[Congressional Record Volume 149, Number 167 (Tuesday, November 18, 2003)]
[Senate]
[Pages S15047-S15051]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                 PRESCRIPTION DRUG BENEFIT IN MEDICARE

  Mrs. LINCOLN. I rise today to offer a few thoughts on the Medicare 
prescription drug conference report that will soon be brought before 
the Senate. As I look back on the 10 years I have served in the 
Congress and I think about probably one of the most important issues we 
have dealt with, it has been looking toward trying to provide a 
component to Medicare that, had we seen or known the importance of 
prescription drugs when Medicare was designed, we would have included.
  As we move forward in the discussion and the debate on the pending 
legislation or the conference report that is being formalized right 
now, I hope we will not lose sight of our original objective; that is, 
to do no harm to a program that has been incredible in this country. It 
has kept seniors out of poverty. It has provided insurance for health 
care in our senior community when private industry would not come to 
the table to provide insurance and health benefits for our aging 
population.
  I hope we will keep our focus on doing no harm to a program that has 
done so much for the well-being of the elderly of this country, that we 
will look to the ways we can improve it and, more importantly, provide 
a prescription drug piece that is actually going to enhance our ability 
to keep down the costs of health care, providing health care to the 
elderly in this country, and improving the quality of life which, after 
all, is, has been, and should be our main objective.
  First, I thank our chairman on the Finance Committee, Senator 
Grassley, and the ranking member, Senator Baucus, along with their 
staffs, for their tireless effort in bringing this package together 
thus far, both in the committee when we marked up the bill and we 
worked hard to bring about a good, bipartisan measure we felt did 
provide reforms and improvements to Medicare but did no harm to the 
basis of a program that has provided so much to so many in this 
country.
  The chairman and the ranking member have really bent over backwards 
to do all they could to keep this conference together and to keep a 
package together that was going to be beneficial for the elderly in 
this country. I know the negotiations at times have been contentious, 
but I am sure my colleagues join me in expressing our heartfelt 
gratitude for their leadership and patience on this critically 
important issue to all elderly Americans and to all American families 
because, as many of us know, it is not just the elderly who are going 
to be affected by this program; it is those of us who have aging 
parents and grandparents. It is those of us who ourselves in years to 
come will be a part of that aging community. It is not just the elderly 
of today, it is the elderly of tomorrow and the young of today who feel 
so involved and think it is such a critical issue to provide that 
quality of care for our patients and for our seniors.
  It is with that that I urge the conferees to keep working and to 
remain committed to the bipartisan principles contained in the 
legislation we passed in the Senate last summer, that we poured over 
and really gave heartfelt consideration and debate to bringing about a 
program that would enhance Medicare and again would do no harm to 
a program that has done so much.

  The bill we passed in the Senate gives all Medicare beneficiaries, no 
matter where they live, access to a Medicare drug benefit. For those of 
us who come from rural States, we find ourselves oftentimes at the low 
end of the totem pole. We find ourselves in a predicament where our 
seniors tend to be certainly living in more challenging demographic 
areas, where their needs and their concerns are more difficult to meet. 
We find our seniors tend to be more low income. It is critical we do 
not put a face on this bill that makes one demographic or one 
geographic area of this country more important than the other.
  Most importantly, our Senate bill preserves the traditional Medicare 
Program as a viable option for seniors by ensuring there is a level 
playing field between the private sector and Medicare. As many of us 
know, the private sector can participate in Medicare today. They choose 
not to. Why? Because we have, over the years, crafted and improved a 
Medicare Program that is most efficient. The fact is, it is difficult 
for them to compete, to come in and to provide the same services, the 
same programs in a cost-effective way where they can actually make 
money.
  Again, we want to do no harm in a program we have begun now to mold 
and shape in a way that is so productive to the seniors and is cost-
effective for our Government.
  I believe it is important we be honest with our Nation's seniors, 
with the taxpayers of this country, and with ourselves, so everyone 
understands what is in this bill, both good and bad, what have we 
accomplished in this conference report and what have we not, so we can 
honestly call this conference report what it is. After all, this is 
more than just a prescription drug package. It includes a wide range of 
other provisions that will affect health care for seniors.
  Over the last several months, I have consulted with Senator Grassley 
and Senator Baucus on this bill. They have

