[Congressional Record Volume 153, Number 126 (Thursday, August 2, 2007)]
[Senate]
[Pages S10762-S10764]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
SCHIP
Mr. GRASSLEY. Mr. President, before I go to further remarks, I want
to give some credit on the passage of H.R. 976 the bill we just had and
the cooperation.
The Grassley-Baucus cooperation has been mentioned here. I really
compliment Senator Baucus for his leadership in working with us. But,
also, it took us 3 or 4 months to put together a bill, and Senator
Hatch and Senator Rockefeller were very much involved in that effort
with many long hours. So I thank them.
I do wish to make the point that what the Senate has done over the
past few days has genuinely served the interests of the American
people. The Senate passed this bipartisan legislation which will cover
an additional 3.2 million children.
The Senate has proceeded in regular order to process amendments.
Every amendment that was offered was defeated--I mean every one on
which we had a rollcall vote was defeated. So this bill basically has
come out of the Senate the same way it came out of the Senate Finance
Committee.
This is how we should do business in the Senate. Amendments were
debated and voted upon. Members had the opportunity to consider a
variety of changes to the Senate Finance Committee bill. Some were
adopted by voice vote. Those that took a rollcall, none of those were
adopted. But regular order was followed, and the Senate worked its
will.
I am pleased with the Senate Committee product, which is a bipartisan
product.
I am also pleased with how the majority and minority leaders have
handled the process. This has been a tough, complicated piece of
legislation. A lot of Members and staff have worked very hard to get us
to this point.
I thank the chairman for his tireless efforts and how he worked in a
bipartisan manner. I wish to thank his staff: Alice Weiss, Michelle
Easton, Bill Dauster, Russ Sullivan, David Swartz, and Rebecca Baxter.
I also thank Senator Rockefeller and his staff: Jocelyn Moore and Ellen
Doneski. Much is also owed to the Senator from Utah, Mr. Hatch, and his
staff. Finally, I wish to thank the staff of the minority--I should say
the Republicans on the Finance Committee: Chris Condeluci, Mark Prater,
Becky Shipp, Rodney Whitlock, Mark Hayes, and Kolan Davis.
Now, I would like to address the Senate since we passed our bill,
since the House last night passed their bill, and soon there will be a
conference between the House and Senate. I wish to speak about some
things I think the House of Representatives has done that are damaging
to Medicare Advantage.
People are saying that Medicare Advantage plans are overpaid. They
talk about cutting payments, and that is what the House of
Representatives has done in their SCHIP bill. But they do not talk
about why Congress set up the payment structure, which was to create
choices of plans in Medicare and to expand private plan choices in
rural America. They do not talk about why Congress set up that choice.
It worries me that those arguing about the plan payments are losing
sight of the Medicare beneficiaries.
These beneficiaries, the seniors and disabled of America, are the
ones who benefit from having Medicare Advantage plans available to
choose from. Congress, in 2003, enacted the Medicare Modernization Act.
That is the act that included the prescription drug program as an
improvement in Medicare. A major goal of the MMA, the Medicare
Modernization Act, was to expand beneficiaries' choice of Medicare
plans. Before MMA, rural beneficiaries, such as my people in Iowa and a
lot of States that are more sparsely populated than Iowa, rarely had a
private Medicare plan to choose from. Now rural and urban Medicare
beneficiaries can decide whether a private plan option or traditional
Medicare works best for them.
I want to tell you why Medicare Advantage can be a good option for
beneficiaries and why the program should not be touched, as it was
recently by the House of Representatives in their SCHIP bill. I want to
explain at the same time why Congress thought all beneficiaries,
whether you were in rural America or urban America, should have a
choice of plans.
The original Medicare benefit is set up based on how medicine was
practiced in 1964, meaning in 1964 the fee for service that is the
traditional Medicare was set up at a time when you went to the doctor.
If you were very sick, then you went to the hospital. Medicine was much
less specialized.
[[Page S10763]]
Patients were treated by one doctor at a time, not the teams of people
who treat patients now. Under traditional Medicare, dating from 1964,
hospital benefits are in Part A of Medicare; physician benefits are
financed and delivered separately in Part B of Medicare. Each set of
benefits has its own deductible. A hospital deductible alone is a lot
higher than most working people have in their health insurance. It is
$992, and it goes up a little bit every year. That is a pretty
significant amount. That deductible alone can impose a big hardship on
a family, if they are relying solely on Medicare for their health
coverage. Medicare also only covers a limited number of hospital days
each year. It is not great protection if you are severely injured or if
you have an illness that has a long hospital stay. Say you happen to
end up in the hospital for months at a stretch, you might end up
exhausting your Medicare coverage. A lot of people don't realize how
limited Medicare benefits can be.
