[Congressional Record Volume 154, Number 112 (Wednesday, July 9, 2008)]
[Senate]
[Pages S6476-S6490]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




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

  Mr. REID. What is the matter now before the Senate?
  The PRESIDING OFFICER. Under the previous order, the motion to 
proceed to the motion previously entered to reconsider the vote whereby 
cloture on the motion to proceed to H.R. 6331 was not agreed to, is 
agreed to and the time until 4 p.m. will be evenly divided before the 
cloture vote.
  Mr. REID. I ask unanimous consent that there be 1 hour prior to the 
vote, which is now set for 4 o'clock, that the time be divided, with 
the last 20 minutes for Senator McConnell and Senator Reid of Nevada; 
that I have the last 10 minutes; that the other 40 minutes be equally 
divided and controlled between the chairman of the Finance Committee, 
Senator Baucus, and the ranking member of the committee, Senator 
Grassley.
  That means there will be 20 minutes for Senator McConnell and me, and 
there will be 40 minutes remaining, equally divided.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Who yields time?
  Mr. BAUCUS. Madam President, may I inquire, what is the pending 
business before the Senate?
  The PRESIDING OFFICER. On reconsideration of cloture on the motion to 
proceed to H.R. 6331.
  Mr. BAUCUS. Madam President, the Prophet Isaiah urged:

     Cease to do evil,
     learn to do good;
     seek justice,
     correct oppression;
     defend the fatherless,
     plead for the widow.

  Since 1965, Medicare has been about defending the disabled. Medicare 
has been about providing for the elderly. From its beginning, Medicare 
has been about doing good. Before Medicare, old age was very much about 
widows.
  In 1960, a man could expect to live a little more than 66 years, 
whereas a woman could expect to live past 73. Now, with the help of 
Medicare providing health care for the elderly, men can expect to live 
beyond 75 and women can expect to live beyond 80.
  Before Medicare, in 1959, more than 35 percent of the elderly lived 
in poverty. When President Johnson signed the Medicare Act into law, he 
said of the elderly:

       Most of them have low incomes. Most of them are threatened 
     by illness and medical expenses that they cannot afford.

  Thus, before Medicare, the elderly received poorer health care. They 
endured more pain. They met early death. But then, 43 years later, in 
July 1965, with my fellow Montanan Mike Mansfield looking on, President 
Johnson signed the Medicare Program into law. This chart to my left 
shows the picture of that day.
  That day President Johnson said:

       No longer will older Americans be denied the healing 
     miracle of modern medicine. No longer will illness crush and 
     destroy the savings they have so carefully put away over a 
     lifetime so they might enjoy dignity in their later years. No 
     longer will young families see their own hopes eaten away 
     simply because they are carrying out their deep moral 
     obligations to their parents.

  Further quoting President Johnson:

       And no longer will this Nation refuse the hand of justice 
     to those who have given a lifetime of service and wisdom and 
     labor to the progress of this country.

  Thus, from its beginning, Medicare has been a moral issue. Medicare 
has been about doing good, about doing what is right. I come to the 
floor today to speak in defense of Medicare. I come to plead for the 
widow. I come to fight for the disabled.
  Today Medicare is threatened. Health care costs have been growing 
rapidly. Federal Reserve Chairman Bernanke told the Finance Committee's 
health care summit:

       Health care has long been and continues to be one of the 
     fastest growing sectors in the economy. Over the past 4 
     decades, this sector has grown, on average, at a rate of 
     about 2.5 percentage points faster than the gross domestic 
     product.

  But the fruits of the 1997 law threaten to cut--yes, cut--payments to 
doctors who treat Medicare beneficiaries unless we act. If we do not 
act, the law will force cuts in payments to doctors by 10.6 percent. We 
have to stop that cut.
  That cut threatens access to care for America's seniors. Already some 
providers are declining Medicare patients. My colleagues hear that 
constantly. Fewer and fewer doctors are taking Medicare; more and more 
are dropping. Why? Because reimbursement rates are already too low, and 
unless we act today, those reimbursement rates will be much lower.
  Doctors know about these cuts. My colleagues in their home States 
hear this constantly. I am sure, over the July 4 break, they heard over 
and over that the doctors are very concerned about Medicare 
reimbursement. The share of doctors accepting new Medicare patients has 
been falling. It is falling for those who accept and do not accept 
Medicare. It is falling for those military personnel in TRICARE who 
seek services from doctors as well because TRICARE payments are tied to 
Medicare.
  Unless we act, those patients in the TRICARE system, our military 
service men and women, will also find that their doctors are not 
treating them either. That trend will accelerate if we do not act. An 
American Medical Association survey found if the scheduled cuts stay in 
effect, 60 percent of doctors will have to limit the number of new 
Medicare patients whom they treat; 60 percent would have to limit, 
unless we restore these cuts.
  These cuts also threaten access to health care for our military men 
and woman. As I mentioned, TRICARE uses the Medicare formula to pay 
their doctors. Those cuts could endanger health care for military 
retirees and even for those on Active Duty.
  I do not think that is well understood, that TRICARE is tied to 
Medicare. If we cut Medicare, we cut TRICARE. That means about 9 
million American service men and women, Active Duty and retirees, the 
doctors who service them will no longer provide that service; a 60-
percent reduction.
  The Military Officers Association of America reports that declining 
participation of providers due to low reimbursements is already one of 
the most serious health care problems facing military families.
  Real and threatened cuts in the level of Medicare reimbursements have 
caused many providers to stop accepting new TRICARE patients.
  Since 1965, there have been those few who did not think that Medicare 
was good. There have been those who have sought to call it evil. In the 
1960s, there were those on the fringe who called it socialized 
medicine. In 1995, there were those who said it was going to wither on 
the vine, those who wanted to do away with Medicare. But the truth is, 
from the start Medicare has had broad,

[[Page S6477]]

very broad, bipartisan, very bipartisan, support. The original Medicare 
Act passed the House of Representatives with a vote of 307 to 16. It 
passed the Senate by a vote of 70 to 24. That broad support was evident 
again on June 24 of this year before the break. That day the House of 
Representatives passed the Medicare Improvements for Patients and 
Providers Act. That bill would stop those cuts in doctors' payments. 
The House passed that bill with an overwhelming vote of 355 to 59; 355 
House Members voted for it. That is better than a 6-to-1 margin. Even 
among Republican Members of the House, more than twice as many voted 
for it than against it.
  On June 26, the Senate fell one vote short of invoking cloture on the 
motion to proceed to that bill. But today the Senate will reconsider 
that vote, and we should. The Senate should take up and pass this 
Medicare bill. The Senate should pass this Medicare bill because there 
is no alternative. If we fail to enact this bill, millions of America's 
seniors will be worse off. We cannot let that happen. This bill can 
prevent that. The House-passed bill is very similar to the Baucus-Snowe 
bill the Senate considered earlier in June, but the House made three 
noteworthy changes. First the House-passed bill includes legislation to 
delay the competitive acquisition program for durable medical 
equipment. Congress needs to ensure that these savings do not harm 
beneficiary access to care. We need to take a closer look at 
competitive bidding before it goes forward. Passage of this Medicare 
bill would allow that. The House-passed bill also does not include cuts 
in funding for oxygen supplies and equipment, and it does not include 
cuts in funding for powered wheelchairs. Those who support these 
reforms make a good case. But ultimately, the cuts could not be 
included as part of this must-pass legislation.
  This bill is a balanced package. It is a compromise. It makes modest 
changes. When the House passed its children's health bill last year, 
the House made major changes to the Medicare Advantage Program. Last 
year's House CHIP bill would have significantly restructured the 
program. This House Medicare bill, however, would not do that. This 
bill includes a reduction in the double payment for medical education 
costs to private plans in Medicare, and this bill would protect seniors 
from unscrupulous marketing practices by private health plans. This 
bill would require so-called private fee-for-service plans to form 
provider networks. It would make sure that there are doctors behind 
those plans. Currently, those private fee-for-service plans do not have 
to do that. By fiat, they deem it to be the case. But it is not 
accurate. This bill would make sure there will be doctors behind those 
plans.
  This bill does not include deep cuts due to the Medicare Advantage 
Program. Some suggest it does. It does not at all. It does not cut 
private fee-for-service plan payments at all. I wish to go further on 
Medicare Advantage. I think we should do more. But this is not the 
time, and this is not the legislation on which to do so. This, however, 
is the time to avert the pending cut in payments to doctors. That 
payment cut would devastate access to care for America's seniors. We 
cannot let that happen.
  For Medicare beneficiaries, this Medicare bill would expand access to 
services. We all talk about greater access to preventive services. It 
would eliminate the discriminatory copayment rates for seniors with 
mental illnesses. We all talk about that. We want mental health parity. 
We do it in this Medicare legislation. And it will provide additional 
needed help for low-income seniors. We all talk about that need too.
  This Medicare bill would take important steps to shore up our health 
care system in rural areas. It includes provisions from the Craig 
Thomas Rural Hospital and Provider Equity Act. Let's do this for Craig 
Thomas.
  This bill also includes important relief for ambulance providers, 
community health centers, and primary care physicians. Primary care 
doctors represent the backbone of our health system. We all hear from 
home that primary care doctors are especially vulnerable and we give 
additional help to them. This Medicare bill would make important 
improvements in pharmacy payments. It would make payments under the 
Part D drug benefit fairer and more timely to those who dispense drugs 
to our Nation's senior citizens. We have all heard that pharmacists 
need this help because they are in a disadvantageous position in 
dispensing Part D drugs.
  This bill would save money by providing a single bundled payment for 
all the services related to treating end-stage renal disease, and that 
will help reduce costs. For the first time, dialysis facilities would 
receive a permanent, market-based update to their payments each year, 
giving them a little bit of predictability. This would ensure that 
Medicare payments keep up with costs.
  The bill would expand emergency health care for veterans in rural 
areas. It would increase payments for doctors who work in rural areas. 
It would stop the payment cut to providers. It would give them a decent 
increase in reimbursement. All of this would help to ensure that 
seniors and military families would be able to keep seeing the doctors 
they need to see.
  On July 30, 1965, President Truman watched President Johnson sign the 
Medicare Act. That is what is shown in this photograph to my left. 
President Truman at that point said:

       Mr. President, I am glad to have lived this long and to 
     witness today the signing of the Medicare bill, which puts 
     this Nation right where it needs to be, to be right.

