Congressional Record, Volume 161 Issue 53 (Tuesday, April 14, 2015)

[Congressional Record Volume 161, Number 53 (Tuesday, April 14, 2015)]
[Senate]
[Pages S2149-S2152]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT

Mr. WYDEN. Madam President, it is my hope that soon the Senate will
be about to start voting on legislation that in one fell swoop will
improve health care for millions of Americans. This discussion should
start with a Medicare milestone. That milestone is abolishing once and
for all the outdated, inefficiency-rewarding, commonsense-defying
system of paying physicians under the Medicare Program.

[[Page S2150]]

As my colleague from New Hampshire knows, what I am talking about in
the technical lingo of health care is the SGR, the sustainable growth
rate. It is a horrendously flawed formula for paying doctors and
providers who treat our Medicare patients. Yet despite this very sour
pedigree, it has dominated much of the discussion about Medicare since
1997.
I wish we had put this flawed reimbursement system in the dustbin of
history last year. As some of my colleagues know, I had sought to do
that, along with the support of others. But I think now we have reached
the point, on a bipartisan basis, where we have a chance for seniors
and their providers to cross the victory line and be better off and
have a better system for all Americans.
I thought I would take a minute or two before discussing some of the
other health care efforts that I hope will go forward today to describe
how this happens. A little over a year ago, there was not much reason
to think we would not just keep passing this leaky boat. That is
essentially what the Senate had been doing for years and years with
this flawed program.
In fact, I remember one of our younger Members of this body was where
the Presiding Officer of the Senate is sitting. I said: At this rate,
we are probably going to be on patch No. 70 or 80 by the time we get
around to really fixing this. So people were not very optimistic a
little over a year ago. Since then, however, since that 17th patch, we
saw Members on both sides of the aisle saying: It is time to start
getting serious and getting traction for a permanent repeal-and-replace
of this flawed reimbursement system.
In January of this year, momentum finally began to grow. In other
words, we used that period in 2014 as a springboard. Discussions began
with Speaker Boehner and Leader Pelosi. Their discussions were really
based on the bipartisan, bicameral framework that was developed in 2014
when leaders in the other body and the Senate got together: Finance
Members, Ways and Means Members, the Energy and Commerce Members. The
combination of that work and Speaker Boehner and Leader Pelosi coming
together leads us to where I hope we will be here before long, and that
is, once and for all abolishing this flawed reimbursement system.
If we did not take this action--and in effect it really has to be
done now--without taking people through the root canal work of how the
reimbursement system works at the Medicare center, what is called CMS,
we do know that if Congress does not intervene, we would see physicians
cut 21 percent. That would, in my view, cast a very strong shadow over
our ability to serve America's older people. I mean, particularly in
the rural areas of this country, we have a lot of those practices that
serve older people walking on an economic tightrope right now. They are
trying to figure out how to pay the staff and pay for equipment and
lighting and everything else. A 21-percent cut would be enough, in my
view, to really put some of those small rural practices out of
business. So it was the judgment of this bicameral group that worked
through 2014, that Leader Pelosi and Speaker Boehner picked up on this
year, to come up with a very different kind of model to replace the
Medicare reimbursement system that was so flawed, the SGR, with a
merit-based incentive payment that rewards those who provide high-
quality, high-value care. That, in my view, is how we get the best
value for America's seniors who, of course, want to get the right