[[Page S15048]]

been very kind and gracious with their time in listening to me as I 
offered my own advice and feedback on the contents of what was 
materializing as a conference report. Today I would like to take this 
opportunity to present some of the questions I have asked of them in 
these recent weeks, because this is not the bill I would have produced. 
As we look at this conference report, it is not the bill the Senate 
produced or that Senators would like to have before us, but it may be 
the best we are going to be able to get in this Congress under the 
leadership we have, both in the White House, in the administration, as 
well as in the House and in the Senate.
  If that is the case, do we hold hostage some seniors because we do 
not have a perfect bill? We are going to have to weigh that out in the 
course of the next 6 to 7 days as we go through the motions of bringing 
that conference to a close and looking at what is actually going to be 
in that conference package.
  I would like to make it very clear I asked these questions as someone 
who wants very much to support a prescription drug package. It is 
something I can see clearly as a tool that can aid this country, not 
only in the quality of care and the quality of life our seniors need 
and deserve in this Nation. The advancement of what pharmaceutical 
drugs and prescription drugs can do in making the aging loved ones in 
our families have a better quality of life is so apparent. It is such a 
critical part of what we must do.
  We also have to know there are other things that are in this package. 
The questions so many of us have asked in looking for what we want to 
see happen--as I said, I want very much to support a prescription drug 
package. I have worked hard on this in the 10 years I have been in 
Congress. I see the importance of it. We want to be able to move 
forward. It is an issue I have championed throughout the years in my 
career in Congress. It is why I have worked hard to secure a seat on 
the Senate Finance Committee so I could have more influence on the 
shape of the final bill.
  In fact, this bill contains several strong provisions which I shall 
address shortly, but I also think it is so important we be honest with 
ourselves in terms of what we are actually going to be dealing with.
  Furthermore, I asked these questions on behalf of my constituents in 
Arkansas, along with the millions of other seniors in this Nation who 
will be affected by this legislation and who have been waiting so 
patiently for us to at least begin this process. They deserve to know 
about all of the components of this bill and how it will affect them, 
wherever they may live in this great country. Like us, they want to 
know this package will make Medicare stronger for the future, not 
weaker. We have not worked these some 40-plus years to now take a step 
in the wrong direction to weaken Medicare. We want to know even if this 
may not be the end-all, be-all package for Medicare, at least it is the 
beginning, the first step in looking at how we can strengthen Medicare, 
both through providing a prescription drug component in a way that 
reaches every senior in this country in a fair and equitable way, as 
well as looking at the ways we can reform and reinforce Medicare 
through coordinated care, through multiple-disease diagnosis and 
physician programs, where our physicians can look and see the multiple 
diseases our elderly are dealing with and deal with them in a 
comprehensive way. My first question concerns the premium support 
model, of which we have heard an awful lot. Premium support carries a 
lot of different visions that people have put on it. The model I would 
like to question is the one which the conferees want to add as a 
demonstration project. I would like to ask the conferees to explain to 
me and to the American people: How would this premium support policy 
make Medicare stronger? That is our question. I am not coming to the 
floor with a preconceived idea. I really want to know, and I think the 
American people want to know how it is going to make Medicare stronger.

