all of these problems. They may have different names, but
the concerns are the same.
Let me give my colleagues just a couple of examples of areas of my
District which are just like any part of our country in terms of health
care. Let us talk about the Hamakua Coast on the island of Hawaii, my
home. The Hamakua Coast is about as rural as one can get in Hawaii. It
is an agricultural-based economy. Its largest crop, sugar, failed along
that coast 10, 15, 20 years ago. And these small towns now have people
that grew up in the sugar industry and are trying to make a go of small
business in agriculture in those small towns, small towns like Pepeekeo
and Papaikou, Laupahoehoe, Paauilo, Honokaa, and their problem is
health care.
Let us take West Hawaii, the other side of the same island, a part of
my Hawaii that has some most of the rural areas of our whole State,
North
[[Page H9063]]
Kohala, Ocean View down in South Kona and Kau. They want those rural
communities to survive. West Hawaii used to have a surgeon that
qualified for Medicare reimbursements. That surgeon is no longer there.
There is no surgeon in West Hawaii at the moment for Medicare people.
So when I walk into the coffee shops, when I walk into the small
family stores and small post offices of my district, when I go into the
bon dances that are so much a part of our culture during the summer,
and I sit down, and I talk to my constituents, and I ask them what is
on their mind, they say health care, health care and health care.
This is not an abstract thought. They are scared about the
availability of health care. They are scared about the availability of
prescription drugs. They are scared about chronic disease and chronic
illnesses and their ability to be able to take care of their medical
needs. They are scared about long-term care, and their children are
scared for their parents.
These are the realities of rural America. The availability of
physicians in this part of my district is significant in the example
that it shows for what is happening in rural health care. There are
about two physicians per 1,000 in urban Honolulu, but if one gets out
there into the rest of the communities in my district, the percentage
drops well below one, down to 0.1 in communities like Molokai.
Let us talk about Molokai, because that is another good example. The
island of Molokai, about as rural as one can get in America, an island,
an island of 7,000 people living on it. They cannot hop a bus or a
train or a boat to get to some critical access hospital when they have
medical care. They have to fly, and flying is expensive. Thousands of
dollars are being spent.
Hawaii is no different from the rest of rural America. I fly over
rural America almost every weekend. I look down. I have been across it
myself, and I look out, and I see places just like my rural Hawaii.
They are their own islands. They may not be surrounded by water, but
they are islands of isolation, islands of small towns, small hamlets,
the prairie towns of the great plains, the mountain hamlets of the
Sierra, the Rockies or Appalachia. This is our heartland, and they are
scared about health care.
In rural America, health care is not an abstract thought either. It
is a Federal program, Medicare. Health care in rural America is
Medicare. For seniors in rural America, it is Medicare. For the
disabled in rural America, it is Medicare, and because in rural America
it is health care and health care is Medicare, as Medicare goes, so
goes rural America.
If we do not have available and affordable medical coverage through
Medicare, we have no rural America. If we do not have adequate
reimbursements, no doctors, no hospitals, no clinics in rural America,
we have no rural America. If we do not have adequate prescription
coverage for our seniors and disabled that live in rural America
through Medicare, we have no rural America.
So one of the things that it is incredibly important to realize is
that the debate about Medicare is not just about Medicare. The debate
about Medicare is not just about health care. The debate about America
is about maintaining rural America. We have to take care of the needs
of rural America, whether they are economic needs, where the
manufacturing base is shrinking or whether they are land use needs,
where the agricultural base is shrinking, and whether they are health
care needs, where the needs are diminishing. That is the reality of
Medicare.
H.R. 1, the Medicare Reform Bill, passed this House by a single vote.
Like most of my colleagues on this sides of the aisle, I voted no on
that bill, primarily because that bill did not help rural America. That
bill did not do the job for rural America that we wanted it to do, and
in fact, that bill hurt rural America, and I voted no. The motion
before us today simply says this: Put your money where your mouth is.
