[Congressional Record (Bound Edition), Volume 147 (2001), Part 15]
[Senate]
[Pages 21175-21182]
[From the U.S. Government Publishing Office, www.gpo.gov]



  DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND 
               RELATED AGENCIES APPROPRIATIONS ACT, 2002

  The ACTING PRESIDENT pro tempore. Under the previous order, the 
Senate will now resume consideration of H.R. 3061, which the clerk will 
report.
  The assistant legislative clerk read as follows:

       A bill (H.R. 3061) making appropriations for the 
     Departments of Labor, Health and Human Services, and 
     Education, and related agencies for the fiscal year ending 
     September 30, 2002, and for other purposes.

  Pending:

       Dorgan amendment No. 2024, to provide for mandatory 
     advanced electronic information for air cargo and passengers 
     entering the United States.

  The ACTING PRESIDENT pro tempore. The Senator from Oregon.
  Mr. WYDEN. Mr. President, first I salute Chairman Harkin and Senator 
Specter for doing, in my view, a superb job with respect to this bill. 
They have really set a special standard in terms of trying to work on 
important issues in a bipartisan way. The chairman has left the 
Chamber, but I want him to know how much I appreciate the good work he 
and his staff are doing on this issue.
  This morning I wish to talk about a health and a scientific issue of 
extraordinary importance, and that is the vacancies that now exist at 
the National Institutes of Health, the Food and Drug Administration, 
and the National Cancer Institute. At a time when the public is focused 
on public health because of bioterrorism, there are many reasons we 
should be concerned about the work of these agencies and get these 
positions filled.
  I want to talk for a few moments about why I am so troubled by the 
vacancies we are seeing at these agencies today. This has been, as all 
of us know, a decade of remarkable scientific progress in the health 
care field. It has really been something of a scientific and health 
care renaissance with extraordinary amounts of information learned 
about cells, about cancers, about what has come to be known as 
biological detectors that are important as we deal with anthrax and 
smallpox, and various other serious health concerns that Americans are 
focused on today.
  This scientific progress has been bipartisan. Democrats and 
Republicans alike have joined to support funding for these very key 
public health agencies, and we have worked together to ensure these 
programs are properly funded.
  I am convinced if those vacancies are not promptly filled, if we do 
not soon get a head of the National Institutes of Health and the Food 
and Drug Administration and the National Cancer Institute--if those 
positions are not soon filled--it threatens to unravel some of the 
important progress that has been made in this country over the last 
decade.
  Suffice it to say, if those positions are not filled, a message is 
sent to the young scientists, to the young future leaders of this 
country in the health care field, that the Federal Government does not 
think this is particularly important. It takes years for companies to 
get products developed and approved, and this is especially true of the 
new products created by biotechnology. It is important that we have 
scientific leadership throughout this process--at the companies 
developing these products and at every level of these two important 
agencies--NIH

[[Page 21176]]