  Yes, from its beginning, Medicare has been a moral issue. Medicare 
has been about doing good. So let us defend the elderly. Let us defend 
the disabled. Let us provide for our military families, and let us 
enact this important Medicare bill.
  I know others are waiting to speak on the other side of the aisle. In 
a moment I will yield the floor, but before doing so, I yield half of 
the time remaining under my control to Senator Schumer and half of the 
time to Senator Durbin for their use when they are recognized.
  The PRESIDING OFFICER. Duly noted.
  Who yields time? The Senator from Utah.
  Mr. HATCH. Madam President, I rise to oppose cloture on the motion to 
proceed to H.R. 6331, the Medicare Improvements for Patients and 
Providers Act.
  I am beginning to feel like the character from the movie ``Groundhog 
Day'' who wakes up every morning to the same day. Here we are again, 
having the same debate about the same Medicare bill that will not be 
signed into law.
  I believe that our time would be better spent working on a bill to 
restore physician payments instead of having a partisan vote just to 
make some political points. It would be better to work in a bipartisan 
way. We could do it in 10 minutes, if we just sit down and do it. I 
know the distinguished chairman and ranking member could do it.
  But it is obvious that some in this body would rather have a 
political battle and put Medicare beneficiaries and their doctors at 
risk.
  In the last month, I stood on the Senate floor, not once, but twice 
emphasizing that I want to work on a bipartisan Medicare bill that will 
be signed into law. In fact, we had a bipartisan agreement in the 
Senate.
  Unfortunately, Senate Democrats are still not permitting a vote on a 
compromise measure or even the Republican alternative.
  The bipartisan compromise bill would have passed overwhelmingly, and 
this issue would be behind us.
  And, quite frankly, H.R. 6331, essentially, the Baucus Medicare bill, 
contains many provisions that both sides strongly support.
  It is troubling that only the Democrat Medicare bill is being given a 
vote on the Senate floor, especially when there is a Republican 
alternative that restores physician payments as well, especially since 
I believe Senators Baucus and Grassley would have worked it out long 
before now without all the hoopla and politicization.
  In addition, when the Democrat Medicare bill failed to get cloture a 
few weeks ago, the minority leader asked for unanimous consent to pass 
a 31 day extension of the December Medicare law. The purpose of this 
extension was to prevent the Medicare physician cuts from going into 
effect until we were able to work out our differences.
  But Senator Reid objected to this unanimous consent request for 
political reasons and told the Senate that

[[Page S6478]]

he wanted the Republicans who voted against cloture to feel the heat 
when they went home for the Fourth of July recess. I was a little 
shocked at that.
  Fortunately, the Centers for Medicare and Medicaid Services, CMS, is 
delaying the Medicare reduction for physicians for 10 business days to 
give us more time. Unfortunately, we do not agree on one key issue--the 
Medicare Advantage Program. This program was created in the Medicare 
Modernization Act of 2003. I was on the conference committee and spent 
months working on Medicare Advantage.
  Today, Medicare Advantage provides beneficiaries with many health 
care choices in addition to traditional Medicare.
  Medicare Advantage plans are very similar to private health plans 
offered to those under 65 years of age. One out of five people in 
Medicare are on Medicare Advantage, and they love the program.
  The Democrat Medicare bill includes reforms to the Medicare Advantage 
Program that are unacceptable to both the White House and many of us 
who support the Medicare Advantage Program.
  Those of us who support Medicare Advantage feel that the provision in 
the Democrat Medicare bill will limit plan choices currently offered to 
beneficiaries.
  Beneficiaries participating in the Medicare Advantage Program are 
happy with their health care coverage.
  Every month, I receive hundreds of letters from my constituents 
telling me how much they like their Medicare Advantage plans.
  Medicare Advantage is working across the country.
  On the other hand, the Medicare+Choice program, which was the 
precursor to the Medicare Advantage Program, did not work very well, 
especially in rural areas.
  That was because the Federal Government did not pay plans enough 
money to operate in rural areas.
  The Utah Medicare+Choice plans left our State because plans could not 
function and they were losing money.
  At that point, Utah Medicare beneficiaries only had one choice--
traditional Medicare. And once we start disassembling the Medicare 
Advantage Program, as some in this body want to do, I believe that 
health care choices for beneficiaries will diminish. Through the 
Medicare Modernization Act, we finally figured out how to provide 
choice to Medicare beneficiaries in both rural and urban areas and how 
to pay plans appropriately.
  But my friends on the other side cannot leave a good thing alone and 
insist on making changes to a program that works well today and that 90 
percent of beneficiaries in Medicare Advantage are satisfied with.
  The Democrat Medicare bill, if signed into law, will no longer allow 
private fee-for-service plans to deem.
  Deeming allows beneficiaries in private fee-for-service plans to see 
any Medicare provider.
  Deeming has been important to those living in rural areas where it is 
difficult for network-based plans to persuade providers to contract 
with them. It is also helpful to employer groups which provide retiree 
health coverage to those living in rural areas across the country.
  The elimination of deeming could take away health care coverage 
choices for Medicare beneficiaries living in rural States.
  In addition, the elimination of deeming could cause some retirees to 
lose their health benefits because the retirement plan cannot establish 
networks in all 50 States.
  According to America's Health Insurance Plans, known as AHIP, 21,000 
Utah beneficiaries may be dropped from their current Medicare Advantage 
private fee-for-service plans if the provision to eliminate deeming 
becomes law.
  In fact, AHIP believes that 1.7 million seniors across the country 
could lose their existing health coverage if H.R. 6331 becomes law.
  A few weeks ago, I mentioned that one Utah employer has said that the 
elimination of deeming will force the company to stop offering health 
care coverage to almost 12,000 retirees, and that is probably the tip 
of the iceberg.
  I fear that the impact of this provision could be devastating, 
especially to beneficiaries living in rural States.
  We truly do not know the full effect of this policy and how it will 
affect Medicare beneficiaries across the country.
  Therefore, I simply cannot support this policy and it is the main 
reason that I am going to vote against cloture.
  Do not be fooled--the bill we are considering today will not be 
signed into law.
  The President has said he will veto the bill and there will not be 
enough votes to override his veto. I suppose some on the other side 
think they have a great political advantage if he vetoes the bill and 
we can't override it. They can use that against Republicans.
  This motion must be defeated for the third time. We should not have 
had to go to three votes.
  Hopefully, my colleagues on the other side of the aisle will want to 
work with us on a bill that can be signed into law because it would be 
bipartisan.
  We must move forward so Medicare beneficiaries will no longer worry 
about their doctors dropping out of the Medicare Program.
  We must move forward so physicians participating in the Medicare 
Program will not be cut by 10.6 percent. I don't think anybody in this 
body believes that we will allow that cut to occur; certainly, I will 
not.
  We must move forward because the American people are getting tired of 
a do-nothing Congress where Members are not able to work out their 
differences.
  Why don't we put all our differences aside? We could solve this in 10 
minutes without making it a political fiasco which is what it has 
become. I think in the end everybody would be better off. Certainly, 
seniors who are on Medicare Advantage would continue to be better off 
than they would be if this very partisan bill passes through this body 
and is vetoed by the President and that veto is sustained.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Illinois.
  Mr. DURBIN. How much time remains on the Democratic side?
  The PRESIDING OFFICER. There is 7 minutes.
  Mr. DURBIN. I yield myself 3\1/2\ minutes and reserve 3\1/2\ minutes 
for the Senator from New York, Mr. Schumer.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. DURBIN. Madam President, this debate is about an important bill 
for 40 million Americans. It is about Medicare. It is about whether the 
doctors who provide benefits under Medicare will have a 10.3 percent 
cut in their reimbursement. Those of us who are for Medicare don't want 
to see that happen. It means fewer doctors treating senior citizens. It 
means fewer doctors who will be part of the program. So we are trying 
to stop this cut from happening. But we are running into resistance 
from the Republican side of the aisle.
  The bill before us is a bipartisan bill that passed the House of 
Representatives by a margin of 6 to 1. Two-thirds of the Republicans in 
the House voted for this measure. It is a very bipartisan approach. But 
unfortunately, on the other side of the aisle, the Republicans are 
determined to oppose this bill.
  Why? Why would they want to see fewer senior citizens with doctors 
they need under Medicare? Why would they want to see fewer doctors in 
the program? Because the way we pay for the doctors' compensation is by 
cutting back on the private health insurance companies currently trying 
to offer Medicare benefits. Now, why would we do that? Because, 
unfortunately, they are overcharging the Government--from 12 to 17 
percent more than what the Medicare Program is charging for the same 
services. We believe they can cut back on their profits, they can 
reduce their costs, and they can still help seniors.
  Remember when we started with private health insurance companies? The 
Republicans said: We want them to be able to play in Medicare. They can 
do a much better job than the Government. They will cut the costs 
dramatically. They will bring it down to 95 percent of what the 
Government charges. Exactly the opposite has occurred. The private 
health insurance companies have increased their costs over the years, 
and the Republicans who oppose this bill want to protect those 
companies. They do not want to see those private health insurance 
companies take

[[Page S6479]]

a hit, get a reduction in the amount of money paid by the Government. 
So they continue to refuse to vote for this measure to help Medicare 
physicians.
  The last time we had this vote, we had 59 Senators who voted for it. 
What do we need today at 4:05 to strengthen Medicare? We need one more 
Republican vote, one more Republican Senator. Madam President, 9 of the 
49 voted with us last time. With 10, we have the 60 votes, and Medicare 
will have a bright future.
  For those who argue, well, President Bush just might not like the 
bill, I am sorry, but this bipartisan bill which passed overwhelmingly 
in the House should pass overwhelmingly in the Senate, and we should 
say to President Bush: It is much more important for us to protect 40 
million seniors under Medicare and, incidentally, about 9 million 
military families under TRICARE from these kinds of cuts in physician 
reimbursement.
  I have listened to the debate on the other side of the aisle, and it 
really comes down to a difference of philosophy. When Medicare was 
created, the Republicans, by and large, opposed it: Oh, it is a big 
Government program. It is socialized medicine. What did Medicare do for 
America? It gave peace of mind to seniors that the next illness would 
not wipe out all their savings. It gave them access to the best doctors 
and the best hospitals.
  Do you know what? Seniors are living longer today than when they 
signed that Medicare bill into law in 1965. That is the proof of its 
success. But many on the Republican side of the aisle have never 
accepted it. They always want to go to the private health insurance 
companies, even when it costs too much for the seniors and for our 
Government.
  This is our chance. One more Republican vote means the Medicare 
Program will be strong for years to come.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Texas.
  Mr. CORNYN. Madam President, how much time remains on this side?
  The PRESIDING OFFICER. There is 12 minutes 20 seconds.
  Mr. CORNYN. Madam President, will you tell me when 5 minutes is 
consumed?
  The PRESIDING OFFICER. I would be happy to.
  Mr. CORNYN. Madam President, Congress should be embarrassed to have 
doctors and seniors come hat in hand every 6 months, every 12 months, 
every 18 months, and say: Please don't cut reimbursement rates for 
physicians. It is just a terrible way to do business. It puts people in 
fear that Congress will not act. It also provides opportunities for 
political gamesmanship that we have seen in an abundance on this 
particular temporary patch.
  The fact is, Congress has only on one previous occasion allowed these 
cuts to go into effect, in 2002. Every year since it has acted. The 
fact is, we will. But what we need is a permanent solution, not a 
temporary patch. This is a terrible way to do business. The fact is, 
Medicare is a deeply troubled program. In fact, it will go bankrupt--
parts of it--by the year 2019. But Congress is just whistling past the 
graveyard--whistling past the graveyard.
  We need a permanent solution to this broken Medicare system. The fact 
is, many Medicare beneficiaries, many seniors cannot even find a doctor 
who will accept new Medicare patients because reimbursement rates are 
below market in many parts of the country. The fact is, the majority 
leader, by objecting to a 30-day extension of current law to allow a 
bipartisan compromise between the chairman and ranking member of the 
Finance Committee, is doing nothing but playing partisan politics with 
something that should be above partisan politics. We need a permanent 
solution.