There has been a lot of talk about helping rural America, but talk is
cheap. Let us prove it. Do not get me wrong, there are some components
in both the House version of Medicare reform and the Senate version of
Medicare reform, there are isolated instances of help for rural America
in both bills. That is not going to be good enough. As these 16 days
tick by to the deadline set by our President and our Senate majority
leader, our attention has to turn back to what are the best aspects of
each bill for rural America, what are the best aspects of the bill that
help the particular problems in rural America, what are the aspects of
the bill that provide prescription drug coverage, what are the aspects
of the bill that provide adequate reimbursements to hospitals and
doctors.
On the island of Molokai, for example, we no longer have long-term
care beds. Why? They cannot provide them under the reimbursement rate
granted by Medicare. That may seem like an abstract thought, but
imagine that a person has grown up their whole life on Molokai, and
their family lives there, too, and it comes time for them to be taken
care of in their old age, and they have to move islands, they have to
leave their home because there is not the coverage available to be
helpful to them if they are needy, and their family has to fly back and
forth. That is not something we want to sanction.
We want to take the best of these two bills. We want to take the best
of these bills on prescription drug coverage. We want to take the best
of these bills on not cutting our hospital payments, and that is what
this motion says.
This motion which has been brought three times now before this House
by my colleagues, and I now bring it here today, simply says let us not
talk anymore, let us do it. Let us take the best of these bills that we
know will do the job, and let us adopt them in conference because we
have the ingredients, right now, to do a good job for rural America.
The question is will we do that job for rural America?
So this bill simply says, on prescription drug coverage, let us have
a fall-back option. If there is no prescription drug coverage available
under Medicare in our rural communities, then there is a fall-back
provision on prescription drug coverage, not by the private sector, but
by our government.
This motion says let us take the best of both the House and the
Senate versions on reimbursing our providers. If we cannot provide
basic services in our communities to those in need, there is something
wrong, and we need to provide for the adequate reimbursements, and this
bill says let us do that, and this bill also says that we need our
hospitals, our critical access facilities in our rural areas. We need
access in our rural areas.
Again, the example of Hawaii, a State that is an island State, where
one cannot simply get to the urban center of Honolulu easily, where
people are spending, like I said, thousands of dollars just on
transportation needs because these are not available in their districts
whether they be Kauai or Molokai or Maui or the Big Island, that we
will provide the necessary payments to our hospitals to keep them open
at a basic level of service for our rural areas. That is what this
motion says, and I think it is pretty simple. It is a matter of
priorities.
If our priorities are to ensure the health of our rural economies,
our rural lifestyle, which is the heart land not only of our country
but of our thinking, of our culture, then we need to protect these
rural communities, and health care is the way to protect them.
So let us not avoid this anymore. Let us just vote on this motion,
let us give our conferees direct instructions that we collectively care
about rural health care and that we intend to follow through and that
we will put our money where our mouth is.
Mr. Speaker, I reserve the balance of my time.
Mr. BILIRAKIS. Mr. Speaker, I yield myself such time as I may
consume.
Mr. Speaker, the gentleman makes a very good case for rural health
care, and I commend him for that and because we have heard the same
case made time and time again, and this is why we have provided an
approximately $25 billion increase in payments to rural providers.
Before I go into that, I would advise the gentleman through the
Chair, if I may, that I certainly agree with him regarding wellness,
preventive health care and whatnot, and for something like 60 years or
30 years after Medicare was devised, we did not have, in Medicare,
provisions for preventive health
[[Page H9064]]
care. And it was not until a few years ago, in the 1990s, in the late
1990s, when finally a group of us got together on a bipartisan basis
and finally for the first time put some preventive health care coverage
reimbursement, if you will, in order to cover those areas.
In the House bill, in the House bill, the gentleman has not referred
to this, we have a provision to the effect that when a person is about
to go under Medicare, there is a reimbursement coverage. In other
words, provided payment by Medicare, for a one-time physical. It is a
voluntary type of a thing, but a one-time physical to encourage people
to take that physical before they go into Medicare, and with the idea,
of course, that many problems, many illnesses, prospective illnesses
might be picked up at a real early stage and thus save not only an
awful lot of money, of course, to the taxpayer ultimately, but
certainly save an awful lot of money and inconvenience and pain for the
beneficiary.
