[Congressional Record Volume 154, Number 107 (Thursday, June 26, 2008)]
[Senate]
[Pages S6225-S6231]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




MEDICARE IMPROVEMENTS FOR PATIENTS AND PROVIDERS ACT OF 2008--MOTION TO 
                                PROCEED

  The PRESIDING OFFICER. The motion to proceed to H.R. 6331 is 
considered to have been made under the previous order.
  The clerk will report.
  The legislative clerk read as follows:

       Motion to proceed to Calendar No. 836 (H.R. 6331) an act to 
     amend titles XVIII and XIX of the Social Security Act to 
     extend expiring provisions under the Medicare Program, to 
     improve beneficiary access to preventive and mental health 
     services, to enhance low-income benefit programs, and to 
     maintain access to care in rural areas, including pharmacy 
     access, and for other purposes.

  The PRESIDING OFFICER. There are now 60 minutes for debate on that 
motion.
  The Senator from Illinois.
  Mr. DURBIN. Mr. President, when we finally vote on the floor, it is 
on the Medicare Program. The Medicare Program is literally a life-and-
death program for 40 million Americans. For 40 million Americans who 
are either over the age of 65 or disabled, this is their health 
insurance program.
  It was created back in the 1960s. When it was created by President 
Lyndon Baines Johnson, its critics said: This is too big. This is too 
much government. This is socialized medicine, they said. And many voted 
against it, saying it was a mistake. Well, after 40 or more years, we 
know it wasn't a mistake. It may be one of the most thoughtful and 
important programs enacted since Social Security because it gave peace 
of mind to senior citizens. They knew when they reached that moment in 
life when they were likely to be more vulnerable to illness and 
disease, they would have health insurance. They could go to a hospital 
or doctor and get basic care and not worry about whether they were 
wealthy enough to have health insurance or enough savings to cover a 
medical catastrophe. So this program, which was derided and criticized 
for being too much government, has been one of the great success 
stories of this country, and the seniors value it. Every one of them 
values it.
  My brother, who retired from the private sector in his early 
sixties--a pretty conservative fellow when it comes right down to it, 
politically--turned out to have had some heart problems. And it turned 
out he also didn't have any health insurance after he retired. He was 
really waiting and hoping he could make it to the age of 65 before 
something else would happen because a few more trips to the hospital 
and a few more surgeries might have really hurt his retirement plans. 
He made it. He is covered by Medicare and doing well. And that is just 
one example of thousands that can be given.
  So we have a vote today which should be a pretty simple vote. It was 
a very simple vote in the House of Representatives. There is a proposal 
to cut the reimbursement, the compensation, for doctors under Medicare 
by about 10 percent on July 1. I think that is a bad idea. These 
providers don't get paid a lot of money for treating Medicare patients, 
and to cut their reimbursement may force many doctors to say: We just 
can't see as many Medicare patients or maybe none at all. So fewer 
doctors, if this pay cut goes through, are likely to treat Medicare 
patients. That is not a good outcome. It means that many of the 
Medicare patients won't be able to go to the doctors who have been 
treating them for long periods of time and there will be real 
uncertainty about their future. So we wanted to make sure this pay cut 
did not go into effect July 1.
  The House of Representatives considered this, and in an overwhelming 
bipartisan vote they voted not to cut the pay for doctors treating 
Medicare parents. The vote was 355 to 59. That is a 6-to-1 margin in 
the House of Representatives--totally bipartisan. You would think a 
bill with that kind of vote would come over here without much 
controversy. But, of course, those people don't know how to measure the 
Senate.
  In the Senate, there have been those on the other side of the aisle, 
the Republican side, who have found reason to object to this effort to 
make sure Medicare doctors get fair pay. It comes down to a lot of 
reasons they have given, but as they say in politics--or as one old 
fellow I used to work for by the name of Cecil Partee, a State senate 
president in Illinois, used to say--for every vote, there is a good 
reason and a real reason. Well, they are using as a good reason here to 
vote against this protection of Medicare doctors that, unfortunately, 
it might involve some increase in taxes or changes in private health 
insurance. The real reason? The real reason is that this bill goes 
after--in a small way--private health insurance companies that are 
selling Medicare coverage, the so-called Medicare Advantage companies.
  You see, there are many on the Republican side who haven't gotten 
over the debate in the 1960s. They still think Medicare is socialism. 
They still think this is too much government. They want to privatize 
this. They believe we could rest easy every night if we were in the 
loving arms of a health insurance company. They obviously haven't had 
to pick up the phone and talk to some clerk in the middle of nowhere 
who is denying your claim because of something in the policy you didn't 
know existed--which has happened to many people across America. No, on 
the Republican side, they are afraid that any cutback in the profit 
taking by these private health insurance companies will be 
uncomfortable for some of their friends. So they are prepared to allow 
this cut in pay for doctors under Medicare to go through to protect the 
private health insurance companies offering Medicare coverage.
  So I guess the honest question is, Are the private health insurance 
companies

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doing a better job than the Medicare Program? The honest answer is no. 
Do you know how much more they charge than the Government's Medicare 
Program? About 17 percent more. They will throw in a few bells and 
whistles, but about 17 percent more. So it isn't as if they are 
cheaper. They are not.
  Secondly, it turns out they are using bullying and strong-arm tactics 
to convince a lot of senior citizens to sign up for those so-called 
Medicare Advantage Programs, so much so that we have had to investigate 
this, and we are going to have to do everything we can to stop this 
from continuing.
  Third, we just had a report from the General Accounting Office. These 
so-called private health insurance companies--it turns out the medical 
care they were reporting for seniors was overstated. They weren't 
giving them the care that was promised. Instead, they were taking more 
profit out of the system.
  If you are a free market advocate who believes that it is caveat 
emptor--let the buyer beware--you can buy into this idea of private 
health insurance companies doing so well, making so much money, 
bullying seniors, and not giving them medical care promised. I don't 
buy it and I think they ought to be held accountable. If there is one 
thing we ought to protect, it is the seniors in America, who have done 
so much for this country and now need our help in their retirement 
years. That is what Medicare is all about.