Medicare also does not actually have catastrophic coverage.
Traditional fee-for-service Medicare, the Medicare since 1964, by
itself does not provide protection against the cost of catastrophic
illness. Some beneficiaries then buy Medigap insurance for this
catastrophic insurance. Medigap insurance can be expensive for those on
fixed incomes. In contrast, and hence why the House of Representatives
should not change Medicare Advantage, Medicare Advantage plans have
catastrophic coverage for those seniors who want to choose it, and they
do it for a much lower premium than the Medigap add-on to traditional
fee-for-service Medicare. That is one of the many reasons Medicare
Advantage should be an option, not just in metropolitan areas, as it
was before we passed the prescription drug bill in 2003. We need rural
equity. And through the MMA, we brought rural equity so that people in
my State and more sparsely populated States can have a choice between
fee-for-service Medicare and Medicare Advantage, which can be a
preferred provider organization, HMOs, or fee-for-service Medicare
Advantage. Prior to 2003, in my State of Iowa, only 1 of 99 counties
had the Medicare Advantage option. That was Pottawatomie County right
across the river from Omaha, because they could work in with Omaha, but
the other 98 counties did not have choice as they have in Los Angeles
and Texas and Arizona, New York and New Jersey, Philadelphia, and
Florida. There may be some others but not really rural States. You are
stuck with fee-for-service traditional Medicare written in 1964, not
much for the practice of medicine in the year 2007.
So I am very concerned that what the House of Representatives did in
their SCHIP bill is such that it is going to put in danger the choices
we now have in rural America between fee-for-service traditional
Medicare and Medicare Advantage such as some of the more metropolitan
States have had for a couple decades.
If you are in Medicare Advantage, you don't have to have the Medigap
add-on to your traditional Medicare. Another plus is that most Medicare
Advantage plans also have a limit on out-of-pocket costs. In Iowa the
plans often have a limit of $1,000 or less. In other States, Montana,
much of New York and California, that is true as well. In some States
and counties, out-of-pocket limits are higher. Traditional Medicare has
no out-of-pocket limits. In original Medicare, to keep costs down,
Congress imposed caps on types of care. For example, there is a $1,780
annual cap on physical therapy. Once a patient hits that cap on
physical therapy, he must pay out of pocket if he needs more therapy,
unless he gets approved for an exception. Many patients hit the cap
early in the year. These are patients who have had a stroke or a
serious accident. After that they have to pay themselves for the
service unless they succeed in appealing for more therapy services.
Then by contrast, Medicare Advantage plans can base coverage for
physical therapy on what the patient needs, not what some bureaucrat in
Washington says there is a limit on. They can avoid these arbitrary
caps.
In original Medicare, patients may see a doctor whenever they like.
That may seem like a good idea. Many patients see a lot of doctors and
are prescribed many different drugs. In original Medicare, physician
care can be disjointed. No one oversees all the care a patient
receives. Some patients prefer it that way. Others welcome having help
navigating the health care system. They would like to choose a plan
that would help them coordinate their care, and most Medicare Advantage
plans do just that. So that is why we don't want the House of
Representatives to cripple Medicare Advantage.
Let's say a patient has diabetes. In Medicare fee for service, there
is no one to help monitor that she is testing her blood sugar. No one
checks to see if she is getting her eyes and feet checked, which are
the result of diabetes. And in most Medicare Advantage plans, somebody
does that oversight. Somebody does that checking. Plans use teams of
people, ranging from doctors to pharmacists to nurses to dieticians to
case managers, all to make sure enrollees are getting the care they
need. Four out of five Medicare beneficiaries have a chronic illness.
In many Medicare Advantage plans, one doctor oversees their care. The
plan assigns a case manager. Patients don't have to navigate the system
alone. For many patients, this can be preferable, and it is because of
Medicare Advantage. We don't want that plan crippled, as the House of
Representatives bill does.
Medicare Advantage is a great program for poor and low-income people.
Critics of the program argue that poor people qualify for Medicaid.
They say Medicare Advantage doesn't help them. I want to make it clear
that this is not true. I am going to get to that point later. But even
the critics cannot argue with the statistics about lower income or near
poor beneficiaries. These beneficiaries can't afford a Medigap policy.
For them, Medicare Advantage is a godsend. According to the Centers for
Medicare and Medicaid Services, the average Medicare Advantage
beneficiary gets $86 a month in extra benefits. Most of those extra
benefits are in reduced cost sharing. Medicare Advantage plans often
reduce copays and deductibles that beneficiaries otherwise would have
to pay.