This is what is in the House bill, as I understand it. It is not the
Senate bill. It is one of those provisions that we, on the Member level
in conference, are going to have to address. The American Cancer
Society supports that provision, and it is my idea, and so, certainly,
I support it. So I agree with the gentleman about preventive health
care, and it is something we are trying to do.
This is, as the gentleman indicated, the fourth time the minority has
offered this motion to instruct conferees. I do find it perplexing that
they continue to offer this motion, and for one reason only, and that
is because by definition, by definition, it would reduce the amount of
funding available for the new Medicare prescription drug benefit by 10s
of billions of dollars.
So, yes, do we want to increase and are we, in fact, increasing the
reimbursements to rural Medicare providers? Yes, we are doing that. If
we increase that amount, we are taking it from where? We are taking it,
of course, from the prescription drug benefits available to seniors.
The author would have the Medicare conferees accept every rural
provider increase contained in both bills, as he indicated. I would
note for my colleagues, and I have already said this, that the House
has already recognized the need to ensure the rural Medicare providers
are paid fairly. In fact, the House-passed bill contains a $24.9
billion increase in payments to rural providers, which will help rural
hospitals and physicians, among others, continue to provide care to
rural Americans. So, if the House bill goes down, or if we do not have
a bill, let us say both bills go down because we want perfection, the
rural hospitals will lose $25 billion as a result of that decision.
Since the authors of this motion continue to emphasize that their
motion will not cause us to exceed the $400 billion laid out in the
budget resolution, we would have to reallocate funds, I have already
said it, away from beneficiaries and towards whom? Towards rural
providers.
{time} 1300
Would we like to do that? Yes. Would we like to take it away from
prescription drug benefits? The answer is no. I do not support it. I
think the House bill strikes the right balance between providing a
meaningful prescription drug benefit and helping ensure that providers,
especially those in rural areas, continue to serve Medicare
beneficiaries.
This motion would also, in some cases, require a type of government-
run fallback. Although the House passed legislation, both bills have a
fallback. The House passed legislation has a fallback. It already
guarantees that every Medicare beneficiary will have a choice of the
least two Medicare prescription drug plans.
In fact, the Congressional Budget Office tells us, and they are, of
course, as bipartisan as you can be, that under both acts, CBO
estimates that all Medicare beneficiaries would have access to
prescription drug coverage. In spite of that, both bills have a
fallback. They are good fallbacks. As time goes on, if, God forbid, we
might have to fall back, if you will, to a fallback, and it looks like
it is not working, then, of course, that is something that can be
adjusted. But there really is not that much of a difference in terms of
what the fallbacks are as I understand it. It is just the case of the
Senate bill fallback would immediately fall back to the government
picking up 100 percent of risk whereas the House bill affords
flexibility, if you will, from the standpoint that one fallback may
result in government picking up a certain percentage of risk in some
areas and in some other areas and pick up a larger risk or smaller risk
or something of that nature.
We have found that, in order to control costs, it is important that
Medicare prescription drug sponsors share some of the risk associated
with providing this new benefit. I am uncomfortable asking the Federal
taxpayer to completely shoulder the weight of this new entitlement.
That is why I do not think we need the government running prescription
drug plans. But the fact of the matter is the fallback is there, and
there is a guarantee in the House bill that a plan will be available
for all beneficiaries.
And, finally, the motion instructs conferees to recede to the Senate
and remove the hospital market-basket update adjustment contained in
the House bill. I would note for my colleagues that we are not cutting
hospital reimbursement. We are not cutting hospital reimbursement. We
have hospitals all over, whether it be urban areas or rural areas, my
area is somewhat in between, if you will, but we are not getting
hospital reimbursements.
According to the Medicare Payment Advisory Commission, which we call
MedPAC, it is the nonpartisan panel of experts that advises Congress on
Medicare policy, hospitals currently make a 10 percent profit for
Medicare inpatient services and a 5 percent profit, on average, for all
services provided to Medicare patients.
So I have already emphasized, if you will, MedPAC unanimously advised
Congress to increase payments by 3 percent, which is what the House
bill does. We have gone along with basically the experts in that
regard, MedPAC.