  My concern is that the premium support would force our traditional 
Medicare Program to compete with private insurance plans in an arena 
where the rules greatly favor the private plan. That is not true 
competition. That is asking a program that we have built over these 
many years to compete with a plan out there that might be able to 
provide something in a more cost-effective way. But we don't know 
because we have too many subsidies going there.
  The Center for Medicare and Medicaid Services said this model would 
lead to wide variations in premium rates for Medicare beneficiaries 
living in different parts of the country and even, perhaps, within the 
same State. This could be devastating for seniors in Arkansas, 
especially in our rural areas. And Arkansas is not the only State that 
is concerned with a lot of rural areas. Why should a senior living in 
the rural delta of Arkansas pay a higher premium than a senior living 
in Little Rock, for the same benefit? That is the question I am asking 
our conferees. Seniors have paid into Medicare all their lives and they 
deserve to pay the same premium no matter where they live. Premium 
support would end this uniformity that has always existed in Medicare.
  The CMS Office of Actuary also determined that premium support would 
significantly increase premiums for traditional Medicare. Healthier 
seniors would leave the traditional program for private plans, thus 
increasing the cost for traditional Medicare. This would mostly impact 
seniors in our rural areas where private plans are not likely to go, 
and where seniors are less healthy. Why are they not likely to go 
there? They are not there now. They have come in; they tried it; they 
left because it is not profitable for them. Without substantial 
subsidies, they are not going to come there again.
  As to using this as a demonstration, we pretty much had a 
demonstration out in rural America to see what is going to happen. It 
is simply unfair to punish these seniors with a premium increase that 
estimates say could surpass 25 percent. The privatization advocates say 
it is only a demonstration of premium support and there are numerous 
exceptions to the policy. That just simply makes me wonder: If the 
policy is so great, why make all of these exceptions?
  I urge the conferees to take a serious look at this controversial 
proposal. Look at the ways we can make it much more clear, much more 
beneficial, and certainly much more economical to the American 
taxpayer, as well as providing the uniform benefit, across the country, 
to all seniors who deserve it equally.
  It is clear to me that its inclusion is based on privatization 
ideology alone rather than sound evidence that it saves money or 
improves the program for seniors. There are way too many studies that 
indicate the other way. I encourage these conferees, when we have a 
once-in-a-lifetime chance to be able to do something productive, make 
sure we are not wasting our time and energy and efforts, and most 
importantly our resources, on demonstration programs that we know 
because of past experience are not going to be profitable for anybody 
if we use our resources that way. Why drain those precious resources 
from the drug benefit for all on a demonstration that would affect only 
a few?

  The premium support demonstration could destabilize the Medicare 
Program for all seniors, and it certainly has the possibility of 
threatening the integrity of Medicare for seniors in Arkansas and 
around the Nation. The Senate bill we passed, with a great bipartisan 
margin, did not include this provision, and it was a strong bipartisan 
bill.
  My second question is, Why does the final agreement not retain the 
Senate's more generous low-income assistance provisions? I am 
enormously grateful because I know Chairman Grassley and Senator Baucus 
worked very hard on the low-income assistance, and it is a good piece 
of this bill, so much better than what happened on the House side. So 
many of us who come from States with a large percentage of low-income 
seniors are very grateful.
  The conferees, however, apparently decided to lower the income 
eligibility level from the 160 percent of poverty to 150 percent of 
poverty, and to subject all low-income seniors to somewhat humiliating 
asset tests.
  When we talk about 150 percent of poverty around here, people just 
assume that everybody knows what that is. But most people don't. Most 
people don't know that 150 percent of poverty,

[[Page S15049]]