  We are going to have a vote in about 45 or 50 minutes. We need 60 
votes to protect these doctors who are providing help under Medicare. 
We only have 51 on our side of the aisle, the Democratic side. We need 
nine Republicans to cross the aisle to join us in this effort to do the 
right thing for Medicare.
  I don't think it is an unreasonable idea that 9 out of the 49 
Republicans would join us when in the House of Representatives the same 
measure passed by a vote of almost 6 to 1 in favor of it.
  This is a good bill, not only because it helps Medicare to continue 
to thrive because it helps beneficiaries pay their premiums if they are 
in a low-income category, it helps pharmacists, it helps many others. 
It has been endorsed by virtually every major organization of 
physicians, seniors, pharmacists, and hospitals. They know this bill is 
critically important.
  If the Republicans fail to give us the votes necessary to reach 60 
votes on the next rollcall, doctors across America treating Medicare 
patients will take a 10-percent cut in pay in a few days. That is the 
reality. Those who have voted that way are doing it in order to protect 
private health insurance companies who are trying to compete with 
Medicare. Those private health insurance companies have plenty of 
lobbyists. They are politically articulate. They can be found in the 
corridors of the Capitol day in and day out. But those folks are not 
speaking for the seniors. The seniors want us to stand up and make sure 
we keep Medicare strong and Medicare providers are there to make sure 
they get the very best care.
  I hope my Republican colleagues will not go in lockstep with the 
private health insurance companies but will, in fact, stand for the 
Medicare Program, join the overwhelming bipartisan majority in the 
House of Representatives who supported this bill. If it costs these 
private health insurance companies 1 or 2 percent, is that the end of 
the world, that they would have to give back a little bit of the money 
they are taking out of our Federal Treasury? I do not think it is. I 
think they have been shown to charge more than the Medicare Program, to 
provide less than they publicly disclose in terms of medical benefits, 
and to engage in marketing tactics which should not be condoned by the 
Senate.
  I hope we will have a good bipartisan rollcall here. It will be a 
great way to end the session as we break for the Fourth of July recess.
  I yield.
  The PRESIDING OFFICER. The Senator from Arizona.
  Mr. KYL. Mr. President, I don't understand why this has to be 
characterized as a partisan issue as my colleague from Illinois has 
done. He said there is a proposal to cut doctors' pay. There is no such 
proposal. Nobody wants to cut physicians' pay. In fact, I daresay all 
100 Senators here are in support of ensuring that physicians get paid 
an increase in the pay next year from what they are paid this year. 
What happens is that the law provides an automatic pay cut so we have 
to pass a bill to prevent that automatic pay cut from taking effect.
  I am on the Finance Committee. A few weeks ago Senator Baucus, the 
chairman of that committee, who has a long history of working with 
Senator Grassley regardless of which party is in the majority, proposed 
that we work in a bipartisan way to draft a bill to ensure the 
physicians would be paid. Those discussions commenced. They produced a 
bipartisan agreement. Then, before that agreement was brought to the 
Senate floor, the majority announced it wanted instead to substitute a 
partisan bill that we would seek to consider on the Senate floor. We 
had a cloture vote on that bill and it failed to get cloture.
  My colleague says he hopes Republicans will not vote in lockstep. I 
can assure my colleagues here Republicans will not vote in lockstep. 
Democrats will vote in lockstep. There will not be a single Democrat 
who votes differently. Republicans will be divided.
  If this is a partisan issue, it is only a partisan issue because 
Democrats will vote in lockstep and because the Democrats insisted on 
bringing a partisan bill to the floor. That was rejected, so Senators 
Baucus and Grassley returned to their negotiations. Again they were 
about done with those negotiations 2 days ago when the House scheduled 
a vote on its own bill and that bill passed. Again that upset the 
bipartisan discussions that were occurring here in the Senate. As a 
result, the majority leader decided to bring the House bill to the 
Senate and ask us to support the House bill. Again, the negotiations 
stopped.
  The vote we are going to have today will either allow the Baucus-
Grassley negotiations, bipartisan negotiations, to be completed or send 
a bill to the President which he will veto--meaning a great deal of 
time will be lost by the time that bill gets to the President, he ends 
up vetoing it, he sends it back to the Congress and we presumably 
sustain the veto. Then what happens after that? Bipartisan negotiations 
resume.
  We can cut out all of that political folderol by simply returning 
this bill to the people who were negotiating it in the first place. 
Either way, July 1 will come with no solution. That is a problem for 
the physicians. The veto route virtually assures that physicians will 
feel the impact of a 10.6 percent cut in payment because of the amount 
of time it will take for us to complete our work.
  On the other hand, if cloture is defeated and the bipartisan 
negotiations can quickly resume, then, depending upon when we could 
pass something after July 4, it is possible that the reimbursement 
checks could reflect the new rates without the cuts ever being applied.
  If you are interested in a truly bipartisan solution in a body that 
is 51 to 49, if you are interested in minimizing the potential impact 
on physicians, do not vote for the House bill that we know will never 
become law.
  Let me conclude with this point. The House bill makes some radical 
changes in Medicare. It doesn't just reimburse physicians; it increases 
Medicare spending by $17 billion over 10 years. It makes larger cuts to 
Medicare Advantage, the highly successful insurance program for 
America's seniors. This will minimize patient choice in both rural and 
urban areas and, according to the Congressional Budget Office, 2 
million seniors would lose their fee-for-service plans by the year 2013 
under the House bill. It would significantly restrict Part D plans' 
ability to negotiate prescription drug prices.
  We can do better than this. We should return to the bipartisan 
negotiations and pass a truly bipartisan bill which will ensure that 
physicians will be paid and Medicare patients will be served.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. Mr. President, here we are again. Once again the Senate 
is being asked to vote to proceed to a bill that is written on a 
partisan basis. As everybody knows who knows how the Senate functions, 
anything that is on a partisan basis does not get done.
  Once again we are being asked if we want to agree to a process where 
no