amount of care at the right time. They want it to be of high quality.
A major part of this legislation will, in my view, help to promote
better coordination of care. American health care is so fragmented and
so strewn, kind of hither and yon, very often a senior can be treated
by a variety of providers. No one really rides point on it. The senior
ends up in the hospital emergency room.
At that point, when providers say: Who should we be in contact with?
The senior is not even sure of all of the people, particularly if that
senior has multiple chronic conditions--perhaps diabetes and a heart
problem--the senior will not even know the array of providers they have
seen, let alone have someone coordinate their care.
The good thing about this reform is it promotes that kind of care
coordination. Also, physicians, as part of this, will have clear
incentives to enter alternative payment models that are going to
promote team services, services where there is a team of health care
providers. It will require more Medicare transparency, more information
about various services that are provided to older people so that there
is some sunlight on this incredibly complicated system, particularly
the Medicare Program that takes over $500 billion a year and spends it
in a way that has not been particularly transparent.
I want to thank Senator Grassley for working with me closely on this
for a number of years.
Finally, this legislation also makes permanent what is called the QI
Program, again fancy health care lingo for an important program that
pays the premiums, the outpatient premiums, for low-income older
people. I think that is especially important, because it says for older
people, particularly those of modest income, that there is going to be
some assistance for the outpatient services, what is called Part B,
which are so critical in terms of keeping older people out of long-term
care facilities.
My guess would be in New Hampshire and Oregon--like in my home State
of Oregon--having that kind of assistance for low-income people in the
community is really key to avoiding institutional care.
I do want to note that I think all of us are going to say this bill
does not meet the test of perfection. I happen to believe the bill
would have been stronger had this body been involved in all of the
negotiations. But clearly to have a milestone for Medicare--and that is
what I think you get when you eliminate what really pretty much is a
fraud. The Medicare reimbursement system has been honored more in the
breach than in the observance. Every year it is waived, it is patched.
I think to replace it with what I have described really is something
that when the history of Medicare is written, people are going to look
back and say: This was an important day. These were sensible changes.
Improving care coordination, putting a new focus on quality, data
transparency, coordination of health care teams, the kinds of things
that this proposal does, are very much in the interests of seniors,
providers, and taxpayers. I think this day will be remembered for
making a very important contribution in the history of Medicare.
I do want to mention several other amendments that I hope will be
offered. I also feel very strongly about the need for this legislation
to reaffirm and strengthen health care in America for our most
vulnerable children. There are more than 100,000 of these youngsters in
my home State alone. I am talking about the Children's Health Care
Insurance Program, what is known as CHIP. My hope is we will have a
chance here to vote to expand on what the other body has done and have
a children's health program that will be extended for 4 years and not
just 2.
The CHIP program has the support of almost 40 Governors. They span
the philosophical spectrum. They have achieved such strong support
because these Governors who are right on the front lines with a program
that involves very close coordination by the Federal Government and the
State governments want some certainty and predictability. They don't
want vulnerable kids and their families to be in limbo.