and the FDA. Without these scientists throughout the process, in the 
companies, and at the Federal level, biotech companies lose the 
incentive to invest in what might be the next medical breakthrough.
  I spoke to a group of students on a college campus just a few days 
ago. A young woman came up to me and only half jokingly said: ``I am 
ready to be the head of the National Institutes of Health. I have 
focused on these issues. I have studied the questions for some time. 
Why in the world can the Federal Government not get somebody to head 
the National Institutes of Health right now?''
  I have focused on health care and technology questions over the last 
few years in Congress, and the business community is especially alarmed 
that these vacancies are open. They want to work with leaders at the 
Federal level to expedite the development of drugs, vaccines, and 
therapies. One of these business leaders told me recently what concerns 
him is that at a time when the public is focused on public health, on 
the question of how to deal with anthrax and smallpox and bioterrorism, 
there is not anybody home in the Federal Government.
  I think it is extraordinarily important that the Congress work with 
the President to get the officials we need sent up for review by the 
key committees. The National Institutes of Health has now been without 
a leader for almost two years.
  The National Institutes of Health is now hemorrhaging the key people 
they need to be effective advocates for the public health. Recently, 
there was another vacancy at the National Institutes on Mental Health, 
and there is a vacancy at the National Cancer Institute. There has been 
a substantial period of time where we have not had anybody heading up 
the Food and Drug Administration.
  If we want to attract the stellar scientists whom I know Democrats 
and Republicans both are so interested in supporting, we are not going 
to be able to do it, and we are going to lose very talented people who 
are in these agencies now.
  We are already seeing a real brain drain in these essential agencies. 
What we need to do, and the Congress is prepared to do, and what the 
chairman and Senator Specter have made it very clear that they are 
willing to do, is make sure these agencies are properly funded. What we 
need now especially are scientifically sound programs to take on 
anthrax, smallpox, and ensure we can allow our scientists to work on 
what are known as biological detectors so we can move more rapidly and 
readily to recognize the agents in the field. We can more precisely 
describe the various strains of these bacteria and diseases. We will 
have a chance to learn more about their genomic sequence and develop 
creative strategies for public health that could pay very significant 
benefits for this country. Certainly the potential benefits to this 
country can be extraordinary.
  I am very interested in working with the President on filling these 
positions. Biomedicine research and science policy has long been 
bipartisan. Senator Mack, for example, from Florida, did yeoman work 
for years and years with Senator Specter, Senator Harkin, myself, and 
others. That is the kind of progress, it seems to me, that is in danger 
of being lost at this time.
  The President of the United States certainly has lots on his agenda 
right now. All of it is extremely important as we deal with the 
question of fighting terrorism. I come to the Chamber today to say it 
is of extraordinary importance these positions at the National 
Institutes of Health and the Food and Drug Administration move to the 
top of the President's agenda, move to the top of the congressional 
agenda, and we work together in a bipartisan way, as we have done on a 
variety of subjects in recent weeks, to get the key officials in these 
agencies in place.
  To make progress in the area of biomedical research and science, we 
need a public-private partnership, one where the Federal Government is 
involved in ensuring our laboratories are helping address issues that 
involve coming up with the basic knowledge that companies and 
scientists can then take to develop the cures and therapies that will 
improve the quality of life for the public.
  I want to work with the President of the United States to get the 
biosciences back on track. I want to make sure we don't step back from 
this golden age of scientific progress, when we had an administration 
committed to ensuring we moved forward with this important research, 
and Congress backed it up on a bipartisan basis. The Congress has the 
power to advise and consent, and it is important that the Congress and 
the President work together to fill the positions at the Food and Drug 
Administration, the National Institutes of Health, and the National 
Cancer Institute.
  We are not dealing just with bioterrorism although that is obviously 
very much on our mind this morning--but the entire public health 
system. We are seeing, obviously, when we open our morning newspaper, 
there are gaps that we need to address. We can best address this if 
officials in these key agencies are in a position to advise the 
Congress.
  It has been too long that we have gone without a leader at the 
National Institutes of Health. It has been too long that we have gone 
without a leader at the Food and Drug Administration. The Senate will 
meet the President of the United States more than halfway. He can speak 
for himself. He has been extraordinarily eloquent on biomedical 
research over the years. Senator Kennedy, who I have discussed this 
with, has made it very clear as chairman of the committee that focuses 
on these issues, he is very anxious to get these officials confirmed.
  I hope this message this morning, at a time when we are working on 
this important bill that funds so many key health agencies, can help 
spark a new effort to speed up getting these key positions filled. I, 
and I believe every Member of the Senate, wants to work with the 
President to get these positions filled. Even though there are so many 
important issues the President has to deal with, this issue of the 
vacancies at the National Institutes of Health, the Food and Drug 
Administration, and the National Cancer Institute has become so 
serious, it needs to be a priority matter that Congress moves quickly 
to deal with. We ought to move quickly to deal with it before we 
adjourn for the year.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Pennsylvania.
  Mr. SPECTER. Mr. President, we urge our colleagues to come to the 
Chamber to offer amendments. There was a long list filed yesterday 
where we have a unanimous consent agreement limiting amendments to 
those which have been listed. Many of them are obviously placeholder 
amendments. We need to move ahead with this bill. We have been on this 
bill now into our second day. We have had only one amendment offered so 
far. We urge our colleagues to come to the Chamber and identify what 
amendments they intend to offer and to be in a position to move forward 
to proceed with the disposition of this bill.
  Mr. REID. Will the Senator yield?
  Mr. SPECTER. I yield.
  Mr. REID. We have an amendment pending, the Dorgan amendment. Has 
there been a decision made whether that would be accepted or do you 
want a vote on it?
  It is my understanding now that staff is still working on that.
  Senator Stevens wanted to alternate back and forth, and I said that 
was fine, but if we could get all Democrats to offer their amendments 
and all Republicans, one after the other--we are so desperate to have 
amendments, we don't care where they come from.
  Mr. SPECTER. If I may respond, I don't think we have a problem on 
alternating. We have a problem finding amendments. If a series of 
amendments from your side of the aisle come forward, we will take them; 
and if a series of amendments from our side of the aisle come forward, 
we will take them. If there is a complication, we will alternate. We 
are now in search of amendments.
  The Senator from Alabama is prepared to offer an amendment. I ask