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amendments will be allowed. Once again we are being told to take it or 
leave it. The damage that is being done to the ability of this body to 
function is extraordinary. It should not be this way and it doesn't 
have to be this way.
  I say this from a lot of experience I have had on the Finance 
Committee and, most importantly, my experience working with Senator 
Baucus, the chairman of the committee. During the last several years, 
the Finance Committee has produced numerous bipartisan health care 
products.
  In 2003, Senator Baucus and I joined together, defied the long odds 
against it and produced a Medicare Prescription Drug bill.
  In 2005, we worked together on a relief package in the aftermath of 
Hurricane Katrina.
  In 2006, we passed the Tax Relief and Health Care Act.
  In 2007, we worked together on a bipartisan Children's Health 
Insurance Program Reauthorization Bill. We also passed the Medicare, 
Medicaid, and Children's Health Insurance Program Extension Act of 
2007.
  I could go on and on. For years the Finance Committee has been the 
model of how a committee can work on a cooperative--and that basically 
means on a bipartisan--basis. I think we work best when we work 
together. For some reason that has not seemed to be the case this year 
and that is not Senator Baucus's fault.
  I have tried to work this year to get a bill that could get signed 
into law. I personally think the White House is drawing lines in the 
sand that are unreasonable. However, there is a fact of our 
Constitution: The President holds the veto pen and if this bill passes 
today, we will see it used, and that is regardless of this Senator's 
position that maybe the White House has been too strict.
  I tried to work toward a bill that can be signed by the President, 
because those are the facts of life. Obviously that was not the path 
the majority of the Senate--meaning the majority party--could follow. 
Even after the first cloture vote, even after it failed in the Senate, 
I tried to get a bipartisan compromise that could be signed into law. 
That effort was abandoned when the House voted to support the bill on 
which the Senate couldn't get cloture. That is not a realistic position 
for the other body to take but it doesn't matter; they took it, so we 
are here.
  When we were in charge around here, I can say we certainly didn't 
appreciate it when, under Republican control in the House of 
Representatives, the Ways and Means Committee tried to dictate terms to 
this body. When Ways and Means Chairman Thomas tried to roll the 
Senate, I think I successfully defended the bipartisan Senate position. 
When I was chairman of the Finance Committee, I don't recall our 
bipartisan efforts being determined by House votes. To the contrary, I 
think we worked together in spite of House votes. In fact, the House 
budget--or the congressional budget adopted in the year 2003 that had 
provisions in it for taxes when the President of the United States 
wanted a $700 billion tax cut--I told enough Republicans in the Senate 
that I would not bring out of conference a tax bill that had more than 
half that amount, $350 billion.
  I didn't tell the House of Representatives that before they voted on 
their budget, but they passed a budget that we could get enough votes 
to pass in the Senate because of the promise I made to some Republicans 
that we were not going to be dictated to by the White House or by the 
House of Representatives. And we didn't do more than a $350 billion 
package. Was there an uproar among House Republicans against me, when I 
had told enough Republicans in the House what we would do on that tax 
bill. So I think I have defended our position.
  But let's be clear about another thing. That House vote I referred to 
went the way it did because Members were assured that the Senate was 
going to fix the problem in this bill. But we are in a process where we 
cannot fix that problem. They are counting on us to fix it so we would 
have a bill the President would sign. They are right about one thing: 
This bill does need to be improved. The bill the Democrats are trying 
to pass is woefully lacking in what it provides for rural America as 
opposed to what Senator Baucus and I were agreeing to by 11 o'clock 
Tuesday of this week.
  I wish to call out one specific provision. Senator Harkin and I have 
worked extensively on a provision for so-called ``tweener'' hospitals. 
These are hospitals which are too large to be critical access hospitals 
but too small to do well under the current Medicare payment systems. We 
had a provision to improve payments to these hospitals. It is not in 
the House Democrats bill, so a vote for cloture misses an opportunity 
to provide critical assistance to rural hospitals all over the country. 
I am sure Senator Harkin and others are disappointed, as I am, with 
this omission. This is not something just for Iowa and for Senator 
Harkin and for Senator Grassley; this is something that affects 181 
hospitals in 31 different States in this country. But that was left out 
in the House of Representatives. Why? Because the House of 
Representatives is controlled by the big States, by the big cities, and 
they don't care about rural America.
  Voting for this bill accomplishes nothing. It will not become law. 
How much more clear can we be about that? To keep the pay cut of 
doctors from happening, we have to defeat this motion so we can sit 
down and finally produce a bill that can become law.
  To improve Medicare, we have to produce a bill that can become law, 
and that means being signed by the President of the United States. To 
make sure that beneficiaries continue to have access to essential 
therapy services, we have to produce a bill that can become law. To 
help beneficiaries, we have to produce a bill that can become law. How 
many times do I have to say that?
  To preserve access for durable medical equipment for seniors, we have 
to produce a bill that can become law. We have to be allowed to do our 
work in the Senate. And that work only gets done if we have 
bipartisanship.
  We have to be allowed to produce the best bill possible through 
bipartisan compromise. Let's show that we can work on a cooperative 
basis. We have to defeat this motion so that we preserve the right of 
the Senate to have input on legislation, that we are not simply a 
rubberstamp for the House.
  We should defeat this motion so that we can show that bipartisanship 
is not dead on important health care issues that matter to millions of 
people who depend on us as stewards of Medicare. Let's do the right 
thing and vote no. Vote no so this body does not abdicate its duties 
under the Constitution. Vote no so that we can get a bill done this 
week that can become law. Vote no so that we can get the job done.
  A ``yes'' vote accomplishes nothing because it is going to delay for 
2 weeks everything to be considered because of the President vetoing 
this bill.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from New Mexico is recognized.
  Mr. BINGAMAN. Mr. President, how much time remains on this side?
  The PRESIDING OFFICER. The majority has 20 minutes, of which 10 
minutes are reserved for the majority leader.
  Mr. BINGAMAN. Mr. President, I will use a maximum of 5 minutes to 
respond to some of the points that were made.
  First, let me say how much respect I have for Senator Grassley. He is 
the ranking member on our Finance Committee. He is a very conscientious 
and fair individual with whom I have enjoyed working on many matters.
  On this particular issue, I disagree with him. Let me point out there 
were three arguments made: First, that this is not bipartisan; it is 
clearly not the bipartisan agreement he and Senator Baucus were working 
to develop, but it is clearly a bipartisan agreement.
  I am informed that 129 Republicans in the House voted for this bill. 
That is two-thirds of the Republicans who serve in the House. The vote 
in the House was 355 in favor. So this is a bipartisan bill by any 
definition. The fact that it has come from the House of Representatives 
rather than originating in the Senate, of course, is another matter. 
But it is bipartisan.
  The second point, of course, is that there are important things that 
have been left out. I do not doubt that there are important things that 
have been left out and that I would like to see included. But the 
reality is, we have a bill that does important things; particularly, it 
heads off the expected cut in physician payments that is scheduled to 
occur next Tuesday. That is a