The $25 billion approximate increase in provider payments in rural
areas is based on certain formulas. Iowa hospitals would receive a
certain percentage, Hawaii hospitals receive a certain percentage,
increases above and beyond that 3 percent I might add.
Additionally, and it has not been mentioned in the motion to
instruct, but under the current law, Medicare providers would have
reduced their reimbursement by 4.4 percent. The House bill increases
that by 1.5 percent. You are talking about a swing of 5.9 percent to
Medicare providers, M.D.-type providers, if you will, which would take
place if we enact this legislation into law. If we defeat this
legislation and defeat any version of this type of legislation, those
providers would be hurting. The rural providers would be hurting
considerably more than they are now. And obviously, the beneficiaries,
to whom we have promised prescription drugs of a sort, would be
hurting.
Mr. Speaker, given the progress the conferees have made toward
reaching an agreement, progress is being made, it is slow, there is no
question about it, but it is moving, I would hope that conferees are
given the opportunity to work through their differences between both
bills. After all, that is what the system is all about. There are
differences between the House version and the Senate version. And
conferees were appointed on a bipartisan basis in order to try to work
out those differences.
Basically what we are saying to the gentleman and to the entire House
is give the conferees the opportunity to work, and hopefully we will be
able to successfully address the many competing issues in a
satisfactory way.
And more importantly, in addition to helping the rural providers and
rural hospitals, all providers, et cetera, we will be providing our
seniors with a prescription drug benefit that they need so very
desperately.
Mr. Speaker, I reserve the balance of my time.
Mr. CASE. Mr. Speaker, I yield myself such time as I may consume.
Mr. Speaker, before yielding to my colleagues, I would simply note
that as to the last comment made by the gentleman from Florida (Mr.
Bilirakis) on the bipartisan nature of this conference, I think it is
well known within this Congress, and I hope that it is well known
outside of this Chamber, that the minority party is not particularly
participating in that conference and is
[[Page H9065]]
not particularly being consulted. And as a result, we are certainly
willing and able to do that in the full glare of publicity before the
whole country.
Mr. Speaker, I yield 4 minutes to the gentleman from Arkansas (Mr.
Berry), a person who understands rural communities, understands rural
concerns. He lives them.
Mr. BERRY. Mr. Speaker, I want to thank the gentleman from Hawaii
(Mr. Case) for his leadership in this matter. And I can say that I know
that my distinguished colleague, the gentleman from Florida (Mr.
Bilirakis), cares about senior citizens and their health. I know that
there are many Members on both sides of the aisle that have a genuine
concern about what happens to our health care system and what happens
to our senior citizens. But I have to tell you, Mr. Speaker, as we
consider H.R. 1, and just as my distinguished colleague, the gentleman
from Hawaii (Mr. Case), just mentioned, every meeting of the conference
committee does not include the Democrats. I do not know why that is,
but that is the way it works around here.
I would probably call this H.R. 1 bill that we are working with right
now, I would be more inclined to call it a fall-back or a fall-off or
fell-off or jump-off or some characterization like that because this
bill just simply does not provide any kind of a guarantee for our
senior citizens as to what it will do or a guarantee to our health care
industry as to what they need to see in the way of the ability to
continue to provide services and do business.
And, certainly, in rural America there are no guarantees. We lose
hospitals almost on a monthly basis across this country in rural
America. We have providers now that just simply do not take Medicare
patients any more. Most of this is as a result of the Balanced Budget
Act of 1997, which I proudly voted against; and it has put our health
care system in great jeopardy.
Now we are talking about another Medicare reform bill that would
reduce payments in some cases to all hospitals, and certainly it would
make it more difficult for our rural hospitals and rural providers to
stay in business, and it does not guarantee any kind of a prescription
drug benefit to our rural seniors who would need it the most.
So I would encourage my colleagues to look carefully at this and not
do something that will hurt rural America and our seniors. It is very
disappointing to think that the possibility even exists that we would
not have a fallback provision that would ensure that our seniors in
rural communities would have access to a Medicare prescription drug
benefit.