So I am very hopeful that amendment will be offered and that it will
get the support of our colleagues.
Third, I hope there will be an amendment to improve health care for
women. I believe we have all followed this debate that I think is
needlessly divisive. There are so many Senators who want to find common
ground to improve health care.
We have gotten bogged down and somehow virtually all the bills now
seem to be a magnet for a debate about abortion. My colleague, Senator
Murray, wishes to offer a very important amendment to expand health
care services and the availability of reproductive health services for
women, community-based care. I am very hopeful that will be offered as
well.
Finally, on a bipartisan basis, Senators Cardin and Collins wish to
offer legislation to really set aside what are

[[Page S2151]]

very outdated approaches with respect to how Medicare provides
services, therapy services, for our citizens. We are talking about
physical therapy, occupational therapy, services with respect to
speech.
Senators Cardin and Collins want to get rid of these arbitrary
therapy caps. I am very hopeful their amendment will be able to be
offered as well.
One last point, on a matter that is not health care related, this
legislation carries an additional program that is particularly
important to the people whom I represent, and that is the Secure Rural
Schools Program would be extended for 2 years.
I wrote this law in 2000 with our former colleague, the Senator from
Idaho, Mr. Craig, because in most of our States--States where the
Federal Government owns much of the lands, heavily forested--as a
result of changes in environmental policy and other changes, a lot of
these rural communities didn't have the money they needed for schools,
roads, law enforcement, and basic services.
We have extended it since 2000. We have had testimony indicating we
are going to need that safety net for some time, even as you try to get
the harvest up in a sustainable way.
I am very pleased this program, an economic lifeline to rural
communities across Oregon and other States, is going to be extended for
2 years. I think that provides us an opportunity to come up with fresh
strategies, both with respect to the safety net.
I would like to--in the future, in the Senate Budget Committee--
support it. I believe my colleague, the Presiding Officer, was
interested to link Secure Rural Schools with the Land and Water
Conservation Program and the PILT Program. We have bipartisan support
for that.
I would like to see us use these 2 years to strengthen the safety net
and get the harvest up in a sustainable way.
I wanted to make mention of that before I wrap up.
In closing, I think the health legislation--that I hope will be voted
on shortly--represents one of those rare moments on a major issue.
I mean, I would go so far as to say--having worked with older people
since my days with the Gray Panthers--I think what we are doing with
the abolition of this outdated Medicare reimbursement system is laying
the foundation for what will be the future of Medicare. The future of
Medicare is not going to be what it was about in the 1960s when it
began--a senior in New Hampshire might need the hospital for a serious
injury, maybe they would see a physician, get Medicare Part B if they
broke their ankle. The future of Medicare is going to be about dealing
with chronic disease. It is going to be about diabetes, cancer, heart
disease, and stroke.
The reality is that Medicare has not kept up with the times. I think
it is worth noting that in the big debate about the Affordable Care
Act, chronic disease was hardly mentioned at all, not by anybody. That
is going to be the foundation of Medicare for the future. More than 90
percent of the Medicare dollars in the future, based on the challenge
of dealing with older people with these chronic conditions, is going to
be about chronic disease.
The reality is, when you abolish this flawed Medicare reimbursement
system and start promoting coordinated care, what would happen in the
State of New Hampshire is you would start seeing teams--perhaps a
nurse, a physician, a pharmacist--a team in New Hampshire or in Oregon
come together, particularly where there aren't the Medicare Advantage
plans, and say we can give, as our colleague from Georgia noted not
long ago, Senator Isakson, better care at lower cost and do it for what
is likely to be the type of health care services that dominates
Medicare in the future, which is chronic disease. We will be better
able to tackle that with the abolition of SGR.
So my hope is shortly we will vote to take that action that I believe
constitutes a Medicare milestone, reaffirms our commitment to America's
youngsters, improves health care services for women--from one end of
America to another--and gets rid of this outdated system of therapy
caps that are restricting what those who need physical therapy,
occupational therapy, and others could get.
This could finally be a punctuation mark in this, the 50th year of
Medicare, and an opportunity for all Senators to see that they were
part of adopting a fresh set of policies to provide a brighter and
healthier future for all our people.
I yield the floor.
I suggest the absence of a quorum.
The PRESIDING OFFICER. The clerk will call the roll.
The senior assistant legislative clerk proceeded to call the roll.
Mr. HATCH. Madam President, I ask unanimous consent that the order
for the quorum call be rescinded.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. HATCH. Madam President, I want to mention what Speaker Boehner
said about this bill we are about to look into--the CHIP bill and the
SGR, the physicians' payment bill. Speaker Boehner said:

Unless the Senate passes the House-passed ``doc fix'' bill,
significant cuts to physicians' payments will begin tomorrow.
The House legislation passed with overwhelming bipartisan
support, and we do not plan to act again, so we urge the
Senate to approve the House-passed bill without delay.