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very important provision. And I think it makes all the sense in the 
world for us to pass what we have in front of us, pass what the House 
of Representatives has passed, fix the problems that legislation fixes, 
and then come back at a future time and try to solve these other 
problems, many of which I am sure I would wind up agreeing with my 
colleague from Iowa.
  The third point is that we should oppose this because the President 
has said he would veto it. Frankly, I am not clear as to the 
substantive reason the President thinks this bill should be vetoed.
  I believe strongly that the way the system is intended to operate is, 
Congress sends bills to the President. If he vetoes them, then Congress 
sees whether it has got enough votes to override the veto. If we do 
not, of course we have to take a different course.
  In this circumstance, it looks to me like at least the House of 
Representatives has enough votes to override a Presidential veto, if 
the President were to take that course. I do not know what we would 
have in the Senate. I hope very much we would have the necessary 67 
votes. I think it would certainly be in the interests of the people I 
represent in New Mexico to see this legislation enacted and enacted 
quickly.
  So I urge my colleagues to support it and hope that colleagues on 
both sides of the aisle will support the legislation.
  Mr. LEVIN. Mr. President, I support the Medicare Improvements for 
Patients and Providers Act, H.R.6331, which makes a number of needed 
changes related to Medicare reimbursement, including reimbursement for 
physicians' services.
  Medicare physician fee schedule payments are updated each year 
according to a complex formula based on a sustainable growth rate, SGR. 
Unfortunately, because of the way the formula is calculated, even if 
Congress prevents the cuts in a given year, scheduled reimbursements 
cuts are likely to increase in subsequent years unless Congress takes 
additional action, such as developing a permanent alternative to the 
SGR formula.
  I support efforts to ensure that physicians receive adequate 
reimbursement for their services. It could be financially unsound for 
physicians to continue to provide services to Medicare beneficiaries if 
reimbursement is inadequate. As a result, allowing reimbursement cuts 
to enter into effect could pose significant access problems as 
physician's are unable to afford providing services to Medicare 
beneficiaries in need of medical attention.
  While I believe past measures to alleviate this burden on physicians 
have been helpful, I know from my discussions with health care 
providers throughout Michigan that more needs to be done. For the long 
term, Congress must find an alternative to the SGR. The SGR is linked 
not to the cost of providing health services, but to the performance of 
the overall economy. The cost of health care has been rising much 
faster than inflation. Our Nation should address the rising costs of 
health care as part of a larger discussion on health care reform. 
Reimbursement should more accurately represent the cost of providing 
services.
  In the meantime, I support this legislation, which includes a delay 
on Medicare reimbursement cuts for physicians' services and replaces 
the cut with a 1.1-percent increase for 2009. I am hopeful that the 
Senate will pass this legislation and that the President will heed the 
will of Congress and the American people and sign this bill into law 
before the cuts enter into effect on July 1.
  Mr. GRAHAM. Mr. President, today I wish to express my disappointment 
in the straight extension of the current temporary assistance for needy 
families, TANF, supplemental grant program, which is included in the 
Medicare bill. I oppose the extension of this program without updating 
the 10-year-old statistics that qualify States for participation in the 
program, and without the appropriate reauthorization and consideration 
of changes necessary to ensure that this assistance is being afforded 
to the States that need it most.
  The TANF Supplemental Grant program was created in 1996 to provide 
additional assistance to States that spend less money per poor person 
on TANF services. Seventeen States qualified for additional TANF 
benefits under this program based on certain statistics collected at or 
around that time. More than 10 years later, these States are still 
receiving supplemental grant benefits based on the same 10-year-old 
statistics. A straight extension of this program does not award this 
assistance based on current conditions in States.
  There is no doubt that our nation is facing challenging economic 
times. Rising gas prices, rising unemployment States, the housing 
crisis and rising food prices all place a particularly significant 
burden on less fortunate families. Some state TANF programs are seeing 
increased caseload pressure.
  South Carolina can only afford to spend 29 percent of the national 
average per poor child on TANF services compared to some States that 
spend well over the national average. To make matters worse, South 
Carolina did not and has not qualified for the supplemental grant 
program due to an old statistic that has since changed.
  Senator Rockefeller and I introduced a proposal to allow States that 
spend below the national average on TANF services to participate in the 
supplemental grant program. Using updated statistics, our legislation 
would ensure that the dollars spent on this program are appropriately 
directed to States that need it most so that they can help struggling 
families get on their feet and back to work.
  Unfortunately, the Senate Finance Committee chose to quickly pass 
this extension as a part of a larger bill in order to avoid the 
discussion of reauthorization and changes necessary to update the 
supplemental grant program. I am disappointed some States, like South 
Carolina, and families that might otherwise receive this additional 
assistance will not have the opportunity to benefit from a mere update 
of the current program, or from the consideration of Senator 
Rockefeller's and my proposal.
  I am committed to ensuring that Federal dollars spent on welfare 
services and benefits are spent efficiently. I am disappointed that the 
reauthorization of the supplemental grant program did not receive the 
attention it deserves, and I am hopeful that this can be addressed in 
the future.
  Mr. AKAKA. Mr. President, I support the Medicare Improvement for 
Patients and Providers Act of 2008. We must quickly enact this 
legislation in order to ensure that Medicare beneficiaries continue to 
have access to health care, enhance Medicare benefits, and extend 
Medicaid disproportionate share, DSH, allotments for Hawaii.
  This essential legislation will maintain Medicare physician payment 
rates for 2008 and provides a slight increase in 2009. If this 
legislation fails to pass, doctors will be faced with a 10.6-percent 
cut in Medicare reimbursements. Rising costs, difficulty in recruiting 
and retaining staff members, and declining reimbursement rates make it 
necessary to make improvements in Medicare reimbursements to ensure 
that Medicare beneficiaries have access to health care services.
  The bill will enhance Medicare benefits. It will increase coverage 
for preventive health care services and make mental health care more 
affordable. In addition, the Act will help low-income seniors access 
health care services that they need.
  In addition, this legislation includes a provision that extends 
Medicaid DSH allotments for Hawaii and Tennessee for another 18 months. 
Medicaid DSH resources support hospitals that care for Medicaid and 
uninsured patients.
  Hawaii and Tennessee are the only two States that do not have 
permanent DSH allotments. The Balanced Budget Act of 1997 created 
specific DSH allotments for each State based on their actual DSH 
expenditures for fiscal year 1995. In 1994, Hawaii implemented the 
QUEST demonstration program that was designed to reduce the number of 
uninsured and improve access to health care. The prior Medicaid DSH 
program was incorporated into QUEST. As a result of the demonstration 
program, Hawaii did not have DSH expenditures in 1995 and was not 
provided a DSH allotment.
  The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection 
Act of 2000 made further changes to the DSH program, which included the 
establishment of a floor for DSH allotments. States without allotments 
were again left out.