Over the last 25 years, over 470 rural hospitals have closed. Rural
hospitals all over the country are in danger of being forced to shut
their doors. Currently, hospitals receive full inflation market-basket
payments for inpatient and outpatient services. H.R. 1 would reduce
hospital payment updates for the next 3 years, costing hospitals an
estimated $12 billion.
Our health care system in this country is on the verge of serious,
serious problems. All we are asking for is a fair deal for rural
America and a fair deal for the people that provide the services to our
senior citizens through Medicare so they can stay in business.
Mr. BILIRAKIS. Mr. Speaker, I yield myself such time as I may consume
to respond to the gentleman, and I appreciate his comments because he
is so very much concerned about health care for our seniors; but I
mentioned the conference is taking place on a bipartisan basis, and the
truth is it is. We have two United States Senators from the other party
who are part of that conference, on an everyday basis, I might add.
Mr. Speaker, I yield such time as he may consume to the gentleman
from Texas (Mr. Burgess).
Mr. BURGESS. Mr. Speaker, I thank the chairman for yielding me this
time and for the opportunity to address this issue.
Mr. Speaker, as previously pointed out, this is the fourth time the
minority has offered this motion to instruct Medicare conferees. I
personally find it perplexing that they continue to offer this motion,
since by definition it would reduce the amount of funding available for
the new Medicare prescription drug benefit by tens of billions of
dollars. The author of this motion would have the Medicare conferees
accept every rural provider increase contained in both bills, both
bills.
I would note for my colleagues that the House has already recognized
the need to ensure that rural Medicare providers are paid fairly. In
fact, the House-passed bill contains, as was previously pointed out by
the chairman, almost $25 billion in increased payments to rural
providers; and that will help rural hospitals and rural physicians
continue to provide care to rural Americans.
Since the authors of this motion continue to emphasize that their
motion would not cause us to exceed the $400 billion laid out in the
budget resolution, they would have to radically reallocate funds laid
out by the House bill in a manner that would disrupt the delicate
balance laid out by the bill. The House bill strikes the right balance
between providing a meaningful prescription drug benefit and helping
provide incentives that providers, especially those in rural areas,
continue to serve Medicare beneficiaries.
This motion would force the Department of Health and Human Services
to offer a Medicare prescription drug plan. This is a Big Government
fallback that is shortsighted and unneeded. The House-passed
legislation guarantees that every Medicare beneficiary will have the
choice of at least two Medicare prescription drug plans. In fact, the
Congressional Budget Office tells us that under both acts estimates are
that all Medicare beneficiaries would have access to prescription drug
coverage.
We have found that in order to control costs it is important that
Medicare prescription drug plan sponsors share some of the risk
associated with providing this new benefit. The taxpayers should not be
asked to completely shoulder the weight of this new entitlement, and
that is why we do not think we need the government running prescription
drug plans.
Finally, the motion instructs conferees to recede to the Senate and
remove the hospital market-basket update adjustment contained in the
House bill. I want to be very clear about how the House bill approaches
the hospital issue. The House bill does not cut hospital reimbursement.
According to the Medicare Payment Advisory Commission, hospitals make a
10 percent profit in Medicare inpatient services, and a 5 percent
profit on average for services provided to Medicare patients. The
Medicare Payment Advisory Commission unanimously advised Congress to
increase payments by 3 percent, which is what the House bill does.
Mr. Speaker, I think I also need to add that the gentleman from
Arkansas who just spoke said that rural providers need our help. And I
would submit that if the other side of the aisle wants to be helpful to
rural providers, they would instruct Members of their party in the
other body to take up and pass meaningful medical liability reform. A
fair justice system would do more to help rural hospitals and rural
providers than any other action.
Finally, Mr. Speaker, given the progress the conferees have made
toward reaching an agreement, I would hope that the conferees are given
the opportunity to continue to work through the differences in both
bills. I am confident that we will successfully address many of the
competing issues in a satisfactory way. Most importantly, we will
provide our seniors with the prescription drug benefit that they so
desperately need.
{time} 1315
Mr. CASE. Mr. Speaker, I yield myself such time as I may consume.