which is what we are talking about to be the high end of low-income 
seniors, is only an annual income, for a couple, of $18,000--$18,000 
for seniors to live on as a couple. For singles, it would be $13,470.
  One hundred-fifty percent of poverty is what we are talking about as 
being the high end of low-income seniors, in terms of support for these 
low-income individuals. I don't know about you, but that is a tough 
annual income to live on as a senior when you are talking about all the 
different expenses they have.
  This would help 3 million fewer people. Going from 160 percent of 
poverty to 150 percent of poverty would help 3 million fewer people 
with their copays than the Senate bill. So I urge the conferees to 
allow Medicaid to wrap around the cost-sharing requirements in the 
Medicare bill and allow them to pay for prescription drugs, not on the 
private plans formulary. This is another component that is going to be 
very advantageous to our low-income seniors.
  This low-income assistance is of special importance to our Nation's 
older women. Those of us, as women in the Senate, recognize how the 
aging population is disproportionately reflected in the number of 
women. I have watched my own mother, as a caregiver, taking care of my 
father until his death last year, and watched how she put the stresses 
and strains on her own health care needs, as well as her own finances, 
to find herself now in the aging population category, more dependent on 
programs than she has ever been before. So, disproportionately, when we 
talk about our low-income seniors and their needs, there is a 
disproportionate amount of those individuals who are women.
  Medicare seniors are disproportionately women and they are 
disproportionately poor, and will be far better served by the Senate's 
low-income provisions on which we worked so hard to come to a 
bipartisan agreement.
  I am concerned that private drug-only plans may not provide the 
stability or the predictability that seniors want and need. The 
insurance companies have told me they don't want to offer a 
prescription-drug-only plan. The Administrator of the Centers for 
Medicare and Medicaid Services has said such a plan doesn't exist in 
nature.
  Quite frankly, I believe we have proven that through the Medicare-
Medicaid veterans programs the Government can do it in a much more 
cost-effective manner. But the point is, we are trying to create 
something that has not existed in nature, and really, quite frankly, 
those who are going to be there to create it don't want to do it.
  I urge the conferees to take a good look at what we are providing 
there. That is why I am glad the Senate contains a Medicare-guaranteed 
drug plan, or safety net, called a fallback.
  I urge the conferees again to retain the fallback and ensure that a 
contract is made available for at least 3 years. But the concern to 
come, if you are a senior out there in rural America and you choose to 
stay with Medicare fee for service, you have to go to one of these 
drug-only plans. There has to be two in your region, but one of those 
two could be a PPO, which means you have to shift your traditional fee 
for service into an overall PPO in order to qualify for that drug plan 
or you can go with one of those two plans. If one of them should leave, 
you have the option of going to the Government fallback. If one of 
those plans or another plan comes back next year, you immediately have 
to go out of the Government plan and go back into one or the other of 
the private plans.
  Seniors are going to find from year to year those changes in their 
premiums, their deductibility, their formularies. They are going to 
find the list of physicians changing. It is really critical.
  I urge our conferees to ensure the fallback is available for seniors 
as an option, even if the private insurers decide to test whether they 
want to offer a benefit in a community. Seniors should not have to have 
fallback plans, especially if the new private plan is significantly 
more expensive for them and it is more restrictive.
  My third question is with regard to consistency and reliability in 
the Medicare Program. Based on what we know about the details of this 
agreement--we still have a lot of time ahead of us to be able to read 
and digest what has actually been negotiated out and put down on 
paper--it appears that the drug plans will vary throughout the country, 
meaning that seniors in Arkansas may have different premiums, cost 
sharing, and formularies than seniors in other States and in other 
parts of the country.
  Even worse, these plans can change their premiums, cost sharing, and 
formularies for other years.
  My question is, How does it strengthen Medicare to make the program 
less consistent and less reliable for our seniors?
  If what we are trying to do is strengthen Medicare with a drug 
benefit and in the reforms we are trying to make, how does it 
strengthen that program if we make it more confusing for our seniors, 
if we make it less consistent and we make their choices less reliable?
  I urge the conferees to make the prescription drug benefit less 
volatile for seniors. If there is anything I know about the seniors in 
my life, it is the confusion they see right now or which they may have 
to address in a package such as this. It is devastating to them. It 
gives them a sense of distrust. That is the last thing we want for our 
loved ones and those for whom we are working so hard to provide quality 
of life. This includes limiting variations in the amount seniors have 
to pay in premiums to only $10 above the national average, no matter 
where they live.

  I, for one, think we should give seniors, most of whom live on fixed 
incomes, some assurance that their premiums will not vary or increase 
unreasonably.
  I urge the conferees to ensure that those seniors who have employer-
sponsored retiree coverage be able to retain it. It is pure and simple. 
We urge the conferees to ensure that the conference report preserve a 
level playing field between traditional Medicare and private insurance 
plans.
  I am concerned--and have been--that the proposed agreement unfairly 
tips the deck against Medicare through the $12 billion stabilization 
fund that the Secretary of Health and Human Services can use to 
encourage private plans to participate in areas where they don't want 
to go. If they wanted to go, they would be there now. But we are going 
to use $12 billion to try to stabilize these plans to go into areas 
where they haven't wanted to go and where they aren't currently 
practicing.
  The Senate bill, which we worked on in a bipartisan way, by contrast, 
provided billions of dollars for private plans to be able to help them 
in terms of incentives to come into these more difficult areas.
  We also have $6 billion in there for Medicare enhancement and 
improvements in the traditional Medicare Program that all beneficiaries 
can use--not just those who happen to live in an area where private 
plans decide to go.
  The conference agreement would allow private plans to be paid at a 
much higher rate than traditional Medicare with no enhancement added 
for beneficiaries.
  I urge the conferees to consider this policy carefully. We want to 
make sure the traditional fee for service and the traditional Medicare 
that is there has the enhancement and the ability to improve itself so 
it can reach all of the seniors in this country, even those in the 
rural areas of my State and the State of the Presiding Officer and 
others who have multitudes of rural areas where seniors need health 
care.
  I wish the drug bill did not have a coverage gap or a donut. I am 
concerned about those seniors who will hit that gap in coverage and 
have to continue to pay their premiums.
  During debate on S. 1, I and many other Senators voted to allow 
employer-sponsored retiree health plan contributions to fill this gap. 
I also voted to eliminate the coverage gap altogether, and I voted to 
prevent seniors from paying premiums when they are in the coverage gap.
  Unfortunately, all of these amendments were defeated, but it doesn't 
mean we can't still address some of these concerns. It doesn't mean our 
conferees can't work together and come up with some provision that can 
help to assist us in making sure some of these gaps, some of these 
holes that have been left are closed for the benefit of the seniors of 
this country.
  I also voted for an amendment to try to contain the skyrocketing 
costs of