[[Page S6229]]

  The Medicare Prescription Drug, Improvement, and Modernization Act of 
2003 made additional changes in the DSH program. This included an 
increase in DSH allotments for low DSH States. States without 
allotments were again left out.
  In the Tax Relief and Health Care Act of 2006, DSH allotments were 
finally provided for Hawaii and Tennessee for 2007. The act included a 
$10 million Medicaid DSH allotment for Hawaii for 2007. The Medicare, 
Medicaid, and SCHIP Extension Act of 2007 extended the DSH allotments 
for Hawaii and Tennessee until June 30, 2008.
  This extension authorizes the submission by the State of Hawaii of a 
State plan amendment covering a DSH payment methodology to hospitals 
which is consistent with the requirements of existing law relating to 
DSH payments. The purpose of providing a DSH allotment for Hawaii is to 
provide additional funding to the State of Hawaii to permit a greater 
contribution toward the uncompensated costs of hospitals that are 
providing indigent care. It is not meant to alter existing arrangements 
between the State of Hawaii and the Centers for Medicare and Medicaid 
Services, CMS, or to reduce in any way the level of Federal funding for 
Hawaii's QUEST program.
  I look forward to continuing to work with Chairman Baucus, Ranking 
Member Grassley, and Senators Alexander, Corker, and Inouye to 
permanently restore allotments for Hawaii and Tennessee. I thank the 
chairman and ranking member of the Finance Committee for all of their 
efforts on this issue of great importance to my home State of Hawaii.
  Mr. President, Hawaii's health care providers continue to struggle to 
care for our growing number of individuals that are uninsured. These 
DSH resources will strengthen the ability of our providers to meet the 
increasing health care needs of our communities.
  I yield the floor, and I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. BINGAMAN. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BINGAMAN. Mr. President, I ask unanimous consent that any time 
under a quorum call on this bill be equally divided.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. BINGAMAN. Mr. President, I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. McCONNELL. I ask unanimous consent that the order for the quorum 
call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. McCONNELL. Mr. President, under the consent agreement that was 
entered, I have 10 minutes?
  The PRESIDING OFFICER. The Senator is correct.
  Mr. McCONNELL. I will yield back the remainder of my time, and then 
am I correct that the only remaining speaker is the majority leader?
  The PRESIDING OFFICER. That is correct.
  Mr. McCONNELL. Mr. President, let me be clear, my side, led by 
Senator Grassley, has been willing to compromise to get a bill that 
could become law. Everyone agrees we need to fix the physician payment 
system. There is no disagreement on that. As Senator Grassley has 
pointed out, we have offered to negotiate. We have offered to extend 
current law. We have tried to find a way to solve the problem. 
Unfortunately, the majority apparently is not interested. The bill we 
are voting on would cause 2 million seniors to lose the extra benefits 
they currently get in their Medicare Advantage plans. It would rob 
millions of rural seniors of the ability to choose a private fee-for-
service plan. I worry about the impact that it would have on the 
Kentucky teacher retirement system.
  We have a solution that would protect seniors' access to care, that 
would prevent a 10.6-percent cut in physician payments in Medicare, 
that would provide billions of dollars to help rural beneficiaries 
access care. This is a solution that could become law right away. I 
hope the majority can find a way to take one of the solutions we are 
offering so that physician payments are not cut and seniors' Medicare 
benefits are not put in jeopardy.
  I yield back the remainder of my time.
  The PRESIDING OFFICER. The majority leader.
  Mr. REID. Mr. President, these are some of the organizations that 
support the Medicare bill now before the Senate. We have the American 
Association of Retired Persons, the AARP; Alzheimer's Association; the 
American Academy of Oncology; the American Academy of Audiology; the 
American Academy of Family Physicians; the American Academy of 
Opthalmology; American Ambulance Association; American Association of 
Nurses Anesthetists; American Cancer Society; American College of 
Cardiology; American Heart Association; American Hospital Association; 
American Medical Association, the AMA; American Medical Technologists; 
American Optometric Association; the American Osteopathic Association; 
American Psychological Association; American Society of Plastic 
Surgeons; Campaign for Tobacco Free Kids; Cleveland Clinic--to name a 
few institutions--National Osteoporosis Foundation; National Renal 
Administrators Association; National Rural Health Association; 
Parkinson's Action Network; Schizophrenia and Related Disorders 
Alliance of America; Society for Thoracic Surgeons; Suicide Prevention 
Action Network; Medical Rights Center; National Community Pharmacists 
Association.
  I ask unanimous consent to print in the Record more than 200 
organizations that want every Senator to vote to finish this 
legislation, to complete this legislation, to pass this legislation.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

 H.R. 6331, ``Medicare Improvements for Patients and Providers Act of 
                2008'' List of Supporting Organizations