I would simply note, with respect to my colleague's comments, the
Department of Health and Human Services under the motion would be
required to do certain things; that is correct. The Department would be
required to provide the reimbursements that are necessary to preserve
rural health care through the hospitals.
I would also note that sometimes the Department does need to be
required to do things. One of the principal issues on the Medicare
Reform Bill remains whether the Department of Health and Human Services
should be required to enter into basic bulk purchasing arrangements to
lower the cost of prescription drugs. The bill that came out of this
House would have prohibited them from doing that; and clearly, in
[[Page H9066]]
this instance, the Department needs to be told to do what every
American knows is the right thing to do.
Mr. Speaker, I yield 5 minutes to the gentleman from Alabama (Mr.
Davis) who totally understands rural America.
Mr. DAVIS of Alabama. Mr. Speaker, let me thank my friend and
colleague from Hawaii for his passion on this issue and for reminding
us that in the United States the face of rural America is not simply
Southern or Western, it can even be Pacific at times.
Let me begin, first of all, by saying or by reiterating something
that my friend from Arkansas said, I do not think that any of us on
this side of the aisle believe that any of our able colleagues on the
other side want to do violence to the interests of rural America or do
not care about what goes on in the heartland of America or in the rural
parts of our country. We are not having a debate about intent today or
a debate about goals today, but we are having a debate about making a
system that will work.
It is a fact, and it is an eventuality under the bill that the
Republican leadership so narrowly pushed through this body, that over a
period of time, the prescription drug benefit, that all of us want and
have endorsed in some sense, will be phased out and delivered through
the private sector in significant parts of our country. Now, that
sounds, from a technical standpoint, like a worthy enough aspiration. I
have heard my colleagues on the other side defend that kind of a world
in terms of the market choices it will open up. I have heard them
defend that kind of a world in terms of the choices it will generate
for the consumers, for senior consumers.
The reality, as so many of us on this side of the aisle know, is
this: We can travel to those places in west Alabama, whole places in
the rural parts of our country where you simply do not have a private
provider network that is capable or available to carry this burden. So
when we are talking about expanding market choices, what a wonderful
thing it would be if those market choices would be available all around
this country.
Our seniors are looking to us desperately for leadership on this
issue. Our seniors are desperately looking to us to give them a
benefit, but not just any benefit. They want one that is fair, and one
that is workable, and one that is available all around America.
I am genuinely amazed that a lot of our colleagues on the other side
of the aisle are willing to have us move into a system where, at best,
we can trust the vagaries of the market to provide this benefit for our
seniors. I talk as I move around my district to far too many seniors
who are having to spend significant chunks of their limited, disposable
income on prescription drugs. I run into too many seniors who are
having to self-medicate, who are told that they have to take medicine
for a certain number of days, and they chop the pills up to extend the
timetable. All Members can cite those stories.
What a tragedy it would be if we had a huge ceremony and a huge
fanfare, and the President stood up and said we had passed a
prescription drug benefit bill, and then within 6 or 7 years from now,
our seniors living in rural America saw what they expected to be a
Cadillac turned out to be a much smaller, less efficient and less
effective vehicle.
Mr. Speaker, I urge my colleagues to support this motion not because
I think the folks on the other side of the aisle have a different set
of values, but because I think they misunderstand the market that we
have and the choices that will be left to our seniors.
I want to address one other point several of my colleagues make.
There has been a lot of talk that we are fixing the rural problem
because we are addressing the disparities in the reimbursement
formulas; and I compliment the other side of the aisle for recognizing
that the reimbursement formulas in Medicare have disadvantaged our
rural areas, but I will make a very basic point here. If the Republican
leadership of this body were serious about fixing the reimbursement
formula, it could do it tomorrow. Just as we came to the floor in
record time last week to speak to the court that ruled on the Do-Not-
Call Registry, we could come to this floor in record time to pass a
stand-alone bill that fixes the unfair reimbursement formulas.
Right now, the reimbursement formula fix is being held hostage to the
completion of this bill. It is nothing more than a bargaining chip at
this point to try to bring conservative Democrats and moderate
Republicans to the table, and we ought to expose that for what it is.