[[Page 21177]]

unanimous consent the pending amendment be set aside so we may proceed 
to the amendment of the Senator from Alabama.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                           Amendment No. 2042

  Mr. SESSIONS. I thank Senator Specter for his leadership and courtesy 
in allowing me to present this amendment which I believe is exceedingly 
important to health care in America. It is a problem with which we 
simply have to deal. It affects hospitals all over America, causing the 
richer hospitals to get richer and the poorer hospitals to get poorer.
  The problem is the wage index. I offer the Wage Index Fairness Act, 
and I send the amendment to the desk.
  The PRESIDING OFFICER. The clerk will report.
  The bill clerk read as follows:

       The Senator from Alabama [Mr. Sessions] proposes an 
     amendment numbered 2042.

  Mr. SESSIONS. Mr. President, I ask unanimous consent reading of the 
amendment be dispensed.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment is as follows:

(Purpose: To amend title XVIII of the Social Security Act to establish 
    a floor on area wage adjustment factors used under the medicare 
   prospective payment system for inpatient and outpatient hospital 
                               services)

       On page 54, between lines 15 and 16, insert the following:
       Sec. __. (a) Floor on Area Wage Adjustment Factors Used 
     Under Medicare PPS for Inpatient Hospital Services.--Section 
     1886(d)(3)(E) of the Social Security Act (42 U.S.C. 
     1395ww(d)(3)(E)) is amended--
       (1) by inserting ``(i) In general.--'' before ``The 
     Secretary'', and adjusting the margin two ems to the right;
       (2) by striking ``The Secretary'' and inserting ``Subject 
     to clause (ii), the Secretary''; and
       (3) by adding at the end the following new clause:
       ``(ii) Floor on area wage adjustment factor.--
     Notwithstanding clause (i), in determining payments under 
     this subsection for discharges occurring on or after October 
     1, 2001, the Secretary shall substitute a factor of .925 for 
     any factor that would otherwise apply under such clause that 
     is less than .925. Nothing in this clause shall be construed 
     as authorizing--
       ``(I) the application of the last sentence of clause (i) to 
     any substitution made pursuant to this clause, or
       ``(II) the application of the preceding sentence of this 
     clause to adjustments for area wage levels made under other 
     payment systems established under this title (other than the 
     payment system under section 1833(t)) to which the factors 
     established under clause (i) apply.''.
       (b) Floor on Area Wage Adjustment Factors Used Under 
     Medicare PPS for Outpatient Hospital Services.--Section 
     1833(t)(2) of the Social Security Act (42 U.S.C. 1395l(t)(2)) 
     is amended by adding at the end the following: ``For purposes 
     of subparagraph (D) for items and services furnished on or 
     after October 1, 2001, if the factors established under 
     clause (i) of section 1886(d)(3)(E) are used to adjust for 
     relative differences in labor and labor-related costs under 
     the payment system established under this subsection, the 
     provisions of clause (ii) of such section (relating to a 
     floor on area wage adjustment factor) shall apply to such 
     factors, as used in this subsection, in the same manner and 
     to the same extent (including waiving the applicability of 
     the requirement for such floor to be applied in a budget 
     neutral manner) as they apply to factors under section 
     1886.''.