       Alliance for Aging Research; Alliance for Retired 
     Americans; Alzheimer's Association; AMAG Pharmaceuticals, 
     Inc.; American Academy of Audiology; American Academy of 
     Dermatology; American Academy of Family Physicians; American 
     Academy of Ophthalmology; American Academy of Otolaryngology; 
     American Academy of Physical Medicine and Rehabilitation; 
     American Ambulance Association; American Association of 
     Bioanalysts; American Association of Cardiovascular and 
     Pulmonary Rehabilitation; American Association for Clinical 
     Chemistry; American Association for Geriatric Psychiatry; 
     American Association for Homecare; American Association of 
     Homes and Services; American Association of Medical Colleges; 
     American Association of Nurse Anesthetists; American 
     Association of Retired Persons (AARP).
       American Cancer Society Cancer Action Network (ACS CAN); 
     American Clinical Laboratory Association; American College of 
     Cardiology; American College of Emergency Physicians (ACEP); 
     American College of Nurse Midwives; American College of 
     Obstetricians and Gynecologists; American College of 
     Osteopathic Internists; American College of Physicians; 
     American College for Preventive Medicine; American College of 
     Radiology; American College of Surgeons; American Counseling 
     Association; American Diabetes Association; American 
     Federation of Labor & Congress of Industrial Organizations 
     (AFL-CIO); American Federation of State, County and Municipal 
     Employees; American Geriatrics Society; American Health Care 
     Association; American Heart Association; American Hospital 
     Association; American Kidney Fund; American Lung Association; 
     American Medical Association (AMA); American Medical Group 
     Association.
       American Medical Technologists; American Mental Health 
     Counselors' Association; American Nephrology Nurses' 
     Association; American Occupational Therapy Association; 
     American Optometric Association; American Osteopathic 
     Association; American Pharmacists' Association; American 
     Physical Therapy Association; American Podiatric Medical 
     Association; American Psychiatric Association; American 
     Psychological Association; American Public Health 
     Association; American Regent, Inc.; American Renal 
     Associates, Inc.; American Society of Anesthesiologists; 
     American Society of Cataract and Refractive Surgery; American 
     Society for Clinical Laboratory Science.
       American Society for Clinical Pathology; American Society 
     for Microbiology; American Society of Nephrology; American 
     Society for Nutrition; American Society of Pediatric 
     Nephrology; American Society of Plastic Surgeons; American 
     Speech-Language-Hearing Association; American Stroke 
     Association; American Telemedicine Association; American 
     Thoracic Society; American Osteopathic Association; American 
     Urological Association; Amgen; Association of American 
     Medical Colleges (AAMC); Association for Community Affiliated 
     Plans; Board of

[[Page S6230]]

     Nephrology Examiners and Technology; California Dialysis 
     Council; California Medical Association; Campaign for Tobacco 
     Free Kids; Center for Clinical Social Work.
       Center for Medicare Advocacy; Centers for Dialysis Care; 
     Cleveland Clinic; Clinical Laboratory Coalition; Clinical 
     Laboratory Management Association; Clinical Social Work 
     Association; Coalition of State Rheumatology Organizations; 
     College of American Pathologists; Colorectal Cancer 
     Coalition; National Osteoporosis Foundation; National 
     Partnership for Women and Families; National Patient 
     Advocate Foundation; National Renal Administrators 
     Association; National Rural Health Association; Northwest 
     Kidney Centers; Parkinson's Action Network; Partnership 
     for Prevention; Prevent Cancer Foundation; Prostrate 
     Cancer Coalition; Quest Diagnostics.
       Renal Advantage, Inc.; Renal Physicians Association; Renal 
     Support Network; Renal Ventures Management, LLC; Roche 
     Diagnostics; Satellite Healthcare; Schizophrenia and Related 
     Disorders Alliance of America; Society of Gynecologic 
     Oncologists; Society of Hospital Medicine; Society of 
     Thoracic Surgeons; Society for Vascular Surgery; Suicide 
     Prevention Action Network USA (SPAN USA); Susan G. Komen for 
     the Cure Advocacy Alliance; U.S. Renal Care; Watson Pharma, 
     Inc.; Y-ME National Breast Cancer Organization.
       Consortium for Citizens with Disabilities Health Task 
     Force, The Council for Quality Respiratory Care; Da Vita, 
     Inc.; Diabetes Access to Care Coalition; Dialysis Patient 
     Citizens; DSI, Inc.; Easter Seals; Emergency Department 
     Practice Management Association; Families USA; Federation of 
     American Hospitals; Food Marketing Institute; Fresenius 
     Medical Care North America; Fresenius Medical Care Renal 
     Therapies Group; Genzyme; Health Industry Distributors 
     Association; ITEM Coalition; Kidney Care Council; Kidney Care 
     Partners; Laboratory Corporation of America; Lance Armstrong 
     Foundation; Leadership Council of Aging Organizations.
       Lutheran Services in America; Marshfield Clinic; Mayo 
     Clinic; Medical Group Management Association; Medicare Rights 
     Center; Mental Health America; National Alliance on Mental 
     Illness; National Association of Anorexia Nervosa and 
     Associated Disorders; National Association of Chain Drug 
     Stores; National Association of Community Health Centers; 
     National Association for Medical Direction of Respiratory 
     Care; National Association of Nephrology Technicians and 
     Technologists; National Association of Social Workers; 
     National Association of State Long-Term Care Ombudsmen 
     Programs; National Association of State Mental Health Program 
     Directors; National Association for the Support of Long-term 
     Care.
       National Committee to Preserve Social Security and 
     Medicare; National Committee for Quality Assurance; National 
     Community Pharmacists Association; National Council on Aging; 
     National Council for Community Behavioral Healthcare; 
     National Home Oxygen Patients Association; National 
     Independent Laboratory Association; National Kidney 
     Foundation; National MS Society.