As I noted, Medicare Advantage plans offer catastrophic coverage. If
an enrollee ends up in the hospital for weeks or even a year, the plan
covers it. That is not true of traditional Medicare fee-for-service,
started in 1964. It doesn't fit the practice of medicine today. But
Medicare Advantage offers medicine delivered on the practice of
medicine in 2007. The benefits may include an annual physical. They may
include lower copays for enrollees needing kidney dialysis. They
include unlimited physical therapy based upon patient need.
Ninety-nine percent of the beneficiaries have access to a Medicare
Advantage plan that plugs the gap in the Part D drug coverage; 98
percent have access to a plan that offers preventive dental benefits.
Beneficiaries in Medicare Advantage plans are more likely to get
preventive services. Almost all Medicare beneficiaries have access to a
plan with no-cost cancer screening. And for this, many beneficiaries
pay no extra premium. They pay only the regular Part B premium, as
everybody else does. Eighty-four percent of beneficiaries had access to
a zero premium Medicare Advantage plan last year.
Many seniors live on fixed incomes. Medicare Advantage may be the
only way they can afford these benefits. It is also easy to use. Many
Medicare Advantage plans let seniors use one health care card, their
Medicare Advantage plan card, for all of their health care needs.
Instead of three cards, they have one card. They pull the same card out
when they go to the doctor, same card they use for the hospital, the
same card they use for the pharmacist. They don't have to worry about
dealing with claim forms from two or three different insurance plans.
But that is not the case for beneficiaries in the original 1964 type
Medicare. If they have Medigap and Part D prescription drug coverage,
they have to deal with multiple plans that don't coordinate their
coverage or coordinate their benefits.
I said I would get back to why Medicare Advantage is good for lower
income seniors. It is true that many lower income beneficiaries are
also covered by Medicaid. These individuals are referred to as dual
eligibles, because they are under both Medicare and Medicaid. But we
have a program
[[Page S10764]]
in Medicare Advantage for people who are eligible for both. This
program is called a special needs plan. It coordinates the care and the
benefits between the Medicaid Program which is run by the States and
the Federal Government. It should be seamless to the beneficiaries.
Have these special needs plans worked perfectly? Not always. The
program is a work in progress. Surely it is a lot better than what
happens without it. Without it, health care for poor beneficiaries is
siloed. The parts covered by Medicare are never coordinated with the
parts Medicaid is responsible for.
Let's say a frail senior is in a nursing home. She has exhausted her
savings so Medicaid is paying. She has Medicare for her health
coverage. She enrolls in one of these special needs plans. When she
gets a fever or an infection, the Medicare Advantage special needs plan
can treat her at the nursing home. In the original Medicare, the
nursing home would send her to the more expensive hospital environment.
The hospital, after 3 days, would discharge her to a skilled nursing
home facility. For her, the Medicare Advantage plan reduces disruptions
and keeps her from being exposed to additional infections in the
hospital. At the same time, you save a lot of money in Medicare. Both
she and Medicare are spared the cost of hospitalization--the most
expensive health delivery.
So the critics who say that Medicare Advantage is not helping poor
people are mistaken. While the program is small, that is because the
program is new. It can be a model for all of us. This is how we want
our care to be delivered to us when we are very old and when we are
very frail.
So Medicare Advantage can be a good choice for very sick people. It
can be a good choice for people with chronic illness. It can be a good
choice for lower income people. It can be a good choice for people who
want some extra benefits. It can be a good choice for people on fixed
incomes. It can be a good choice for rural beneficiaries as well as
urban ones.
When the House of Representatives gets done with it all, we will not
have it in rural America. But they will still have it in urban America,
and that is very unfair. That inequity was meant to be taken care of
when we passed the prescription drug bill in 2003, and I am not anxious
to let that sort of equity between rural and urban America go away. But
it can also be a good choice for seniors.
All Medicare beneficiaries, whether they live in a city, a small
town, or on a farm, ought to be able to choose their own plan. They
know best what suits their needs--the original 1964 Medicare or the
2003 Medicare Advantage plan. The House bill would gut the Medicare
Advantage program. It would take these choices away from our
beneficiaries. The Senate SCHIP bill avoids this.
I urge my colleagues to remember why we decided to give Medicare
beneficiaries a choice of health plans. I urge my colleagues to reject
efforts to cut Medicare Advantage.
I yield the floor.
The PRESIDING OFFICER (Mr. Menendez). The Senator from Tennessee.
Mr. ALEXANDER. Mr. President, let me ask, through the Chair, the
manager of the previous bill, is he finished with what he would like to
do this evening? If I could ask the Senator from Iowa, does he need any
more time on the subject he has been talking about? I will be glad to
wait.
Mr. GRASSLEY. No. I am going home.
Mr. ALEXANDER. Congratulations.
Mr. GRASSLEY. I thank the Senator for listening to me.
Mr. ALEXANDER. Mr. President, I thank the Senator from Iowa.
____________________