He summed it up pretty well. The fact is this has been a long ordeal
that a lot of us have worked on for a long time, a lot of people on
Capitol Hill. If we can pass this bill tonight, it will be a major
accomplishment and we can go back to the child health insurance bill.
I remember standing here on the floor with Ted Kennedy on the other
side passing a bill that brought a lot of angst to a lot of people but
which has helped millions of children who were deprived of good health
care. So this is a very important bill and I hope we don't foul it up.
I don't think we will.
Madam President, I stand today in support of H.R. 2, the Medicare
Access and CHIP Reauthorization Act of 2015. If enacted, this
legislation would repeal and replace the Medicare sustainable growth
rate, or SGR. That is the formula called the sustainable growth rate.
It will extend the CHIP program for an additional 2 years--a program
that has worked very well--and will put in place much needed reforms to
the Medicare Program--something that hasn't happened in a long time.
This bill represents more than 2 years of hard work on both sides of
the Capitol. It passed overwhelmingly in the House of Representatives
with 392 votes. I expect it will also get broad bipartisan support here
in the Senate. It certainly has to.
We have all grown tired of the seemingly endless cycle of passing
temporary SGR patches year after year after year. It is not a new
problem. It is one we have been dealing with for a long time.
A little over 2 years ago, a group of leaders from both the House and
the Senate set out to fix this problem once and for all. As I mentioned
yesterday, I was part of this group, as was former chairman of the
Committee on Finance, Max Baucus. Together Senator Baucus and I worked
with the leaders on the relevant House committees to craft legislation
that would repeal and replace the SGR with an improved payment system
that rewards quality, efficiency, and innovation. That legislation,
which we reported out of the Committee on Finance by voice vote in late
2013, formed the basis of the legislation before us today.
I want to compliment the House for the great work they have done on
this bill. I have to give a lot of credit to them. It is my hope we
will act quickly to pass this bipartisan, bicameral legislation and
send it to the President's desk as soon as possible.
This legislation demonstrates what Congress is truly capable of when
Members work together. We all talk about the need for more
bipartisanship in Washington. This bill can be a template for how
things should work around here.
It also represents a step forward in the effort to reform our
Nation's entitlement programs. As I mentioned, to go along with the
permanent SGR fix, the bill includes a meaningful downpayment on
Medicare reform. These reforms include a limitation on so-called
Medigap first-dollar coverage, more robust means testing for Medicare
Parts B and D, and program integrity provisions that will strengthen
Medicare's ability to fight fraud.
Clearly, these reforms by themselves won't fix all of Medicare's
fiscal problems. Indeed, much more work needs to

[[Page S2152]]

be done. But like many of my colleagues, I have been pushing for
entitlement reform for years. During all that time I have seen politics
and fear get in the way of progress. With this bill we have a chance
to, at the very least, take a meaningful step forward--a bipartisan
step, no less--in the effort to secure the safety net for future
generations. Any Senator who, like me, supports entitlement reforms
will welcome the changes we have made in this bill.
I am not here to say the bill is perfect. It is certainly not. But as
the saying goes, we should not make the perfect the enemy of the good.
This is a good bill. Once again, it passed in the House with a huge
bipartisan majority and it is supported by groups across the health
care spectrum. I ask unanimous consent to have printed in the Record a
list of groups supporting this legislation at the conclusion of my
remarks.
As it stands right now, in less than 12 hours doctors all over the
country will face a 21-percent cut in Medicare reimbursements. In other
words, we are out of time. We need to pass this legislation and we need
to do it now. In fact, it is encouraging to see that even Members on
the other side of the aisle support this good policy now, and I am
proud of them for doing so.
Let's get this done. I hope all of my colleagues will join me in
supporting H.R. 2.
I repeat what Speaker Boehner said today:

There being no objection, the material was ordered to be printed in
the Record, as follows:

H.R. 2, the Medicare and CHIP Reauthorization Act (MACRA)