If the leadership were serious about fixing this problem, it should be
done tomorrow as a stand-alone piece of legislation. Let us address the
hard and serious problem of getting a prescription drug benefit, but
let us address, in a separate context, the very real problem of
disparities in this formula that burden so many of our areas.
Mr. BILIRAKIS. Mr. Speaker, I yield myself such time as I may
consume.
Just to respond very briefly to the gentleman from Alabama (Mr.
Davis), this is my 21st year in the House. Virtually all of that time,
I have been a member of the Subcommittee on Health, and the question of
reimbursements to rural providers has always been there. If it were
simple to correct, it could have been corrected. It could have been
corrected when the other party was in charge. It could have been
corrected when this party has been in charge, which is a lot less years
than when the other party was in charge. It is very difficult, but it
is being addressed. The conferees are spending a lot of time on that
particular issue, and, hopefully, they will reach agreement.
Again, I would say to my colleagues, I have talked to members of the
AARP who have come into my office back home. Yes, we have all received
a seven-page letter to the effect of what they want in that bill, but
they say we want a bill which will help some people now, and,
hopefully, provide a foundation we can improve upon as we go on.
If all of us are just going to stand fast and say this is not in the
bill or that is not in the bill, or this is in the bill and I do not
like it and we want perfection, we are not going to have a bill. As I
said before, at least the rural providers are receiving some benefit,
some help out of this bill. That $25 billion is certainly not chicken
feed.
It is significant that we have a piece of legislation that is going
to be of some help to the rural providers. It may not be enough, it may
not be as much as the gentleman would like, and I do not blame him.
This is a representative system of government, and they are
representing their people, and they are doing a good job of it insofar
as wanting to help their rural communities. But again, we have to have
a bill, and it is critical that we all try to work together as much as
we can.
All of the conferees are not always meeting together in every
conference that we have. That is unfortunate, but there are some
Members who have indicated that they are against anything at all
involving this type of legislation; and, consequently, I suppose those
are the reasons. I do not make those decisions, but it is unfortunate.
But a lot of work is being done every day at 3 p.m., Monday through
Friday, on a bipartisan basis.
Mr. Speaker, I reserve the balance of my time.
Mr. CASE. Mr. Speaker, I yield 3 minutes to the gentleman from
Florida (Mr. Boyd).
Mr. BOYD. Mr. Speaker, I thank the gentleman for bringing this
subject to the floor.
I think we all, as Americans, understand this prescription drug issue
very well, and I think we understand the importance of Medicare to this
Nation. I like to tell my constituents back home that since the advent
of Medicare 40 years ago, there has been a significant decline in the
level of folks below the level of poverty. Prior to the advent of
Medicare, if you reached the age of 65 in this country, there was a
greater than 50 percent chance that you would be below the poverty
level. Today that figure is less than 10 percent. There is a dramatic
drop in poverty in this country, and we think much of that can be
credited to the successful Medicare and Social Security programs we
have had in place.
I think everybody knows that we need a prescription drug component
because of the changes in health care and technology in the last 30 to
40 years. We have to reform the Medicare program. We all understand
that. It is absolutely going to break this country as we move into the
retirement of the
[[Page H9067]]
baby boomers if we do not do something. This Congress, both sides of
the aisle, have laid aside $400 billion to deal with this issue. I want
to commend the leaders of this House, including the gentleman from
Florida (Mr. Bilirakis) for his attempts to reform Medicare and bring
those issues to the floor of the House and try to get a bill that we
can get the President to sign.
The thing that I want to encourage, though, is that we have got to
keep the provisions of the current Medicare system that work. One of
the key components of the current Medicare system is that it is a
defined benefit. When you reach eligibility age, everybody qualifies
for it. I do not care what the situation is, if you live rural America,
urban America, you qualify because it is a defined benefit, and
everybody receives that. We have some Medicare+Choice-type programs
within Medicare now that try to set up HMOs or insurance incentive
programs to deliver prescription drugs to folks, and they do not work.