                   Unanimous Consent Request--S. 2729

  That is why, Madam President, I ask unanimous consent that the 
Committee on Finance be discharged from further consideration of S. 
2729, the Ensuring the Future Physician Workforce Act, and that the 
Senate proceed to its immediate consideration; that the bill be read a 
third time and passed, the motion to reconsider be laid on the table, 
and that any statements relating to the measure be printed in the 
Record.
  The PRESIDING OFFICER. Is there objection?
  Mr. BAUCUS. Madam President, reserving the right to object, I have 
looked at the Senator's bill, and I must say that any objective 
observer would know that this is not a serious effort. It is a big warm 
kiss on doctors to show to them that they love doctors when, in fact, 
this is going nowhere. It is a $380 billion bill unpaid for. It is not 
a serious effort whatsoever. I regret the Senator from Texas has the 
audacity to bring this up.
  I object.
  The PRESIDING OFFICER. Objection is heard.
  Mr. CORNYN. Madam President, I take exception to the chairman of the 
Finance Committee's insulting remarks. I would say to him that on this 
bill I have worked in consultation with the Texas Medical Association, 
which has endorsed it heartily, and what people should be insulted by 
are these temporary patches every 6 months that do nothing to solve the 
problem, that provide a political football for the majority party to 
play to try to take advantage in the next election, to put seniors in 
doubt as to our seriousness at keeping our commitment for Medicare.
  I think it is the chairman of the Finance Committee and the majority 
leader who should be embarrassed by their objection to sensible and 
good-faith efforts to try to fix on a permanent basis this broken 
system. I regret Congress, once again--no wonder the U.S. Congress has 
a single-digit approval rating, with only 9 percent of the country 
believing it is doing a good or excellent job.
  It is no secret that people are absolutely disgusted with the 
partisan politics that do not permit real solutions to serious 
problems, such as fixing Medicare once and for all, and particularly 
this part that is broken, the payment reimbursement system.
  So I take very grave exception to the remarks of the chairman of the 
Finance Committee. It is he who is not serious about solving the 
problem. It is he who insists on partisan gamesmanship rather than real 
solutions. And I think it is a very sad day for the Senate.
  Mr. DODD. Madam President, I rise in support of this legislation and 
want to thank the senior Senator from Montana for his leadership and 
commitment to ensuring a strong Medicare Program.
  Medicare is one of the twin pillars of the retirement security 
compact we have with our seniors. It says that after a lifetime of hard 
work and paying taxes, seniors deserve the dignity of a secure 
retirement. That includes quality, accessible health care. At a time of 
skyrocketing health care and prescription drug costs, this bill 
strengthens our commitment to our seniors by eliminating the scheduled 
10.6 percent fee cut for Medicare physicians while providing a 1.1-
percent update in payments. Why is that so important, Mr. President? 
Because it directly impacts how we care for seniors. Because doctors 
are already facing this payment cut because we were prevented from 
acting on this legislation before recess. Because my State of 
Connecticut could be looking at a loss of $190 million over the next 18 
months--funds that would otherwise help pay for the care of elderly and 
disabled patients. Nearly a half million seniors in my State alone 
would be affected. And because military families will also benefit from 
this bill because they rely on TRICARE which ties its payments to 
Medicare. Indeed, absent this action, we could be putting at risk 
health care for not only military retirees but even for those on Active 
Duty. For all they have given to this country, we absolutely cannot let 
that happen. More than 50,000 TRICARE patients in Connecticut alone are 
depending on us.
  There are other components of this bill I strongly support as well. 
Included among the $4 billion in improvements for Medicare 
beneficiaries is assistance for low-income seniors, who need this 
assistance the most. This legislation also protects access to therapy 
services, reduces out-of-pocket costs for beneficiaries who seek mental 
health care, and provides important improvements for our Nation's 
pharmacies and rural providers.
  Ultimately, this legislation sends a message to our seniors and those 
who serve our country--it says that a promise made will be a promise 
kept. With this bill, we are keeping our word to

[[Page S6480]]

these men and women that there is no higher priority than ensuring our 
seniors and military families receive the quality health care they 
deserve.
  Lastly, it is particularly appropriate that we move to deepen our 
commitment to Medicare on the day one of its biggest champions returns 
to the Senate. Throughout our history, there has been no greater 
advocate for our seniors and for health care than Senator Kennedy. He 
is a friend to me, but more importantly he is a friend to every 
American who struggles to receive the affordable, quality health care 
they deserve, and we are thrilled to welcome him back.
  Again, I want to thank Chairman Baucus as well as the majority leader 
for their leadership and dedication.
  Mr. LEVIN. Madam President, the Medicare Improvements for Patients 
and Providers Act, H.R. 6331, makes a number of needed changes related 
to Medicare reimbursement, including reimbursement for physicians' 
services. Due to the unwise filibuster by the minority, we missed our 
chance to pass this legislation before July 1, when reimbursement cuts 
were scheduled to take place. We now have another opportunity to do the 
right thing. I strongly urge the Senate to pass this legislation 
promptly.
  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. If they do not, some physicians will 
not continue to provide services to Medicare beneficiaries. As a 
result, allowing reimbursement cuts to go into effect could pose 
significant access problems for many Medicare beneficiaries.
  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 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. Until and unless we discover a way to 
contain health care costs to inflation, we should decouple Medicare 
reimbursement for physicians' services from the performance of the 
overall economy. Reimbursement should more accurately represent the 
cost of providing services.
  In the meantime, we need to pass this legislation, which includes, 
among other important provisions, an 18 month delay on Medicare 
reimbursement cuts for physicians' services and replaces the cut with a 
1.1 percent increase in 2009. I am hopeful that the minority will end 
their filibuster, 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 are implemented and cause 
many Medicare beneficiaries to lose access to health care providers.
  Mr. SPECTER. Madam President, this Medicare legislation is very 
important. I believe that it is vital for the Senate to take up this 
important measure to have open debate to give Senators an opportunity 
to offer amendments and to have the Senate work its will on these 
important questions.
  As noted in previous floor statements, I have been concerned about 
Majority Leader Reid's practice of employing a procedure known as 
filling the tree, which precludes Senators from offering amendments. 
This undercuts the basic tradition of the Senate to allow Senators to 
offer amendments. Regrettably, this has been a practice developed in 
the Senate by majority leaders on both sides of the aisle, so both 
Republicans and Democrats are to blame.
  On June 12, 2008, I voted in favor of cloture on the motion to 
proceed on S. 3101, legislation similar to H.R. 6331, the Medicare 
Improvements for Patients and Providers Act, to prevent the reduction 
in Medicare payments to physicians. At that time, I was assured by 
Majority Leader Reid that he would not make a procedural motion to fill 
the tree. Following the failure to obtain cloture on the motion to 
proceed to S. 3101, Finance Chairman Baucus and Ranking Member Grassley 
began to negotiate a bipartisan bill that could be brought before the 
Senate. I have concerns with some provisions that may have been 
contained in such an agreement. However, the prospect of the Senate 
working its will and allowing other Senators and me to offer amendments 
to such a bill is more favorable than filling the amendment tree.
  On June 26, 2008, the majority leader brought up H.R. 6331. The 
posture of the Senate was such that for the majority leader to complete 
action on H.R. 6331 and send it to the President before the physician 
payment reduction was scheduled to go into effect at the end of June, 
the Senate must pass the same legislation the House of Representatives 
passed. This is the case because the House of Representatives adjourned 
for the Independence Day recess prior to the Senate vote on cloture on 
the motion to proceed to H.R. 6331. Since the House went out of 
session, there was no possibility for the House to consider a Senate-
amended Medicare bill. To guarantee that the same Medicare legislation 
would be passed by the Senate, no amendments to the legislation were 
permitted. By bringing this legislation up at the last minute after the 
House of Representatives adjourned, the majority leader prevented the 
opportunity to offer amendments and undermined Senate procedure.
  If cloture were to have been obtained on the motion to proceed to 
H.R. 6331 the legislation would have been vetoed by President Bush. 
That veto would have resulted in a further delay, since the House would 
not be in session to override the veto and the scheduled physician 
payment reductions would go into effect at the end of June. There was 
an expectation that the Senate would extend the current physician 
payment rate for 30 days and prevent the pending reduction from going 
into effect. However, when this legislative extension was offered by 
Senate Republican Leader McConnell it was objected to by Majority 
Leader Reid. The majority leader was aware of this issue for some time 
and scheduling should have accommodated the amendment process. I voted 
against cloture because there was no opportunity to amend the 
legislation that came before the Senate.
  On June 28, 2008, I wrote to President Bush requesting that he use 
his constitutional authority to call the Congress back into session so 
that the Senate could act on H.R. 6331 with appropriate amendments and 
send it back to the House for its concurrence. This would have allowed 
for prompt action on this important matter and prevented the payment 
reduction from going into effect.
  On Monday, Tuesday and Wednesday of this week, I spoke with Majority 
Leader Reid regarding today's vote on cloture on the motion to proceed 
to H.R. 6331. During those conversations I requested that he allow 
Senators to offer amendments to the legislation. On those occasions he 
said he would not allow amendments. During the vote, when more than 60 
Senators had voted for cloture, it was not possible to preserve the 
principle of Senators' rights to offer amendments so I voted for 
cloture because I agreed with the objectives of this legislation.
  I have a strong history of preventing reduced payments to physicians. 
In April 2003, as Chairman of the Labor, Health and Human Services, and 
Education Appropriations Subcommittee; I worked to reverse a 4.4 
percent cut in physician fees which had gone into effect in January of 
that year. This $54 billion effort also provided a 1.6 percent 
increase. In June 2003, I introduced an amendment to the Medicare 
Modernization Act to provide an increase in physician payments for 2 
years. This provision was agreed to and was included in the bill. This 
prevented decreases in physician payments in 2004 and 2005, and 
increased payments by 1.5 percent in each of those years. I have 
consistently voted in favor of increasing Medicare physician payments 
and will continue to support the policy, but Senators must be allowed 
to offer amendments and let the Senate work its will.

[[Page S6481]]