  Mr. HARKIN. Will the Senator yield?
  Mr. SESSIONS. I yield.
  Mr. HARKIN. Which amendment?
  Mr. SESSIONS. The Wage Fairness Index Act.
  Mr. HARKIN. I thank you.
  Mr. SESSIONS. I note that Iowa is also adversely impacted by this 
wage index formula.
  I introduced this amendment as a bill earlier this year with my 
colleagues, Senator Shelby and Senator Hutchinson. We have a terrible 
inequity in the system and in the index formula. This amendment will 
establish a floor on the area wage index adjustment factors that are 
utilized under the Medicare prospective payment system for inpatient 
and outpatient hospital services. I believe this is the best way to do 
that.
  Several other Members have other proposals to help fix this problem. 
This is a solution I believe would be most effective. Over the past 
several years, I visited a number of hospitals, 15 or more, in the 
State of Alabama. In every one, hospital administrators and staff have 
urged me to do something about the wage index. Time after time it has 
been cited to me in personal and confidential discussions, just heart 
to heart, as we discussed the frustrations and problems they face in 
hospitals, and in particular rural hospitals. It has been raised to me 
as a No. 1 issue facing hospitals in Alabama.
  The Alabama Hospital Association and its members have helped craft a 
plan. They consider it an emergency problem and a priority for them. 
The National Hospital Association has recognized this as a problem, and 
they support reform.
  A complicated and a mostly arbitrary formula, the wage index, is part 
of the hospital prospective payment system which was created just in 
the early 1990s, about 10 years ago. We are just now beginning to feel 
how it plays out in real life. It was an effort to cut Medicare 
spending. It established a base rate for Medicare reimbursement based 
on two components--the labor component and the nonlabor-related costs. 
That is how a hospital is paid for Medicare services they render to a 
person who is not otherwise paying. This could be the elderly on 
Medicare and they come in and the hospital provides services. All they 
get for that service is what the Federal Government pays them under the 
Medicare Act.
  So everyone knows that basically hospitals are not making any money. 
In fact, they lose money, often, on Medicare patients. It is the 
individuals who pay their way or have insurance to pay their way who 
help them be a success. The hospitals that have larger numbers of 
Medicare patients who serve a poorer population are more critically 
impacted by this problem. Once again, the wage index is falling 
particularly hard on hospitals that serve a disproportionately high 
number of Medicare patients and poor patients--Medicaid also.
  It established a base rate for paying Medicare costs. They decide how 
much we are going to pay for a gall bladder operation, how much we will 
pay for pneumonia and other things, and that is what the hospital gets. 
They factor that on labor and nonlabor costs.
  Nonlabor costs--that is the material and all--are similar nationwide, 
and the factors come out the same. But labor-related costs must be 
adjusted to regional differences in wage costs. This adjustment is made 
according to the wage index. The wage index, by the way, is a larger 
component of the cost of hospital care than the other factors. It is 
the biggest component. I believe about 60 percent of the reimbursed 
rate is based on the wage rate.
  Rural areas such as Alabama and other States have lower wage costs, 
which is not a good thing. We don't like it that our nurses and support 
personnel aren't paid the same wages as in other States. But it is true 
we have some lower wage rates. Therefore, the Medicare reimbursement 
cost for health care in Alabama and many other States and rural areas 
even within larger States is much lower. Actually, Alabama has the 
lowest average wage index in the country and Montgomery, AL, the 
capital--a good, strong city, not some small rural town--has the lowest 
wage rate in the State. In fact, the wage index for all Alabama 
hospitals is between .74 and .89, well below the national average of 
1.0.
  In other words, where the national average is hospitals are 
reimbursed at the rate of $1, they are reimbursed at the rate of maybe 
78 cents in Alabama, many of them at 74 cents. Some hospitals in the 
country that have somehow, some way, under this formula found their 
costs higher, they get as much as $1.50. So it is twice as much, 74 
cents to $1.50, on 60 percent of the formula on the payment for health 
care. This is too big a gap. This is more than we ought to accept. For 
person in Iowa, a person in Alabama, their health care is just as 
valuable and as important as the health care of someone in New York or 
California.
  To further exacerbate the problem, Alabama has to compete for nurses 
and hospital personnel with nearby urban areas such as Atlanta. To 
recruit these