[[Page S15050]]

prescription drugs. Every one of us in this Chamber knows that in the 
next 20 years or less we are going to almost double the number of 
seniors putting demands on the Medicare Program. We are going to go 
from 41 million seniors to over 70 million seniors in this country. It 
doesn't matter what kind of program we put together if we don't look at 
trying to have some kind of handle on the escalation in costs for 
whatever program we have. If we almost double our number of seniors who 
are putting pressure on this program, we are not going to be able to 
afford it. It is critical that we look at ways we can make more 
efficient the use of the dollars that we have.

  One measure I supported which passed seeks to increase access to more 
affordable and equally effective generic drugs--something on which I 
think most of us could agree.
  I also voted for an amendment which failed to help consumers better 
compare the cost effectiveness of prescription drugs.
  Finally, I also voted for a successful amendment to allow wholesalers 
and pharmacists to import prescription drugs from Canada which will 
provide substantial savings to consumers while ensuring their safety.
  These are just some of those components where we in the Senate made 
corrections and improvements to the bill, some of which were accepted, 
some of which were not, but most of which I hope, as a conference, they 
will look at, because the bill we are trying to produce out of this 
conference should be a bill that will enhance a program that has done 
so much for all seniors and all Americans.
  I urge our conferees to try to retain some of those positions that we 
took in the Senate; the provisions that we passed.
  I look forward to hopefully seeing us complete some of those things 
that I think will make the bill a better bill. I know reaching this 
point has been a long and difficult process.
  I compliment my Senate colleagues for fighting to include several 
good provisions that are contained in this bill. This agreement 
contains a comprehensive rural package that significantly decreases or 
eliminates the disparity of Medicare payments between rural health care 
providers. I was very involved in working with the chairman, Members, 
and others to move some of those provisions forward and certainly 
making sure that health care was available to seniors and to all people 
in rural areas.
  I can't tell how necessary these provisions are to rural hospitals 
and physicians and ambulance providers, home health providers and rural 
health clinics in Arkansas and elsewhere across the country.
  It is my hope that the conference agreement will also contain the 
Senate policy for Medicaid low-DSG States. I am glad the physicians 
won't receive a cut in payment but a small update as in this conference 
report.
  I encourage my colleagues to include a physician's demonstration on 
chronic care management that I helped to author in the Senate Finance 
Committee.
  If there is anything we know, it is that our seniors are having 
multiple chronic illnesses which they are having to deal with. If we 
don't look at how we manage the chronic care multiple diseases they are 
dealing with, we will never get the economic efficiency out of Medicare 
that we could.