  Mrs. FEINSTEIN. Madam President, I rise to discuss the Medicare 
Improvements for Patients and Providers Act, H.R. 6331. This bill makes 
much needed changes to the Medicare program, and will pay doctors at a 
rate that will allow them to continue to participate in this vital 
program.
  Medicare is a great success story, providing retirees with a health 
care safety net, but the formula that determines physicians' payment 
levels is seriously flawed. Unless Congress takes action immediately, 
doctors will receive a 10.6 percent cut in their reimbursements.
  The consequences of such cuts would be dire. According to the 
California Medical Association, more than 60 percent of California 
physicians say they would be forced to either stop taking new Medicare 
patients or leave the Medicare program altogether if these reductions 
occur.
  The same payment rate reductions will apply for health care provided 
to our servicemembers and their families who receive coverage through 
the TRICARE program. Over 870,000 Californians and at least 8.9 million 
Americans depend on TRICARE for their health care. We owe these 
families, who have sacrificed so much for our country, access to 
physicians and medical care when they need it.
  I voted to consider and pass this bill, because we need to block 
these cuts and make improvements for beneficiaries.
  However, much to my dismay, this bill contains a delay on a program 
to competitively bid for durable medical equipment. Can you believe it? 
A block on competitive bidding of commonly available medical goods.
  Let me tell you what this means. Medicare began a competitive bidding 
program for durable medical equipment on July 1 in 10 metropolitan 
areas across the country--including the Riverside-San Bernardino area 
in my home State of California.
  The program enabled medical supply companies to bid on 10 products, 
including wheelchairs, diabetic supplies, oxygen concentrators, walkers 
and hospital beds, in those 10 metropolitan areas. Companies that 
offered the best prices were awarded contracts to supply Medicare 
beneficiaries with medical equipment.
  As a result, seniors on Medicare in these areas can expect to pay a 
lot less for some of their medical supplies.
  In Riverside, CA, diabetic test strips, once $37 will now be $18, and 
portable oxygen, which cost Riverside Medicare patients $77 per month, 
can now be bought for $61.
  The bid prices are an average of 26 percent lower than prices set by 
the Centers for Medicare and Medicaid before the enactment of the 
competitive bidding program.
  Because beneficiaries pay copayments equal to 20 percent of the cost 
of their healthcare and medical equipment, that savings is also felt by 
the elderly and disabled Americans who rely on Medicare.
  Competitive bidding makes sense, because there is no good reason why 
Medicare or seniors should pay above-market prices for medical 
equipment--especially as other health care costs continue to skyrocket.
  The Centers for Medicare and Medicaid discovered that it was paying 
$1,825 for a hospital bed that can be bought for $754 online. On the 
Internet, you can purchase a power wheelchair for $2,174--far less than 
the $4,023 Medicare pays out for the same product. z
  Competitive bidding forces Medicare suppliers to compete for their 
customers--much like retailers do. It also helps to control costs while 
providing the elderly and the disabled with quality healthcare and 
medical supplies. Participating companies must be accredited, to ensure 
that Medicare beneficiaries receive high quality equipment and service.
  Allowed to continue, the program is expected to save $125 million in 
its first year. Expanded nationwide, that number would grow to $1 
billion in savings for taxpayers and Medicare beneficiaries.
  But just as this pilot program gets off the ground--another 70 
metropolitan areas are expected to be added in 2009--this bill 
endangers the program's future.
  Losing bidders have complained that the selection process was flawed 
and have convinced some of my colleagues to support a delay of the 
program for another 18 months and start the selection process over.
  The bill before us today would terminate the existing competitively-
bid contracts and delay the program launch for a year and a half.
  This should not be permitted to happen. Seniors and taxpayers deserve 
to pay fair prices for their medical equipment. Medicare beneficiaries 
in Riverside, in Cleveland, in Dallas, learned about this new program, 
selected new providers, and are already saving money. Stopping this new 
effort midstream will only lead to confusion.
  We all agree that entitlement programs like Medicare need to be 
reformed, but if we can't change a small portion of this sprawling 
entitlement program, how will we ever succeed in making major reforms?
  Competitive bidding is a smart way to ensure that Medicare pays 
reasonable rates for medical equipment at a time when medical costs are 
soaring. We should not ask taxpayers to fund someone else's cash cow.
  While I will vote to consider and pass this bill today, I will 
continue to work to see that competitive bidding moves forward, and I 
urge my colleagues do the same. This is a matter of common sense.
  Mrs. CLINTON. Madam President, today we are voting on a piece of 
legislation that has the potential to make a real difference for 
seniors, Americans with disabilities, physicians, hospitals, and 
pharmacies. We are voting to ensure that doctors who care for the 44 
million people in Medicare and the millions of people who rely on 
TRICARE, the military health care system, do not see a sudden and 
dramatic cut in reimbursements. And we are voting to implement a series 
of reforms to improve our capacity to provide preventive care, to use 
more health information technology in our medical system, and to 
measure the quality of care patients receive.
  We hear a lot of talk about our broken health care system in this 
Chamber--and on the campaign trail--by Members on both sides of the 
aisle. However, all too often, there have been some all too willing to 
lament the crisis until it comes time to address it. But the fact is, 
all that matters--to seniors, to people with disabilities, to our men 
and women in uniform--is whether we deliver on the rhetoric. That is 
our test in this Chamber. And that is our test with this vote.
  The choice is simple. How will we address the crisis in our health 
care system, as costs skyrocket, coverage declines, and quality 
suffers? Do we continue in this race to the bottom--or do we choose a 
new course?
  I believe we must take immediate steps to modernize and reform our 
health care system to control costs, increase coverage, and improve 
care. The goal--as I have proposed, advocated, and championed my whole 
adult life--is quality, affordable health care for everyone, no 
exceptions, no excuses. And we all look forward to the return of our 
friend, Senator Kennedy, one of America's great health care champions, 
to help us reach this goal.
  The solution will not be to cut corners while cutting funding that 
will drive more and more people and providers out of the health care 
system. The solution has not been and will never be to stick our heads 
in the sand to avoid the tough work of dragging our system of care into 
the 21st century.
  The solution is tougher--and more complex--but no less real: 
comprehensive reform to provide coverage for every American that 
emphasizes prevention, measurable improvements in quality, and a 
modernized system to dramatically improve efficiency and reduce errors. 
And we will achieve it by asking everyone to be part of this solution: 
patients, providers, insurance companies, employers, and, yes, the 
government.
  That is why I hope more of my Republican colleagues will join the 
growing bipartisan majority in the House and Senate to support this 
legislation and end this Medicare blockade--an obstruction that 
survived by a single vote--which stands between patients and their 
physicians, and between this chamber and demonstrable progress in 
Medicare.
  Here is why this legislation is so critical. First, unless we act, 
the 10.6 percent cut in payment to physicians will

[[Page S6482]]

compromise care for seniors, Americans with disabilities and--though 
this is largely unknown--men and women who have served in our Nation's 
military. TRICARE sets its physician reimbursement rates according to 
Medicare. So a 10.6-percent cut in Medicare is a 10.6-percent cut in 
TRICARE.
  The consequences may be catastrophic. A recent survey by the American 
Medical Association found that 60 percent of physicians would limit new 
Medicare patients if this cut is allowed. Almost 9 million people who 
have served in the military would face the prospect of newly limited 
access to medical care, including more than 180,000 in New York.
  The answer is not haphazard cuts and temporary formula fixes. The 
answer is a comprehensive, permanent solution which reflects the costs 
of doing business for providers--as well as the goals we all share for 
fixing the incentives in the health care system and controlling costs 
by improving care--not limiting it.
  And preventing this cut is only the beginning. I am proud that we 
have included a number of important reforms I have championed that will 
help us chart a new course for Medicare and our health care system: We 
have included a provision to cover new preventive care recommended by 
the U.S. Preventive Services Task Force, a proposal for which I have 
advocated and which I believe should be part of our solution to achieve 
health care for everyone. Coverage for screenings for osteoporosis, 
breast cancer, or high blood pressure, for example, will help detect 
illness at the earliest stages, before becoming life-threatening and 
more costly.
  I am proud that we have taken an important step in health information 
technology, requiring electronic prescribing by 2011. That will reduce 
errors dramatically. If all hospitals used a computerized order entry 
system we would reduce adverse drug reactions by an estimated 200,000 
each year and save $1 billion annually. Health information technology, 
which I have proposed and hope to pass through the Senate soon, will 
allow us to make giant leaps in our health care system to cut errors, 
improve care, and discover new treatments--while protecting patient 
privacy and safety and dramatically reducing costs.
  The bill also extends the Medicare Physician Quality Reporting 
Initiative and provides for the endorsement of quality measures, as I 
have long championed. In fact, the first bipartisan health IT 
legislation I introduced with Senator Bill Frist in 2005 included this 
idea and it remains in the legislation that I have cosponsored with 
Chairman Kennedy, Senator Enzi, and Senator Hatch. Linking quality with 
coverage is essential. Today, we don't know what we don't know. With 
new data we can find new ways to treat illnesses and new ways to 
improve the care we provide.
  We have previously failed by one vote. One vote between improving 
care or undermining it. One vote that can make the difference between 
solving problems in our health care system or making matters worse. 
This is not about politics. This is about the real people whose health 
and lives will be affected by our votes today. This is about the far 
reaching consequences of our decision in this Chamber.
  I have met people across New York and our country who cannot find the 
medical care--or afford the health care--they need.
  Mothers who whisper to me in tears, terrified that their children 
will get sick because they lost their insurance. Nurses who feel like 
each day is a deluge, as patient loads rise. Doctors forced to see more 
and more patients--with less and less time to do their jobs and more 
and more paperwork piling up. Seniors with multiple chronic illnesses 
who have trouble juggling the recommendations and medications from 
multiple health care providers.
  And hospitals like A.O. Fox Memorial Hospital in Oneonta, NY, which 
stands to lose hundreds of thousands of dollars it cannot afford to 
lose. Or Bassett Healthcare in Cooperstown, NY, that stands to lose 
about a million dollars.
  These are local hospitals struggling to provide care as that care is 
assaulted on all sides: rising costs, declining reimbursements, more 
uninsured patients walking through the emergency room doors. It would 
be a disgrace if these hospitals looked to us for solutions--and found 
that with these cuts, we were part of the problem.
  These are the stakes and this is our test. I am grateful to my 
colleagues who have labored on this legislation and I urge my 
Republican colleagues to join us. And I will continue to do all I can 
to be champion for the people across New York and the country who feel 
like they do not have a voice, who look to us, who are counting on us, 
who depend upon us. I will always stand with them--and I urge my 
colleagues to stand with us.
  Mr. AKAKA. Madam President, we must enact the Medicare Improvements 
for Patients and Providers Act of 2008. This legislation is vital to 
ensuring that Medicare and TRICARE beneficiaries have continued access 
to health care. The bill will also enhance Medicare benefits. In 
addition, the legislation will provide additional support for Hawaii 
hospitals that care for the uninsured and Medicaid beneficiaries.
  I hope that my colleagues who previously opposed this legislation had 
an opportunity to meet with their physicians, beneficiaries, and 
military families during the recess. If so, I hope my colleagues now 
understand how tremendously important it is to seniors, individuals 
with disabilities, and members of our armed services and their families 
that this legislation be enacted to protect their access to health 
care.
  The act will maintain Medicare physician payment rates for 2008 and 
provide a slight increase in 2009. If this legislation again fails to 
pass, doctors will be subject to a 10.6 percent cut in Medicare 
reimbursements for the rest of the year. This dramatic cut could 
severely limit access to health care for our troops and their families 
because TRICARE reimbursement rates are linked to Medicare 
reimbursement rates. Rising costs and difficulty in recruiting and 
retaining qualified health professionals make it essential that we 
improve reimbursements to ensure that Medicare and TRICARE 
beneficiaries have access to health care services.
  The act will enhance Medicare benefits. It increases coverage for 
preventive health care services and makes mental health care more 
affordable. In addition, the act provides additional help for low-
income seniors to obtain the health care services that they need.
  Finally, the legislation will provide much needed relief for Hawaii 
hospitals. The legislation will extend Medicaid Disproportionate Share, 
DSH, allotments for Hawaii until December 31, 2009.
  Hawaii hospitals are struggling to meet the increasing demands placed 
on them by a growing number of uninsured patients and rising costs. 
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 FY 
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.
  The Medicare Prescription Drug, Improvement, and Modernization Act of 
2003 made additional changes to the DSH program. This included an 
increase in DSH allotments for low DSH States. Again, States lacking 
allotments were 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 provided an 
additional $7.5 million for a Hawaii DSH allotment.
  This additional extension in the Medicare Improvements for Patients 
and Providers Act of 2008 authorizes

[[Page S6483]]

