[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for all the outdated, inefficiency-rewarding, commonsense-defying 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:

       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.

  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.

                          ____________________