  Many of my constituents have said when they finally have gotten a 
coordination for their elderly loved one, it is unbelievable. They were 
seeing five different doctors in five different places who were not 
talking to one another. They did not have a nutritionist or someone 
consulting on depression. When they got that coordination of care, they 
better understood all of the chronic illnesses their loved one was 
going through, not to mention getting more efficiency out of the 
dollars they were spending in Medicare. That individual, that loved 
one, that elderly person was getting the quality of care they deserve 
in a more cost-effective way. They were able to manage all of those 
things in a way that was making the quality of care the best it could 
be.
  One of the demonstrations should take place in a State that has a 
department of geriatrics with a rural outreach site. Rural areas are 
one of the most difficult areas to serve our elderly. Unless we have 
the knowledge of how we can coordinate the care for individuals in 
rural America, we will never see the efficiency we need. It is critical 
we have this demonstration so we can determine the healthy outcomes 
that result when a geriatrician is paid appropriately for caring for a 
patient with multiple chronic conditions.
  I am also pleased the drug bill will include coverage for insulin 
syringes and that there is a new benefit providing screening for 
diabetes. Roughly 40 percent of the senior population with diabetes, or 
1.8 million seniors, uses syringes every day to inject insulin to 
control their diabetes. Without coverage, the syringe purchases, which 
could be especially expensive for seniors on fixed incomes, would not 
count toward cost-sharing and yearly out-of-pocket expenses. The new 
diabetes screening benefit will help with the fact that approximately 
one-third of the 7 million seniors with diabetes, or 2.3 million 
people, are undiagnosed. They simply do not know they have this very 
serious condition with complications that include heart disease, 
stroke, vision loss and blindness, amputation, and kidney disease.
  I understand there is also a provision to temporarily waive the late-
enrollment penalty for military retirees and their spouses who sign up 
for Medicare Part B and to permit year-round enrollments so retirees 
can access the new benefits immediately.
  It is important in seeking to strengthen Medicare we reflect on the 
program's origins and mission. Medicare provides health care for a 
special population of Americans: millions of seniors, individuals with 
disabilities, and people with kidney failure, those who are uninsurable 
in the private marketplace. Over 50 percent of them were uninsurable in 
the private marketplace when Medicare was started. Congress created 
Medicare in the first place because private insurance plans were 
failing to provide affordable health-care coverage for this high-risk 
population. Therefore, we should proceed cautiously when making major 
changes to the traditional Medicare Program.
  In my home State of Arkansas, over 400,000 people rely on Medicare 
for their health insurance. Without it, they likely would be among the 
ranks of the uninsured. This is why I want to ensure if this bill 
passes it is built upon policies that will make Medicare stronger and 
more reliable for all of its beneficiaries, that we know as we move 
forward there is no possible way we could do everything we needed to do 
in this bill. This is not the bill I would have written, but I was not 
in charge. I also do not want to see a missed opportunity for being 
able to move the ball down the field, to do something for which seniors 
in this country have been waiting patiently.

  Some of my colleagues will argue, don't worry, it does not take 
effect until 2006. Some of these things do not happen until 2010. There 
will be so many elections between now and then; you do not have to 
worry. We will change it and fix it and it will have a new appearance 
by the time we get there. I hope if that is what we are hanging our hat 
on, we can be sincere as these conferees come out with a plan that will 
leave intact the purpose of Medicare originally: to provide for those 
who were the uninsurable, the elderly, the loved ones for every one of 
us in this body, to make sure when the marketplace would not provide 
for them, there would be an honest standard benefit so they could get 
the quality of care, regardless of where they live in this country, 
that they are due for the great things they have done for our country.
  I look forward to reading the legislative language in the coming days 
to determine my ultimate support for this bill. I hope our conferees 
are not finished. I hope they continue to look at the ways this bill 
can be improved. Our work is never done in this Senate, whether we pass 
a bill into law and look toward 2006 or 2010 or whenever may be that we 
think some of the unreasonable things in here we can shut our eyes to 
and move forward with, but that we can make the changes now and we can 
create a bill that is the best we can do, knowing it is not perfect but 
that it will move us forward to provide a critical prescription drugs 
component in the 21st century to a program we started many years ago 
that has meant so much to so many.

[[Page S15051]]

  Ultimately, I must weigh whether the benefit contained in this bill 
to provide prescription drugs is better than no benefit at all. I hope 
that is not the case. I hope the case will be we have done everything 
we possibly could, looking at the bipartisan package the Senate passed, 
and how hard we worked to get there to make this final product the best 
it can be for some of the most special people in this country.
  I yield the floor.
  The PRESIDING OFFICER (Mrs. Dole). The Senator from Idaho.

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