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. This act will provide $15 million for Hawaii 
DSH allotments through December 31, 2009.
  These DSH resources will strengthen the ability of our providers to 
meet the increasing health care needs of our communities. All States 
need to benefit from the DSH program. This legislation will make sure 
that Hawaii and Tennessee continue to have Medicaid DSH assistance.
  I will continue to work with Chairman Baucus, Ranking Member 
Grassley, Senators Alexander, Corker and Inouye to permanently restore 
allotments for Hawaii and Tennessee. However, we need to enact this 
legislation to continue to help our struggling hospitals.
  We must enact this legislation. It will protect access to health care 
for seniors, individuals with disabilities, and members of our armed 
services and their families. The bill will improve Medicare benefits 
and provide much needed financial assistance for hospitals in Hawaii 
that care for the uninsured and Medicaid beneficiaries.
  Mr. CARDIN. Madam President, our vote today on H.R. 6331 carries real 
and immediate consequences for people who depend on Medicare. Action on 
this legislation is mandatory now because, 8 days ago, the temporary 
fix we passed at the end of last year expired. The cuts are in effect.
  Next Tuesday, when the Centers for Medicare and Medicaid Services 
begins paying claims for services rendered after June 30, 2008, 
payments will be cut unless we pass this measure.
  Because I return home every evening to my State, I interact 
frequently with Maryland providers. They cannot sustain a nearly 11-
percent cut in their Medicare payments; they and many of their 
colleagues will stop accepting new Medicare patients unless we pass 
this bill.
  The pending cuts are the result of a flawed system that pegs provider 
reimbursement to the growth of the Nation's GDP. It was created by the 
1997 Balanced Budget Act as a way to rein in dramatic growth in 
Medicare spending on physician services. But this system, known as SGR, 
has not worked as intended. In fact, every year since 2001, Congress 
has had to act to prevent the cuts from going into effect. We know that 
the SGR formula must be repealed.
  I have introduced legislation in past years to eliminate SGR and 
replace it with a system that reimburses based on the actual reasonable 
costs of providing care. The bill that was passed overwhelmingly by the 
House, H.R. 6331, provides another temporary fix through December 31, 
2009. That is sufficient time for the next Congress, working with a new 
administration and the provider community, to develop a new mechanism.
  But although ``doctor fix'' is the shorthand often used, this bill is 
far more than that, and our failure to pass it has repercussions far 
beyond physician offices. Another provision that expired on June 30 is 
the exceptions process for outpatient rehabilitation services. The 1997 
Balanced Budget Act imposed dollar limits of $1,500 on Part B therapy 
services--one cap for physical and speech-language therapy, and another 
for occupational therapy. They are adjusted annually for inflation and 
are now at $1,810. I was a member of the Ways and Means Health 
Subcommittee at the time. Congress held no hearings on this issue to 
examine how the caps might affect patient care. The authors of the 
provision had no policy justification for imposing them, and the dollar 
amount was arbitrary. These caps were imposed for purely budgetary 
reasons. They were a crude budget-cutting measure designed to deliver 
savings--$1.7 billion over 5 years.
  This misguided policy ignored clinical needs and it restricted care 
for the most frail patients--such as those who are recovering from 
stroke or hip fracture, and those with multiple injuries in a given 
year.
  And because the dollar limits are not adjusted for cost variations 
across the country, seniors in high cost areas reach their caps even 
sooner.
  The University of Maryland's Shock Trauma Center was the first such 
unit in the Nation. It is a world-renowned leader in caring for 
critically injured patients. They see patients with extensive 
fractures, severe burns, spinal cord and brain injuries, and other 
debilitating conditions. These patients require lengthy therapy 
sessions to restore basic functioning. They cannot be rehabilitated for 
$1,810 a year.
  The therapy caps actually went into effect once before, on January 1, 
1999, and they had serious consequences for beneficiaries. By April, 
many patients in skilled nursing facilities had exceeded the limits and 
were unable to receive necessary care. The administration recognized 
the danger of this provision, stating:

       The limits will reduce the amount of therapy services paid 
     for by Medicare. The patients most affected are likely to be 
     those with diagnoses such as stroke and amputation, where the 
     number of therapy visits needed by a patient may exceed those 
     that can be reimbursed by Medicare under the statutory 
     limits.

  That year, I joined the now-junior Senator from Nevada, John Ensign, 
to introduce a bill to repeal the caps. We had significant bipartisan 
support and at the end of 1999, Congress delayed implementation for 2 
years. Since that time, Congress has acted several times to prevent the 
caps from taking effect.
  In 2006, Congress created an exceptions process that would allow 
beneficiaries needing care above the statutory caps to receive those 
services. It was the right thing to do. This process has worked well. 
Medicare is saving money and patients are getting needed care. In 
February, the Centers for Medicare and Medicaid Services released a 
study concluding that:

       The exception process that allows beneficiaries who need 
     therapy to get that therapy, even if the cost goes beyond the 
     cap, has worked to control cost growth. This study reveals 
     that from Calendar Year 2004 through 2006, although the total 
     number of therapy users continued to increase by 3.5 percent 
     the overall expenditures actually decreased by 4.7 percent.
       This suggests that the exceptions process in CY 2006 may 
     have satisfied to some extent the Congressional intent to 
     assure access to medically necessary services while 
     controlling the growth in expenditures.

  The CMS study shows that the exceptions process works to control 
costs, yet still assures access for the more than 4.4 million 
beneficiaries who need additional care. The exceptions process allowed 
them to get the therapy they need to recover, function optimally, and 
live more productive lives. It allowed them to learn to cook, clean, 
and care for themselves after a stroke, to walk correctly and strongly 
after a hip replacement, and to speak and communicate after cancer 
surgery. But as of Tuesday, July 1, the process has expired. Section 
141 of the bill we are voting on today continues the exceptions process 
through December 31, 2009.
  This provision takes up just two lines of the bill. It is a small 
provision, but it has a major impact on seniors.
  The story of Steve Kinsey and his patients illustrates why we must 
pass this bill without further delay.
  Steve operates Hereford Physical Therapy in Baltimore County. He is 
anxious to know what the Senate will do this afternoon and so are the 
seniors he cares for. Steve's practice has about 9,500 patient visits 
each year, and one-fifth of them are covered by Medicare. He told me 
about two patients who are waiting for the Senate to act.
  The first is a 72-year-old gentleman. He is a wheelchair-bound 
quadriplegic who needs physical therapy to keep up his strength. He 
qualified through the exceptions process, and so, although he exceeded 
the $1,810 cap in March, he has been able to receive therapy 2 days 
every other week to maintain his level of function.
  The second patient is an 83-year-old woman who had a total knee 
replacement earlier this year. She received 20 visits and was under the 
cap, until a few weeks later when she fell and fractured her hip.
  The cost of her care exceeded the cap 6 weeks ago, but after 
qualifying through the exceptions process, she has been able to 
continue treatment.

[[Page S6484]]

  Because of the actions of a few Senators, as of Tuesday, July 1, 
these two Medicare beneficiaries can no longer receive care.
  On July 1, CMS told providers: (1), that the exceptions process 
expired on June 30, 2008; (2), not to submit any claims with the code 
for exceptions because they will be automatically rejected; (3), that 
providers can check a CMS Web site to determine the amount of services 
their patients have received so far this year; and; (4), that patients 
who have reached the caps can go to an outpatient hospital department 
for care or pay out-of-pocket.
  Because the exceptions process was in place for the first 6 months of 
this year, patients who have already gone beyond the cap--the patients 
most in need of care--must stop therapy or pay for it themselves. The 
average charge is about $80 for a 45-minute session. This is wrong.
  If we do not reinstate the exceptions process as the bill before us 
would do, these individuals who need more care will be harmed. They 
received appropriate therapy under appropriate rules, but that does not 
matter: On July 1, they were effectively cut off from services that 8 
days ago they were deemed eligible for. This is unfair and it is 
harmful.
  Let's not forget that therapy services are also paid under the 
Medicare fee schedule, so the 10.6 percent cut will also apply to these 
services as well.
  Now, as CMS stated, there is a last resort--to go to the outpatient 
department of a hospital for additional care. But Steve has learned 
that the two hospitals near his practice--GBMC and St. Joseph's--are 
turning away new patients because they don't have the capacity to see 
them.
  Because of the shortage of therapists in Maryland and in other 
States, hospitals are already overloaded. So, Steve has 10 patients who 
are waiting at home for him to call and say they can come back in for 
therapy. They have no where else to go for treatment unless they pay 
out-of-pocket. They can't afford that.
  Outpatient therapy services are paid under Medicare Part B. The 
people waiting for Steve's call are seniors who worked hard to qualify 
for Part A coverage and who are paying premiums for Part B. Working 
Americans--taxpayers--who do not yet qualify for Medicare, are paying 
to subsidize Part B premiums. The American people as a whole, not only 
providers and beneficiaries, should be outraged that a minority of the 
Senate is preventing us from moving forward on this legislation.
  The 43 million seniors and persons with disabilities who rely on 
Medicare deserve a program that meets their health care needs. Our goal 
should be to ensure that Medicare provides comprehensive, affordable, 
quality care.
  The bill also includes important beneficiary improvements. In 1997, I 
worked in a bipartisan way to add to the Balanced Budget Act the first-
ever package of preventive benefits to the traditional Medicare 
Program. That was 11 years ago. At that time, the members of the Ways 
and Means Committee recognized what medical professionals had long 
known--that prevention saves lives and reduces overall health care 
costs.
  Preventive services such as mammograms and colonoscopies are vital 
tools in the fight against serious disease. The earlier that breast and 
colon cancer are detected, the greater the odds of survival. For 
example, when caught in the first stages, the 5-year survival rate for 
breast cancer is 98 percent. But if the cancer has spread, the survival 
rate drops to 26 percent. If colon cancer is detected in its first 
stage, the survival rate is 90 percent, but only 10 percent if found 
when it is most advanced.
  Seniors are at particular risk for cancer. In fact, the single 
greatest risk factor for colorectal cancer is being over the age of 
50--when more than 90 percent of cases are diagnosed.
  Sixty percent of all new cancer diagnoses and 70 percent of all 
cancer-related deaths are in the 65 and older population. Cancer is the 
leading cause of death among Americans aged 60 to 79 and the second 
leading cause of death for those over age 80. So preventing cancer is 
essential to achieving improved health outcomes for seniors. Screenings 
are crucial in this fight.
  In addition to improving survival rates, early detection can reduce 
Medicare's costs. Under Chairman Conrad's leadership on the Budget 
Committee, we have had fruitful debates about the long-term solvency of 
Medicare. A more aggressive focus on prevention will help produce a 
healthier Medicare Program.
  Medicare will pay on average $300 for a colonoscopy, but if the 
patient is diagnosed after the colon cancer has metastasized, the costs 
of I care can exceed $58,000.
  There is no question that these vital screenings can produce better 
and more cost-effective health care.
  The 1997 law established place improved coverage for breast cancer 
screenings, examinations for cervical, prostate, and colorectal cancer, 
diabetes self-management training services and supplies, and bone mass 
measurement for osteoporosis. Since then, Congress has added screening 
for glaucoma, cardiovascular screening blood tests, ultrasound 
screening for aortic aneurysm, flu shots, and medical nutrition therapy 
services. In addition, in 2003, a Welcome to Medicare Physical 
examination was added as a one-time benefit for new Medicare enrollees 
available during the first 6 months of eligibility.
  But we can only save lives and money if seniors actually use these 
benefits. Unfortunately, the participation rate for the Welcome to 
Medicare physical and some of the screenings is very low. I have spoken 
with primary care physicians across my State of Maryland about this. 
One problem is the requirement to satisfy the annual deductible and co 
pays for these services.
  Most colonoscopies are done in hospital outpatient departments, where 
their copay is 25 percent or approximately $85. Our seniors have the 
highest out-of-pocket costs of any age group and they will forgo these 
services if cost is a barrier.
  The other barrier to participation is the limited 6-month eligibility 
period for the one-time physical examination. By the time most seniors 
become aware of the benefit, the eligibility period has expired. In 
many other cases, it can take more than 6 months to schedule an 
appointment for the physical exam and by that time, the patients are no 
longer eligible for coverage.
  I have introduced legislation to eliminate the copays and deductibles 
for preventive services and to extend the eligibility for the Welcome 
to Medicare physical from 6 months to 1 year. My bill would also 
eliminate the time consuming and inefficient requirement that Congress 
pass legislation each time a new screening is determined to be 
effective in detecting and preventing disease in the Medicare 
population.
  It would empower the Secretary of Health and Human Services to add 
``additional preventive services'' to the list of covered services. 
They must meet a three part test: (1) they must be reasonable and 
necessary for the prevention or early detection of an illness; (2) they 
must be recommended by the U.S. preventive Services Task Force, and (3) 
they must be appropriate for the Medicare beneficiary population.
  H.R. 6331 incorporates several elements of my bill in the very first 
section. It will waive the deductible for the physical examination, 
extend the eligibility period from 6 months to 1 year, and allow the 
Secretary to expand the list of covered benefits.
  This bill will also help low income seniors by raising asset test 
thresholds in the Medicare savings programs and targeting assistance to 
the seniors who most need it. It extends and improves assistance 
programs for seniors with incomes below $14,040 a year, including the 
QI program, which pays Part B premiums for low-income seniors who don't 
qualify for Medicaid.
  As this Congress continues to make progress toward passing a 
comprehensive mental health parity bill, this bill provides mental 
health parity for Medicare beneficiaries, moving their copayments from 
50 percent to 20 percent gradually over 6 years. Depression, bipolar 
disorder, and other mental illnesses are prevalent among seniors, and 
yet fewer than half receive the treatment they need. This provision 
will help them get that treatment.
  It will also ensure that a category of drugs called 
``benzodiazepines'' are covered by Medicare Part D. When Part D took 
effect on January 1, 2006, millions