They do not work in rural areas. My constituents do not get them
because the insurance companies cannot make enough money on them, so
they go to the larger communities, the urban communities, the big
cities, where they can make money.
Mr. Speaker, I just would encourage us to keep those provisions that
work, and one of them is the defined benefit, the fall-back provision
which the gentleman from Hawaii (Mr. Case) is stressing here.
The House bill fails to meet the needs of one-fourth of the Medicare
beneficiaries of this country that live in rural areas. The Senate bill
addresses this problem by establishing a guaranteed fall-back
provision. Again, we need reform, but I would encourage the leadership
and the conference committee to include the fall-back provision.
Mr. BILIRAKIS. Mr. Speaker, I have no further requests for time, and
I yield back the balance of my time.
Mr. CASE. Mr. Speaker, I yield myself the balance of my time.
Mr. Speaker, in closing, this has been a good but all-too-short
discussion which has highlighted some of the principal differences
between the majority and the minority on the issue of Medicare.
I would like to respond to some of the points made by the gentleman
from Florida (Mr. Bilirakis). I agree with my colleagues on the
minority side that the gentleman from Florida (Mr. Bilirakis) does care
about Medicare. In fact, he reminds me of a country doctor, nice, calm,
reassuring presence. And if I was the majority party, I would want a
nice, calm person to stand up and talk about Medicare, and I have no
doubt about his sincerity.
But I will say that in terms of the positions which have been taken
by his party, the positions that have been advocated by this
administration and the positions that are now pending in Congress,
actions speak louder than words. Perception is not reality. We would
not be standing here bringing this fourth motion, and we bring this
fourth motion because we care about rural America. We care about health
care in rural America, and we believe that it is at risk, serious risk
right now.
{time} 1330
We want people to know that so that in the 16 days remaining before
the largest health care reform initiative in decades, if you want to
call it reform, comes up to us for a final yes or no vote, the people
of this country can weigh in. That is why we keep on bringing this
motion and we will keep on bringing this motion.
I want to highlight some of the things that were said here today.
First of all, much has been said about affordability. Affordability is
a matter of priorities. Affordability is a matter of where you put your
money. You ask any rural hospital, rural clinic, any senior living in
rural America where they think that the resources of this country
should be devoted and they will tell you health care, and they will be
right.
So this is a box that the majority has put itself in. It has decided
that there are these limits and that is all that we are going to give
to this problem and then we are going to live within these limits.
When we on this side say, those limits are not accurate, those limits
are not good, they say, well, you are trying to get out of the box. You
bet we are trying to get out of that box. That box does not work for
America.
Reforming Medicare is one thing. We all agree that Medicare needs
reforming. We all agree that Medicare needs fixing, but reforming it
should not be destroying it, and that is what is at risk here.
There are good ingredients in both the House and the Senate versions.
All we are asking in this motion is to take the best of both the House
and the Senate provisions, homogenize them, do not duplicate them. We
are not asking for things to be duplicated and run up; we are saying
take the best. Guarantee a prescription drug coverage where the private
sector is not going to provide it if, in fact, the effort to privatize
Medicare is successful. Make sure that our rural areas have basic
hospitals.
We do not want a country where everybody has to take a train, plane,
boat or other means of transportation to get to some big city that has
some big hospital. That is not the answer to health care in this
country. That is what we care about.
I would close by saying again that this motion, this issue, is not
just about Medicare. It is not just about health care. It is not just
about seniors. It is about rural America. And when it is about rural
America, it is about the America that we live in and that we want to
preserve.
I urge my colleagues to support this motion. It is a simple motion.
Just take the best. Do what is necessary for rural America. Put rural
America first.
Mr. Speaker, I yield back the balance of my time.
The SPEAKER pro tempore (Mr. Bass). All time has expired.
Without objection, the previous question is ordered on the motion to
instruct.
There was no objection.
The SPEAKER pro tempore. The question is on the motion to instruct
offered by the gentleman from Hawaii (Mr. Case).
The question was taken; and the Speaker pro tempore announced that
the ayes appeared to have it.
Mr. CASE. 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
Chair's prior announcement, further proceedings on this motion will be
postponed.
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