  Mr. REID. Mr. President, this bill has many items in it, one of which 
we call the doctors' fix, which prevents a 10.6-percent pay cut for 
physicians who participate in Medicare. It provides a payment freeze 
for 2008 and a 1.1-percent update for 2009. These are very important to 
the medical community.
  The reason this legislation is important is, sure, the doctors should 
not have to take a pay cut. But the main thing is, this bill does not 
protect physicians; it protects patients because doctors have been 
dropping out of Medicare for a long number of years. There are many 
physicians in America today who will not treat Medicare patients 
because the payments are too low. But it is a spiraling effect. It is a 
snowballing effect. Many reimbursements through insurance companies and 
other organizations are based on what the Medicare reimbursement is. If 
this is low, then doctors all over the country will be affected. 
Patients will be affected. People, I repeat, will no longer be able to 
be treated by their physicians.
  We know all these doctors' organizations that are part of this 200-
plus organizations I submitted, the reason they are in favor of it is 
they want their physicians to treat Medicare patients. This will drive 
people out of Medicare.
  We all recognize that President Bush does not like Social Security. 
He does not like Medicare. He wants them to go away. He wants to 
privatize Social Security, and he wants to do away with Medicare. This 
is his effort to do so. But it is the wrong thing to do. It is 
certainly the wrong thing to do.
  This legislation will provide help for rural health care deliverers. 
Beneficiary investments are significant. Yet there are additional 
provisions in this legislation for pharmacies, dialysis patients, 
community health centers, ambulances, rural providers, e-prescribing, 
psychologist, social workers, and many others.
  This is a fine piece of legislation. Remember, we already over here 
had an opportunity to do work on this bill. Every Democrat voted for 
it, and nine Republicans. Here is where we find ourselves tonight. 
Earlier this week, the House passed this identical legislation by a 
vote of 355 to 59. The Presiding Officer and I served in the House of 
Representatives. That is an overwhelming vote. It was a bipartisan 
vote. Democrats and Republicans voted for it. The legislation they 
passed would help, as I have stated, Medicare beneficiaries and head 
off looming cuts facing doctors.
  Why is Medicare important? My first elective job was on a hospital 
board. We ran countywide in Clark County, Las Vegas. It was my first 
elective job. During the time that I was on that hospital board was a 
transition period. During the time I was there, Medicare passed back 
here and became the law all over the country. So for a part of my term, 
there was no Medicare for patients coming into Southern Nevada Memorial 
Hospital. The rest of the term, it was.
  Prior to Medicare passing, 40 percent of the senior citizens who came 
to that hospital had no insurance. What happened is that wives, 
mothers, fathers, sons, daughters, neighbors, friends would have to 
sign that they would be responsible for their bill. If they didn't pay 
the bill, we had an extremely big collection department. It was a 
county hospital. It was an indigent facility. We would go after those 
people who would sign that these people needed hospital care.
  After Medicare came into being, 99-plus percent of the seniors who 
come into a hospital have health care through Medicare. It is a 
wonderful program. Is it a perfect program? No. But is it a program 
worth following President Bush over the ledge to destroy it? That is 
what is going to happen tonight, Mr. President. If the Republicans do 
not support this legislation, they are having Medicare go over the 
cliff. People will be devastated by what is happening.
  We have all had people visit our offices, I hope, this week. They 
visited mine, talking about how devastating this would be--not to the 
doctors. The doctors are going to survive with a 10-percent pay cut, 
most of them. But they are going to drop out of the system. It hurts 
the patients, and that is what this is all about.
  Medicare is an important program. It is part of the legacy of our 
country, and we know our health care delivery system is in trouble. 
Medicare is one of the strong parts of it. We should continue it, not 
destroy it. A ``no'' vote on this legislation tonight is destroying 
Medicare.
  The House bill was very similar to a bill drafted by Senator Baucus 
and supported by every Senate Democrat and many Senate Republicans 
earlier this month. We all know the issue must be resolved by July 1. 
It must be resolved by July 1. Our Republican colleagues argue, there 
will be other opportunities to address this issue. That, using a term 
of the marketplace, is a ``loss leader.'' There is no other way to do 
this. We have to do it tonight or it won't be done. July 1 comes next 
week. We are out of session next week. The House is out of session now. 
If not, they will be shortly. There are no other opportunities to 
address this issue. Some ask for a 30-day extension. A 30-day extension 
requires passage by this body and the House. The House, if they are not 
adjourned, soon will be. Both Speaker Pelosi and the House majority 
leader have issued statements that could not be more clear.
  Quoting Speaker Pelosi:

       The House will not consider any further Medicare 
     legislation.

  This means that the 30-day extension is not an option, a week 
extension is not an option, a 10-minute extension is not an option.
  The bill we seek to proceed to represents the only chance for 
Congress to head off the cuts that doctors will face at the end of this 
month. This is a good piece of legislation.
  Some Republicans also say the Senate should have more time to speak 
on the bill and debate it. Yet the same Senators who make those claims 
are the ones who voted against proceeding it 2 weeks ago. You can't 
have it both ways. We asked to proceed to this 2 weeks ago. It was 
objected to.
  We have had an interesting situation in the Senate.

[[Page S6231]]

  I have a chart I have asked to be brought out here. Obviously, no one 
is running very hard to bring it, but it should be here quickly.
  We have had an unusual situation. This is, it appears, the 79th 
filibuster. That is too bad: to filibuster something to preserve 
Medicare? That is what this is all about. It is too bad. This is 
legislation that is important.
  I say to everyone within the sound of my voice, there are no excuses. 
This is it. You go home and explain to your family physician: Well, I 
wanted to talk about it more or I wanted a 20-day extension; they would 
not give it to me.
  We have had 79 Republican filibusters, and the sad part about it is, 
we are still counting. Remember, this is our Velcro chart. Remember, a 
short time ago, it was 78. We stuck on a ``9'' back there, and I guess 
when we come back after the recess we will have to peel that off and 
put on an ``8'' and a ``0.'' Seventy-nine filibusters: untoward. And 
people who refuse to vote to let this legislation pass are destroying 
Medicare in the near future--certainly during the next 6 months.
  Senate Republicans are playing a dangerous game of chicken, I guess. 
They have the audacity to say there are other ways of doing this. But 
in this game of chicken, the only losers will be Medicare patients--old 
people. Doctors will lose.
  The Republicans who choose to block this important bipartisan 
legislation are going to lose. If there was any doubt that Republicans 
will regret this path of blindly following on this legislation, one 
need only look at their own. One need only look at a Congressman by the 
name of Wally Herger. Wally Herger is a long-time experienced 
Congressman. He represents the Second District of California. Here is 
what he did when he realized how good this legislation was. He realized 
that by blindly following the Republicans--who he thought knew what 
they were doing in the House--he made a big mistake.
  Congressman Wally Herger was one of 59 Members in the entire 435 
Members of the House of Representatives--one of 59--to vote against 
this legislation. Now, this is not some new guy who made a mistake 
because he did not know what hole to punch in the deal over there. He 
voted, and as soon as dawn broke in the House, he was on the House 
floor saying: I made a big mistake. Help me out of the dilemma I am in.
  In fact, he was so concerned about this, he sent a letter to all of 
his constituents in his congressional district. He said, among other 
things:

       From my conversations with House Republican leaders, it was 
     my understanding that the bill--

  The bill we are debating right here tonight; this bill--

     voted on by the House was primarily a political exercise. . . 
     .