[[Page S6485]]

of beneficiaries found that the medicines they took were not covered by 
the new law. A little-known provision in the bill actually excluded 
from coverage an entire class of drugs called benzodiazepines. These 
are anti-anxiety medicines used to manage several conditions, including 
acute anxiety, seizures, and muscle spasms. The category includes 
Xanax, Valium, and Ativan. Most are available as generics.
  The current-law exclusion has led to health complications for 
beneficiaries, unnecessary complexity for pharmacists, and additional 
red tape for the States. Beneficiaries who are not eligible for 
Medicaid have had to shoulder the entire cost of these drugs or 
substitute other less effective drugs. In 2005, I first introduced 
legislation that would add benzodiazepines to the categories of 
prescription drugs covered by Medicare Part D and Medicare Advantage 
plans.
  This provision is essential for our seniors; without it, dual 
eligibles would have to rely on continued Medicaid coverage for 
benzodiazepines. Medicare beneficiaries who are not eligible for 
Medicaid will have to continue to pay out-of-pocket for them. For those 
who cannot afford the expense, their doctors would have to use 
alternative medicines that may be less effective, more toxic, and more 
addictive. This is a significant improvement for our seniors who are 
enrolled in Part D and for the fiscal health of our States.
  This bill will also help our community pharmacies. I have heard from 
pharmacies throughout Maryland who cannot receive prompt reimbursement 
from private plans. This bill requires plans to pay them within 14 days 
of receiving a clean claim. It also requires plans to update their 
price lists weekly so that pharmacies have accurate data about what 
they should be reimbursed.
  H.R. 6331 is paid for by small reforms to the Medicare Advantage 
program, in particular to private fee-for-service plans. The 
nonpartisan Medicare Payment Advisory Commission, MedPAC, has 
recommended that we equalize payments between Medicare Advantage and 
traditional Medicare.
  As we discuss the solvency of the Medicare Program, we must take note 
that private health plans are not saving the Federal Government money. 
In fact, they are costing us money. I was a member of the Ways and 
Means Committee when health plans approached us with an offer.
  If the Federal Government would pay them 95 percent of what we were 
spending on the traditional Medicare Program, they would create 
efficiencies through managed care--efficiencies that they said were 
lacking in traditional Medicare--that would save the Federal Government 
billions of dollars each year. They promised to provide enhanced 
coverage, meaning extra benefits as well as all the services covered by 
traditional Medicare, for 95 percent of the cost of fee for service. 
Congress gave them a chance to do just that.
  Instead, what we saw across the country was cherry-picking of 
younger, healthier seniors. Each time Congress indicated that it would 
roll back their overpayments to a more reasonable level, they responded 
by pulling out of markets. In Maryland, the number of plans declined 
over a 3-year period from eight to one, abandoning thousands of 
seniors. Since 2003, when payments were substantially increased, the 
number of plans has steadily increased as well, but at too high a cost 
to beneficiaries, taxpayers, and the future of the Medicare Program.
  Right now, these plans are paid up to 19 percent more than the amount 
that we would pay if these seniors were in fee-for-service Medicare. 
Over 10 years, we are overpaying them by more than $150 billion.
  That is enough money to fund significant valuable improvements in the 
overall Medicare Program, or to permanently repeal the sustainable 
growth rate formula. It is time, for the health of the Medicare 
Program, to pay these plans appropriately. This bill would make small 
adjustments to these overpayments as well as prohibit the abusive 
marketing practices, such as cold calling, door-to-door sales, and 
offering incentives such as free meals, which have led to many seniors 
being enrolled in private plans without their knowledge or consent.
  Mr. President, this is a balanced and responsible bill that addresses 
immediate reimbursement concerns while setting the foundation for a 
higher quality, more cost-effective Medicare Program.
  The time to act is now. With the support of just one more Senator, we 
can pass an urgently needed bill and restore the promise of improved 
access, adequate reimbursement, low-income assistance, and additional 
needed benefits to the seniors who depend on Medicare. I urge my 
colleagues to support this legislation,


                       Medical Home Demonstration

  Mr. BINGAMAN. I rise today in support of legislation that will avert 
a 10.6 percent reduction in payments to providers who care for our 
Nation's Medicare beneficiaries. It is critical that we pass this 
legislation today in order to ensure that seniors, who rely on 
Medicare, will continue to have access to high quality health care.
  I also wanted to take this opportunity to engage briefly in a 
colloquy with Senators Harkin, Murkowski, and Collins about a provision 
in this bill relating to an expansion of the medical home 
demonstration.
  This bill contains a provision that gives the Secretary of Health and 
Human Services discretion to expand the Medicare medical home 
demonstration initially enacted as part of the Tax Relief and Health 
Care Act of 2006. I am troubled that the current demonstration does not 
permit nurse practitioners and other non-physician providers to lead 
medical home demonstrations. I believe Congress must include these 
providers in the demonstration.
  In my home State of New Mexico, nurse practitioners have been able to 
practice independently and with full prescriptive authority since 1993. 
This recognition of their ability to function as independent primary 
care providers has allowed them to provide care for the most needy of 
our citizens. New Mexico is a very rural State. In some parts of my 
State, nurse practitioners are the only primary care providers 
available. They already serve as medical home providers for many of our 
citizens and without them many families would have no health care at 
all.
  A June 2008 MedPAC report on primary care includes a discussion of 
the value of medical home demonstrations, stating ``Medical practices 
led by physicians, nurse practitioners, and physician assistants are a 
logical place to turn for these services, particularly practices with 
strong nursing and other dedicated staff support . . .'' In that 
report, MedPAC recommended seven requirements for a primary care 
provider wishing to lead a medical home demonstration. The provider 
must: furnish primary care, including coordinating appropriate 
preventive, maintenance, and acute health services; conduct care 
management; use health information technology for active clinical 
decision support; have a formal quality improvement program; maintain 
24-hour patient communication and rapid access; keep up-to-date records 
of beneficiaries' advance directives; and maintain a written 
understanding with each beneficiary designating the provider as a 
medical home.
  I firmly believe that nurse practitioners, or other non-physician 
providers meeting these standards should be able to lead a medical home 
demonstration. Furthermore, nurse practitioners epitomize the delivery 
of high quality, cost-effective primary care that is crucial to the 
medical homes model.
  At a time when primary care providers are so greatly needed, the 
exclusion of more than 700 nurse practitioners in New Mexico--and more 
than 137,000 nurse practitioners across this country runs counter to 
the need for more qualified primary care providers.
  Mr. HARKIN. I want to thank my distinguished colleague for raising 
this issue, which is also a great concern of mine. I am also pleased to 
support the legislation pending before the Senate today, which will 
ensure that Iowa's seniors continue to have access to their health care 
professionals. Iowa, like New Mexico, is a rural State where 
approximately 1,300 nurse practitioners provide critical access to care 
in Iowa's underserved areas. As you know, rural America has a higher 
proportion of elderly Americans than nonrural areas. In addition, 
Medicare providers face several unique challenges in rural America that 
make ensuring access to health care even more difficult. As part

[[Page S6486]]

of our expansion of the Secretary's authority, I would encourage the 
Secretary to allow nurse practitioners to fully participate and lead 
medical home demonstrations.
  Approximately 90 percent of nurse practitioners in rural areas do 
primary care. Approximately one-third of nurse practitioners have 
practices where more than 50 percent of patients would be classified as 
``vulnerable populations''.
  This year, Iowa's State legislature passed legislation to use the 
medical home model to reduce disparities in health care access, 
delivery and health care outcomes and, ultimately, allow each Iowan to 
have access to health care. This legislation includes nurse 
practitioners as medical home leaders who are responsible for providing 
for appropriate patient care, coordinating specialty care and 
guaranteeing a quality of care based in evidence, and fully coordinated 
with patient and family.
  Ms. MURKOWSKI. I want to thank my colleagues for engaging in this 
colloquy and raising this issue, which is also of importance to my home 
State of Alaska. Like New Mexico and Iowa, Alaska is a rural State 
where approximately 600 nurse practitioners provide critical access to 
care in Alaska underserved areas. As a matter of fact some areas of 
Alaska are so rural and isolated they are primarily served by providers 
who use airplanes as their mode of transportation. Among these 
providers are nurse practitioners, who often are the most accessible 
providers in certain areas in Alaska.
  Alaska has one of the highest numbers of nurse practitioners per 
capita of any other State. Nurse practitioners function as partners in 
the healthcare of their patients, so that, in addition to clinical 
services, nurse practitioners focus on health promotion, disease 
prevention and health education and counseling, guiding patients to 
make smarter health and lifestyle choices.
  NPs provide healthcare to people of all ages, all over the State of 
Alaska, in diverse healthcare settings such as private offices, 
community clinics, hospitals, long-term care facilities, schools, and 
health departments, and about 40 percent of nurse practitioners in 
Alaska practice in rural settings, outside the major cities in Alaska, 
and an estimated 25 percent practice in medically underserved areas of 
Alaska.
  For these reasons and to allow Alaskans the easiest access to a 
provider in the medical home demonstration, I would encourage the 
Secretary to allow nurse practitioners to fully participate and lead 
medical home demonstrations.
  Ms. COLLINS. Madam President, I rise in strong support of the 
outstanding work of our Nation's nurse practitioners--most especially 
the 850 or so nurse practitioners in Maine who have practiced 
independently since the mid-1990s. Nurse practitioners in Maine are 
credentialed as participating providers and serve as primary care 
providers in managed care organizations in my State.
  Similar to my colleagues from New Mexico, Iowa and Alaska, a large 
percentage of Mainers live in rural areas. As such, residents are often 
a considerable distance from health care facilities and may be hindered 
from getting care because of transportation and other obstacles. Nurse 
practitioners fill the void for high quality primary health care in our 
underserved areas.
  We need to encourage medical home demonstrations that allow nurse 
practitioners to fully participate in these models.
  Mr. BINGAMAN. I thank my fellow Senators for joining me to discuss 
this important issue.
  The PRESIDING OFFICER. Who yields time?
  Mr. GRASSLEY. Madam President, I will yield 3 minutes to the Senator 
from Oklahoma.
  The PRESIDING OFFICER. The Senator from Oklahoma is recognized for 3 
minutes.
  Mr. COBURN. Madam President, as a practicing physician in the Senate, 
I remember the last time a Medicare fix came through and we had the 
problems associated with it. I would make four points about what is 
going on here.
  No. 1, if this bill goes through, 2.3 million senior citizens who are 
on Medicare Advantage will lose Medicare Advantage. Madam President, 
2.3 million will lose. Not only will that happen, but also all Medicare 
patients will pay $200 million more per year in copays for durable 
medical equipment. So we have a bill that is supposedly going to do the 
doctor fix, but under the sleight of hand in the dark of night we are 
going to raise the fees on Medicare patients by $200 million for 
durable medical equipment, and we are going to tell 2.3 million 
Medicare patients who are very pleased with the program they have now 
that they cannot have that anymore.
  We have two choices in health care in this country. We can let the 
Government run it all--which this is a step toward moving toward that--
or we can allow the ingenuity and creativity of this country through a 
market-based phenomenon--which is what Medicare Advantage is going to--
to create an allocation of scarce resources on the basis of quality, 
great outcome, and patient choice. There is very limited patient choice 
now because doctors do not want to take Medicare patients because the 
reimbursements are so low. Well, guess where they will take it. Where 
the reimbursements are higher because their costs are going like this, 
and their reimbursements are going down.
  So remember this: If, in fact, you vote for this bill, 2.3 million 
Medicare patients on Medicare Advantage will lose that coverage, and 
$200 million in additional copays will fall to all Medicare patients 
across the board in terms of their copay for durable medical equipment.
  We can fix this problem. We ought to fix it right. This is not the 
way to fix it.
  I yield back.
  The PRESIDING OFFICER. Who yields time?
  The Senator from New York.
  Mr. SCHUMER. Madam President, are we in a quorum call?
  The PRESIDING OFFICER. No, we are not.
  Mr. SCHUMER. Madam President, I rise in strong support of this 
legislation vitally needed from one end of the country to the other. 
Ask doctors who will face a significant cut, ask pharmacists who are 
going bankrupt because they are not being paid appropriately, and ask, 
most of all, our Medicare patients who will not have the ability to 
visit doctor after doctor after doctor.
  This legislation is essential, and it is compromise legislation. The 
other side says ``compromise''? Sixty percent of the cuts come from 
medical education--something near and dear to me and my State. Only 40 
percent comes from fee for service. Yet they say: Compromise. Do you 
know what compromise is to the other side, those opposed here? They 
want it all. All the money should come out of IME, none out of fee for 
service, or they will not budge.
  Who is hurt when they play this political game? Millions of senior 
citizens. I would prefer to have all the money come out of fee for 
service. So would Chairman Rangel. So would many others from States 
such as mine that have medical education. But we are willing to go part 
of the way for the seniors.
  I say to my colleagues on the other side of the aisle: Substantively 
and politically, this is among the worst votes that you will take if 
you oppose this legislation; among the very worst both substantively 
because it hurts our seniors and cripples Medicare, and politically 
because people really care about this. I have never seen organizations 
such as the AMA, the pharmacists, and the AARP in unison.
  So I would urge at least one of my colleagues from across the aisle 
to reconsider for the sake of those who work so hard in the health care 
field and, most of all, for the sake of our senior citizens.
  This bill is essential to keep things going in Medicare. I know there 
may be some who want to get rid of Medicare, but most of us want to 
fight to preserve it. If you care about Medicare, if you care about 
seniors, if you care about fair pay for pharmacists and doctors, the 
only vote is yes.
  I yield the floor.
  Mr. McCONNELL. Madam President, how much time remains on this side?
  The PRESIDING OFFICER. There is 4\1/2\ minutes left of the initial 
time that was designated for the chair and ranking member of the 
Finance Committee. Then there is 20 minutes of time divided between the 
minority leader and