Letters of Support

Alliance for Academic Internal Medicine (AAIM), Alliance of
Specialty Medicine, AMDA The Society for Post-Acute and Long-
Term Care Medicine American Academy of Allergy, Asthma, and
Immunology (AAAAI), America's Essential Hospitals, American
Action Forum, American Congress of Obstetricians and
Gynecologists (ACOG), American Health Care Association,
American Hospital Association, American Medical Association,
American Academy of Dermatology Association, American Academy
of Family Physicians, American Academy of Neurology (AAN),
American Academy of Pediatrics, American Academy of Physician
Assistants, American Association of Clinical Endocrinologists
(AACE), American Association of Neurological Surgeons/
Congress of Neurological Surgeons, American Association of
Nurse Anesthetists, American Association of Nurse
Practitioners (AANP) American Academy of Ophthalmology.
American Association of Orthopedic Surgeons, American
Association for the Study of Liver Diseases (AASLD), American
College of Allergy, Asthma and Immunology (ACAAI), American
College of Cardiology (ACC), American College of Chest
Physicians (CHEST), American College of Gastroenterology,
American College of Physicians (ACP), American College of
Radiology, American College of Rheumatology (ACR), American
College of Surgeons, American Gastroenterological Association
(AGA), American Geriatrics Society (AGS), American Health
Care Association (AHCA), American Medical Society for Sports
Medicine (AMSSM), American Medical Student Association,
American Osteopathic Association (AOA).
American Psychological Association Practice Organization
(APAPO), American Society for Blood and Marrow
Transplantation (ASBMT), American Society of Clinical
Oncology, American Society for Gastrointestinal Endoscopy
(ASGE), American Society of Hematology (ASH), American
Society of Nephrology (ASN), American Society for Radiation
Oncology (ASTRO), American Thoracic Society (ATS), Americans
for Tax Reform, Association of American Medical Colleges,
Association of Departments of Family Medicine, Association of
Family Medicine Residency Directors, Aurora Health Care,
Billings Clinic, Bipartisan Policy Center, California
Hospital Association, California Medical Association,
Catholic Health Association of the United States, Center for
American Progress (CAP).
Center for Law and Social Policy (CLASP), Children's
Hospital Association, College of American Pathologists,
Council of Osteopathic Student Government Presidents (COSGP),
Digestive Health Physicians Association, Endocrine Society
(ES), Essentia Health, Families USA, Federation of American
Hospitals, Fight Crime: Invest in Kids, Grace-Marie Turner
for the Galen Institute, Greater New York Hospital
Association (GNYHA), Gundersen Health System, HealthCare
Association of New York State, Healthcare Leadership Council,
Healthcare Quality Coalition, HealthPartners, HealthSouth,
Hospital Sisters Health System, Iowa Medical Society.
Infectious Diseases Society of America (IDSA), Latino
Medical Student Association Midwest, Let Freedom Ring,
Louisiana Rural Health Association, LUGPA, March of Dimes,
Marshfield Clinic Health System, Mayo Clinic, McFarland
Clinic PC, Medical Group Management Association, Mercy
Health, Military Officers Association of America (MOAA),
Minnesota Hospital Association, Minnesota Medical
Association, National Association of Community Health
Centers, National Association of Psychiatric Health Systems,
National Association of Spine Specialists, National
Association of Urban Hospitals, National Coalition on Health
Care, National Retail Federation, North American Primary Care
Research Group, Novo Nordisk.
Oregon Association of Hospitals and Health Systems, Premier
healthcare alliance, ReadyNation, Renal Physicians
Association, Rural Wisconsin Health Cooperative, Society for
Adolescent Health and Medicine (SAHM), Society of Critical
Care Medicine (SCCM), Society of General Internal Medicine
(SGIM), Society of Teachers of Family Medicine, Student
National Medical Association, Student Osteopathic Medical
Association, Tennessee Medical Association, Texas Medical
Association, The 60 Plus Association, ThedaCare, The Hospital
& Healthsystem Association of Pennsylvania, The National
Committee for Quality Assurance (NCQA), The Society of
Interventional Radiology, VHA Inc., Wisconsin Collaborative
for Healthcare Quality, Wisconsin Health and Educational
Facilities Authority, Wisconsin Hospital Association,
Wisconsin Medical Society.

Mr. HATCH. Madam President, I suggest the absence of a quorum.
The PRESIDING OFFICER. The clerk will call the roll.
The legislative clerk proceeded to call the roll.
Mr. WHITEHOUSE. Mr. President, I ask unanimous consent that the order
for the quorum call be rescinded.
The PRESIDING OFFICER (Mr. Gardner). Without objection, it is so
ordered.
Mr. WHITEHOUSE. I ask unanimous consent to speak in morning business
for up to 15 minutes.
The PRESIDING OFFICER. Without objection, it is so ordered.

____________________