  It was ``primarily a political exercise.''
  And he said:

       Clearly, the outcome of today's vote changed the dynamics 
     of the situation.

  Now, this is a direct quote from someone in the House of 
Representatives, a couple days ago, who voted against this legislation. 
Here is what he said:

       Clearly, the outcome of today's vote changed the dynamics 
     of the situation. . . . Had I known the process would play 
     out this way, I would have supported the House bill. And if 
     the bill comes back to the House for final approval, I intend 
     to fully support it.

  Now, my friend, Wally Herger, whom I know--I used to see him in the 
House gym--recognizes he has made a big mistake, and he takes a full 
page and sends this letter to all his constituents saying: I made a big 
mistake. Forgive me.
  So Senate Republicans do not have the luxury of changing their minds 
like Congressman Herger did because right now you have to make a 
decision, and you know what the facts are. Wally Herger learned them 
later. And I am sure the other 58 who voted ``no'' feel the same way. 
This was an overwhelming vote in the House of Representatives on a 
totally bipartisan basis to do the right thing for the American people. 
We must decide now whether to stick with President Bush as lemmings 
going over the cliff, or should we do the right thing and pass this 
legislation?
  A ``no'' vote will wreak havoc on our health care delivery system in 
America. And who will it hurt the most? It will hurt the most senior 
citizens. And it would be too bad as we leave here for 10 days that 
this legislation will, in the vernacular, go down. It should not. This 
is legislation that is meritorious. As Wally Herger said, if he had 
understood the dynamics of this legislation, he would not have voted 
``no.''
  Mr. President, I believe it is time for the vote.


                             Cloture Motion

  The PRESIDING OFFICER. Under the previous order, pursuant to rule 
XXII, the Chair lays before the Senate the pending cloture motion, 
which the clerk will state.
  The assistant legislative clerk read as follows:

                             Cloture Motion

       We, the undersigned Senators, in accordance with the 
     provisions of rule XXII of the Standing Rules of the Senate, 
     hereby move to bring to a close debate on the motion to 
     proceed to H.R. 6331, the Medicare Improvements for Patients 
     and Providers Act.
         Harry Reid, Max Baucus, Debbie Stabenow, Jeff Bingaman, 
           Patty Murray, John D. Rockefeller, IV, Thomas R. 
           Carper, Mark L. Pryor, John F. Kerry, Dianne Feinstein, 
           Richard Durbin, Daniel K. Inouye, Bill Nelson, Bernard 
           Sanders, Jon Tester, Jim Webb, Frank R. Lautenberg.

  The PRESIDING OFFICER. By unanimous consent, the mandatory quorum 
call is waived.
  The question is, Is it the sense of the Senate that debate on the 
motion to proceed to H.R. 6331, the Medicare Improvements for Patients 
and Providers Act of 2008, shall be brought to a close?
  The yeas and nays are mandatory under the rule.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. DURBIN. I announce that the Senator from Massachusetts (Mr. 
Kennedy) is necessarily absent.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Arizona (Mr. McCain).
  The result was announced--yeas 58, nays 40, as follows:

                      [Rollcall Vote No. 160 Leg.]

                                YEAS--58

     Akaka
     Baucus
     Bayh
     Biden
     Bingaman
     Boxer
     Brown
     Byrd
     Cantwell
     Cardin
     Carper
     Casey
     Clinton
     Coleman
     Collins
     Conrad
     Dodd
     Dole
     Dorgan
     Durbin
     Feingold
     Feinstein
     Harkin
     Inouye
     Johnson
     Kerry
     Klobuchar
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lieberman
     Lincoln
     McCaskill
     Menendez
     Mikulski
     Murkowski
     Murray
     Nelson (FL)
     Nelson (NE)
     Obama
     Pryor
     Reed
     Roberts
     Rockefeller
     Salazar
     Sanders
     Schumer
     Smith
     Snowe
     Stabenow
     Stevens
     Tester
     Voinovich
     Webb
     Whitehouse
     Wyden

                                NAYS--40

     Alexander
     Allard
     Barrasso
     Bennett
     Bond
     Brownback
     Bunning
     Burr
     Chambliss
     Coburn
     Cochran
     Corker
     Cornyn
     Craig
     Crapo
     DeMint
     Domenici
     Ensign
     Enzi
     Graham
     Grassley
     Gregg
     Hagel
     Hatch
     Hutchison
     Inhofe
     Isakson
     Kyl
     Lugar
     Martinez
     McConnell
     Reid
     Sessions
     Shelby
     Specter
     Sununu
     Thune
     Vitter
     Warner
     Wicker

                             NOT VOTING--2

     Kennedy
     McCain
  The PRESIDING OFFICER. On this vote, the yeas are 58, the nays are 
40. Three-fifths of the Senators duly chosen and sworn not having voted 
in the affirmative, the motion is rejected.
  Mr. REID. Mr. President, I enter a motion to reconsider the vote.
  The PRESIDING OFFICER. The motion is entered.
  Mr. REID. Mr. President, we have something that is long overdue. We 
have an agreement to take care of this. Nelson Mandela will soon be 90 
years old, in a matter of days. The old organization he was a member of 
decades ago--and he is probably still a member, but I am not too sure--
the African National Congress is still treated as a terrorist 
organization. This takes care of that. We will eliminate that. So the 
people coming here from that great country, which has done so well for 
so long now, will be able to come in without being considered 
terrorists.

                          ____________________