[[Page S6487]]

the majority leader following that time.
  Mr. McCONNELL. All right. Madam President, I ask unanimous consent 
that the Senator from Florida have 4 minutes of my time that is 
remaining.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The Senator from Florida.
  Mr. MARTINEZ. Madam President, this is indeed an important debate we 
are having about a very important issue to many in my State of Florida. 
There is no doubt that my State has a large population of people who 
depend on Medicare for their health care. This is an important matter 
to them.
  We also have, of course, the doctors who deliver health care who also 
have a concern, a great concern, about a potential cut at a time when 
everything else in their lives is rising--an unfair cut. The fact is, 
we know doctors are tremendously stressed today because of many issues 
in their practice. The fact is that hard-working doctors do not deserve 
a pay cut. I know whoever created this condition years ago was well-
intentioned, but it has not worked and it does not work. Doctors should 
not be expected to come before the Congress hat in hand each and every 
year or 18 months to ask for yet another extension or a deferral of a 
pay cut. The next cut in pay, which would come 18 months from when we 
do the right thing and move beyond the politics and get something done, 
will be a 20-percent cut--unsustainable.

  I would say the real answer for the long term is to fix Medicare and 
to fix the doctors' pay problem. Unfortunately, we have not been able 
to come to an agreement. I daresay I don't believe we will today 
either. So I believe the real answer to the issue is to extend the 
program temporarily. We have not done so in the past, even though it 
has been requested. I wonder why.
  The fact is that to date, the Congress has passed 28 temporary 
extensions for programs where agreement has yet to be reached so these 
programs can continue without interruption during the time those 
differences are ironed out. These extensions are commonplace, as 
demonstrated by the 28 temporary extensions during this Congress alone. 
In fact, at the time the majority objected to the first request for a 
short-term extension, Medicare payment rates were already operating 
under a 10-month temporary extension from last December.
  So I would say it is time for us to stop the political ``gotcha'' 
games and allow the doctors to be assured that they will not be 
suffering a pay cut while we get to a bipartisan agreement because it 
is important that this be a bipartisan effort and that we come at it in 
a bipartisan way with ideas from both sides of the aisle. We can do 
that. While that takes place, I believe the only way to proceed would 
be for there to be a 30-day extension that can allow uninterrupted 
payments to continue. The differences can be worked out, as they always 
are in this environment, although not always on a timely basis, and 
then we can move forward.


                       Unanimous Consent Request

  At this time, I ask unanimous consent that if cloture is not invoked 
on the motion to proceed to the House-passed bill, the Senate proceed 
to the immediate consideration of a Senate bill which I will send to 
the desk, and it is clean, a 1-month extension of the Medicare payments 
bill. I further ask unanimous consent that there be 15 minutes of 
debate equally divided and that following the use or yielding back of 
time, the bill be read a third time and the Senate proceed to a vote on 
passage without any intervening action or debate.
  Mr. REID. Madam President, reserving the right to object, in the 10 
minutes I have before the vote, I will address in some detail why this 
is such a fallacious idea, and I object.
  The PRESIDING OFFICER. Objection is heard.
  Mr. McCONNELL. Madam President, the issue before us is the physician 
payment update, and on that point we don't disagree at all. Everyone 
agrees we should prevent the cut and preserve seniors' access to care 
under the Medicare Program.
  Republicans have been flexible on finding a solution. When it was 
clear that the Senate wouldn't move to the last partisan bill that was 
proposed, I asked my friends on the other side to work with us on a 
bipartisan compromise with Senator Grassley and Senator Baucus. Both 
have a long history on finding workable compromises on very tough 
issues. If that wasn't possible, we proposed an 18-month extension of 
current law. Then we proposed a 1-month extension. There is no good 
reason patients and physicians should suffer while Congress works out 
its disagreements. The majority objected to all of these proposals out 
of hand. They weren't interested. They even rejected the opportunity to 
have a single amendment on the bill--no amendments.
  So now, rather than resolving the problem in a way that is acceptable 
to everyone and in a form the President will sign, we are no closer to 
a solution for seniors and their doctors than we were 2 weeks ago. 
Rather than passing a short-term safety net bill while we get a good, 
bipartisan bill to protect 2 million seniors from losing their private 
Medicare Advantage plans, the majority chose an all-or-nothing 
approach.
  It seems to me that if we can't resolve policy issues today, we 
should at least agree to a short-term extension of existing law, which 
my good friend from Florida just offered, including a bipartisan 
proposal to delay competitive bidding that is identical to a provision 
in the House bill that the other side has already voted for.
  So let's sum it up. The Democrats don't want a bipartisan compromise. 
They don't want a long-term extension of current law. They don't want a 
short-term extension of current law. Yet they are not to blame for this 
Medicare cut going into effect? We know how to prevent this cut from 
going into effect, but we can't stop it. We can't protect the doctors, 
and we can't protect access of choice for seniors if the Democrats 
won't let us.
  How much time remains on this side?
  The PRESIDING OFFICER. There is 8 minutes 14 seconds remaining.
  The Senator from Iowa.
  Mr. GRASSLEY. Madam President, I wish to review some facts.
  At the end of last year, we agreed to a short-term Medicare extension 
so that we could complete work on a bipartisan Medicare package this 
year that would fill out the 2 years that we previously had planned to 
do it. We were very close to a deal then and needed time to finish that 
work, so that is why we did the short-term extension. Both sides agreed 
that we would work quickly to get a bill that could be signed into law. 
Unfortunately, that effort has been intentionally derailed by the 
majority's desire to play politics with Medicare.
  The fact is that the majority has twice walked away from good-faith, 
bipartisan negotiations. The fact is that we had been working for 
months before the rug was pulled. The fact is that we had actually 
completed that bipartisan deal 2 weeks ago yesterday, about 11 o'clock 
in the morning. It was a deal that would be signed into law--in other 
words, not be vetoed by the President of the United States. But the 
other side thought they saw a political advantage, and they have taken 
that into consideration. So they scuttled the deal in favor of a bill 
that would, in fact, be vetoed by the President of the United States, 
and that is where we are again right now. Now they have spent the last 
2 weeks engaged in an effort to scare seniors and providers, and the 
worst thing yet is that it has been aided and abetted by the American 
Medical Association.
  The bill is riddled with problems and missed opportunities. First and 
foremost, the bill we are going to be voting on would do serious harm 
to Medicare drug benefits on which millions of seniors have come to 
depend. It would tie the hands of Medicare Part D plans, resulting in 
higher drug prices and higher premiums for seniors.
  Let me quote from a communication I received today from the Medicare 
Office of the Actuary. Their conclusion is that it would ``very likely 
result in additional Federal spending for the Part D program.'' Also, 
outside analysts have likewise concluded that this provision has the 
potential to undermine the long-term financial sustainability of the 
Medicare drug benefit.
  This provision, which is tucked away in a seemingly harmless 
provision intended to clarify what classes of drugs might be protected 
under Part D, is a perfect example of why we work best in this body 
when we work together and

[[Page S6488]]

when we do it in a bipartisan way. When we work together, we catch 
these little landmines tucked away in House-passed bills that could do 
real harm to a program seniors rely on for their drug coverage.
  Instead of writing a bipartisan bill, the majority twice walked away 
from the table, and now we are in a position of ``take it or leave 
it.'' The process here today does a disservice to the purpose of the 
Senate, but more than that, it does a disservice to seniors, to 
doctors, and everyone who depends on Medicare.
  There is a deal to be reached here. We could vote on a deal today 
that includes many of the policies in the underlying bill but fixes 
glaring problems. We could vote today on a bill that would provide a 
1.1-percent update for physicians. We could vote on a bill today that 
would not be vetoed.
  To my colleagues today, I say we should vote no on this motion so we 
can get back to something the President will sign and get it done and 
get it done quickly.
  I yield the floor.
  The PRESIDING OFFICER. Who yields time?
  Mr. McCONNELL. Madam President, I yield back the remainder of our 
time.
  The PRESIDING OFFICER. The majority leader is recognized.
  Mr. REID. Madam President, thank you very much.
  My distinguished counterpart, the Republican leader, has often said 
there is a right way and a wrong way to get things done here in the 
Senate. The right way, he says, is through bipartisanship. I agree with 
my colleague.
  Before the Fourth of July break, we saw such a stunning moment of 
bipartisanship in the House of Representatives. Democrats and 
Republicans saw the harm our country could face if Congress did not 
take action to pass the doctors fix. Members of Congress knew that 
without bipartisan leadership, doctors would face cuts in the payments 
they receive, which would cause them to drop patients and even drop out 
of Medicare completely. Members of the Senate knew that if they sat on 
their hands, nothing would be done, obviously, but the House of 
Representatives knew that if they sat on their hands, millions of 
senior citizens, people with disabilities, Active Duty, retired 
military, and their families could all face a reduction in the quality 
of their care. So the Democrats and Republicans in the House of 
Representatives passed an identical bill that is now before us, the so-
called doctors fix--listen to this--by a bipartisan majority of 355 to 
59. Every single Democrat voted for the measure. Two-thirds--two-
thirds--of the Republicans joined them.
  This is bipartisanship at its very best. When the House, by a vote of 
359 to 55, votes as they did, this is bipartisanship at its best. In 
fact, one of the small number of Republicans who voted no felt so badly 
after the vote took place that he wrote a letter to all the physicians 
in his district and all the senior citizens in his district and said: I 
am sorry. I am sorry. I made a mistake. I didn't know it was so 
important. He said: If I ever have a chance to vote on it again, I will 
vote with the vast majority of the Members of the House of 
Representatives.
  If Senate Republicans are looking for bipartisanship, they need to 
look no further than the bipartisan breakthrough we saw on Medicare in 
the House of Representatives. Republicans in the Senate should have 
seen the overwhelming support for this critical legislation from both 
sides of the aisle in the House and joined the effort here in the 
Senate.
  As I look across this body, I see a number of us who have served in 
the House of Representatives: the ranking member of the Finance 
Committee, the Senator from Michigan, the Senator from Illinois, the 
chairman of the Finance Committee, and others. The House of 
Representatives is known as a partisan body. We are not. They showed 
that, for the good of the American people, they could set their 
partisanship aside and vote, and they did that.
  If, in fact, the Republicans here in the Senate had looked and 
studied what took place in the House of Representatives, this bill 
would have passed before the break we took before Fourth of July and it 
would have been sent to the President and we would be spending our time 
today focusing on other critical priorities for the American people 
such as gas prices, such as housing, and issues on which Republicans 
have done a lot of talking but no legislating. Instead, though, Senate 
Republicans have once again chosen the side of delay and obstruction.
  The Republicans may talk about bipartisanship--and when they do, we 
agree with every word they say--but words alone won't solve the 
Medicare problem today. Words won't support doctors. Words won't keep 
senior citizens healthy or veterans or Active military and their 
families getting proper health care. This critical problem calls not 
for words but action, and the only action the Republicans have taken on 
this Medicare issue is delay, delay, delay.
  What can the American people conclude, except that the Republicans 
have chosen the side of the insurance companies--the insurance 
companies--and the HMOs that are already making untold fortunes. Last 
year, the so-called Medicare Advantage, they made $15 billion. How did 
they make it? They made it at the expense of millions of senior 
citizens who rely on Medicare to stay healthy.
  This morning in the Senate, the Republican leader made a very 
interesting point, and all should listen to the point he made. He said 
that with more than 300 Members of the House of Representatives having 
voted in favor of the legislation, the Senate should follow suit and 
pass it immediately.
  He argued that delaying or trying to amend a bill with such strong, 
bipartisan support from the House would serve no purpose but to delay 
its implementation. Senator McConnell was talking about the Foreign 
Intelligence Surveillance Act, FISA. But it appears that the Republican 
leader and his colleagues on the other side of the aisle want to have a 
different set of rules for each piece of legislation. On FISA, having 
an overwhelming 300 votes meant don't delay it and vote for it here. It 
means something different on Medicare, when even more voted for it.
  If the 300-plus vote in the House was good enough on the FISA bill, 
shouldn't the 355 votes for Medicare be good enough as well? I would 
hope so.
  In their effort to block this critical legislation, the Republicans 
have now concocted an argument that their opposition lies in their 
inability to offer amendments.
  Think about that. Their opposition lies in the fact that they cannot 
offer amendments.
  If only the majority would allow amendments, they say, this bill 
would sail through passage. But the facts are clear. The Senate 
Republican leadership was at the table when the process of the bill was 
discussed. The Republican leader agreed to the process about which we 
are now engaged. This process was agreed to unanimously by every single 
Senator, Democratic and Republican alike. We are here today because of 
that unanimous consent agreement.
  The process--to which, I repeat, all Republicans agreed and all 
Democrats agreed--was that after a 60-vote margin on a motion to 
proceed, the bill would go directly to the President. There was ample 
opportunity to make the case for amendments prior to the unanimous 
consent agreement.
  I have gotten to know Max Baucus, of Montana, very well in my 26 
years in the Congress. I don't know of a Senator who has more of a 
reputation for bipartisanship than the Senator from Montana. He is 
known as a person who works with Republicans. That is why we, on the 
Democratic side, so admire him and support his chairmanship of the 
Finance Committee. But even Max Baucus has had enough. He has had 
enough. He knows he has tried. He knows this is stalling and that this 
is obstruction. Even Max Baucus--I believe the most bipartisan Member 
of the 100 Senators here--said that is enough.
  Well, I made it clear a long time ago to Senator Baucus and others 
that we would have considered any reasonable proposal. But that time 
has long since passed. If Republicans were serious about passing this 
legislation and amendments were the only thing standing in the way, 
that would be one thing. They would have negotiated for amendments long 
before the 59-vote debacle of 2 weeks ago and certainly long before 
now.
  It could not be clearer that the amendment argument is the latest

[[Page S6489]]

thinly veiled excuse for opposing this legislation to provide for 
doctors, senior citizens, and veterans.
  These excuses for voting the wrong way aren't convincing anyone. 
Doctors, senior citizens, military families who rely on TRICARE, and 
all Americans see these Republican tactics for what they are. The 
Republican call for a 31-day extension is another duck and dodge. Let's 
think a minute. Where are we going to be in 31 days? Do you think there 
might be conventions going on, where Obama is being nominated and 
McCain is being nominated? We are out of session. That shows how 
fallacious and foolish a 31- or 30-day extension is. What would happen 
when that time runs out? We would be out of session. Well, of course, 
that would lead to nothing but redtape and confusion for Medicare 
providers during the next 30 days.
  This legislation that is before this body is the very same that 
passed the House of Representatives, with all the Democrats and two-
thirds of the Republicans voting for it, and it is supported not by a 
bunch of fringe groups. For example, AARP supports this. The physician 
community, including the American Medical Association, and all the 
specialist groups, such as the internists, orthopedic surgeons, and 
brain surgeons, all support this legislation.
  The pharmaceutical industry supports it. My friends say this is very 
bad for seniors as it relates to pharmaceuticals. Why in the world 
would the pharmaceutical industry support what we are trying to do? 
Hospitals, the American Hospital Association, patient groups such as 
the American Heart Association, American Cancer Society, and hundreds 
and hundreds of other organizations support this.
  Who opposes this bill? I will tell you who. Not hundreds of 
organizations, not AARP, not the American Cancer Society. Only two 
organizations: the insurance industry, that always has the best 
interests of the American people in mind. They always look out for us, 
as you know. Who is the other special interest group that supports 
doing nothing? The HMOs. How many of you remember that Jack Nicholson 
movie, when they brought up HMOs and whole theaters booed all over 
America when that provision came up?
  The American people are booing the Republicans today because they 
have sided with the insurance industry and the HMOs. We have sided with 
senior citizens and with the veterans and their families. We know 
President Bush opposes this legislation and he threatened to veto it. 
Some Republicans said: Why pass a bill now when the President is going 
to veto it? Think about this. First of all, talk to my colleagues on 
the other side of the aisle. We have a government that is founded by 
our Constitution as three separate and equal branches. We have to do 
the right thing. That is how checks and balances work.
  We should pass this bill because we owe it to senior citizens, 
veterans, the doctors who are working hard. I remind our Republican 
friends that the House of Representatives has more than enough votes to 
override the veto. There is no reason we cannot do the same in the 
Senate. I also remind our colleagues of what happened to the GI bill of 
rights, one of the landmark pieces of legislation to pass this country 
in the last 50 years. When Senator Webb and others introduced that 
legislation to give something back to our troops in the form of 
educational opportunities to help them succeed when they return home, 
President Bush and many Republicans, including John McCain, declared 
the bill was too generous. The President vowed he was going to veto the 
bill.
  Surely then, some Republicans said that if the President opposes the 
bill, the Senate has no business debating and passing it. But we did 
our job. We did what was right for our troops and veterans, and we 
passed the GI bill overwhelmingly. To his credit, President Bush 
acquiesced.
  I believe that if the Senate Republicans follow the lead of their 
House counterparts by voting for cloture today and sending the Medicare 
doctors fix bill to the President's desk with an overwhelming 
bipartisan majority, President Bush will heed the calls of the House 
and the Senate, of doctors, of patients, of advocacy groups, and of our 
troops.
  I, personally, support this legislation on behalf of the 320,000 
Medicare patients in Nevada and Dr. Edward Kingsley, a cofounder of the 
Comprehensive Cancer Centers in Las Vegas, who said:

       Some physicians are not going to be able to afford [to 
     continue taking Medicare patients]. . . . That's ultimately 
     what we all fear--these patients are not going to have access 
     to the care they need.

  I support this legislation also on behalf of the approximately 
320,000 Nevadans who are Medicare patients.
  I support this on behalf of the almost 9 million service men and 
women and families enrolled in TRICARE.
  I support this legislation on behalf of the 44 million senior 
citizens and the people with disabilities who rely on Medicare to stay 
healthy and live their golden years to the fullest. That is what 
Medicare is about.
  Since President Lyndon Baines Johnson signed the Medicare law more 
than 40 years ago, the Congress and Senate has always worked to improve 
and maintain it. Congress has never seriously threatened Medicare or 
the benefits our senior citizens have earned.
  Before the July 4 recess, 59 Senators voted to move toward passage of 
the doctors fix. All Democrats voted yes--every one of us. We were 
joined by a small group of exemplary Republicans who were willing to 
stand up to the insurance companies and HMOs and the veto threats of 
the President.
  We needed 60 votes to pass this. We came up one short. Today, we 
remain one Republican vote away from passing this bill. As I look 
across the aisle to my Republican friends, the 60th vote is there.
  I urge my colleagues to vote for cloture so we can send this 
legislation to the President with an overwhelming bipartisan vote to 
reflect overwhelming support for it among the American people.
  The PRESIDING OFFICER. Under the previous order, the clerk will 
report the motion to invoke cloture.
  The 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.

  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 assistant legislative clerk called the roll.
  Mr. KYL. The following Senator is necessarily absent: the Senator 
from Arizona (Mr. McCain).
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 69, nays 30, as follows:

                      [Rollcall Vote No. 169 Leg.]

                                YEAS--69

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

                                NAYS--30

     Allard
     Barrasso
     Bennett
     Bond
     Brownback
     Bunning
     Burr
     Coburn
     Cochran
     Craig
     Crapo
     DeMint
     Domenici
     Ensign
     Enzi
     Graham
     Grassley
     Gregg
     Hagel
     Hatch
     Inhofe
     Kyl
     Lugar
     McConnell
     Sessions
     Shelby
     Sununu
     Thune
     Vitter
     Wicker

                             NOT VOTING--1

       
     McCain
       
  The motion was agreed to.
  The PRESIDING OFFICER. Upon reconsideration, on this vote the yeas 
are 69, the nays are 30. Three-fifths of the

[[Page S6490]]

Senators duly chosen and sworn having voted in the affirmative, the 
motion is agreed to.
  Under the previous order, all postcloture time is yielded back and 
the Senate will proceed to consideration of the bill.
  Under the previous order, the clerk will read the bill for the third 
time.
  The bill was ordered to a third reading and was read the third time.
  The PRESIDING OFFICER. Under the previous order, the bill is passed 
and the motion to reconsider is considered made and laid upon the 
table.
  The bill (H.R. 6331) was passed.

                          ____________________