[[Page 21178]]

highly qualified health care professionals, Alabama hospitals must 
compete with urban wages. This has become a bidding war and has really 
impacted adversely the bottom line of hospitals in the State. Until we 
fix this problem, Alabama hospitals and hospitals all over the country 
will continue to lose millions of dollars each year. Unfortunately, it 
is falling hardest, and the losses fall most often, on hospitals in 
poorer areas, the ones that are actually doing the care and the good 
deed of treating people who otherwise would not have health care. They 
are already forced to make the most of limited resources and to 
continue to provide care for the State's uninsured.
  These hospitals will face tough decisions regarding health care 
services. They will continue to postpone important projects and the 
purchasing of much needed equipment. The rich are getting richer and 
the poor are getting poorer.
  In fact, what happens is, when your wage index is low and you talk 
with your nurses about what kind of raises they might expect, or how 
many RNs and how many LPNs and how many less skilled personnel you have 
because you are not being reimbursed at the national rate but maybe 75 
percent of the national rate, you end up cutting those salaries even 
more, so you have more LPNs rather than RNs, you have more support 
personnel than nursing personnel to try to get by, and what happens 
then? Your wage index goes down even further. They come in and say: 
Look, your wage index isn't that high. You don't get reimbursed as 
much. So your formula can even go down worse.
  The Center for Medicare and Medicaid Services, CMS, the Medicare 
Payment Advisory Commission, and the MedPAC have recognized the 
problem, and they have even made recommendations to improve the wage 
index.
  In addition to these recommendations, several pieces of legislation 
have been introduced in this Congress to address the wage index. Five 
bills have been introduced so far this year to address the wage index. 
Forty-five Senators from twenty-nine States have either sponsored or 
cosponsored wage index legislation.
  Eight members of the Senate Finance Committee, including the ranking 
member, Senator Grassley, agree something must be done. Unfortunately, 
although many have recognized the problem with the wage index, we have 
not been able to do anything to fix it.
  So I raise this issue today to call attention to what is a critical 
problem in health care in America. Particularly in light of September 
11, we know we are going to have to be sure we have a healthy health 
care system to deal with crises with which we may be faced at any time. 
If we allow an unfair reimbursement system to continue, then we will 
allow our hospitals to weaken and eventually close.
  This is a matter of serious import. The wage index is irrational. It 
is not working correctly. It is ratcheting down wages on poorer 
hospitals in rural areas. When the hospitals cut and reduce and cut and 
reduce, then the next year the wage index formula people come in and 
say your wages are lower, and your index drops even further, and you go 
down even more.
  This is something we have to confront. I will share this specific 
example from my hometown of Mobile, AL. The wage index dropped from .81 
to .77, whereas 50 miles away in Pensacola, FL, it is maybe .87; it is 
in the high .80s in Pascagoula, MS, an hour's drive either way from the 
city. That means millions of dollars of reimbursement for those people. 
Montgomery, our capital, has the lowest rate in the Nation. Its 
hospitals are hurting as a result.
  Mr. President, this is an important issue. The time has come to 
address it. Although this is a Health and Human Services bill that 
deals with health care issues, I recognize that this amendment is not 
appropriately favored to be offered here--although we could offer it 
with a point of order. I hope we can begin to draw some attention to an 
issue that is getting out of control. The gap is simply too large. We 
cannot accept it. We cannot allow it to continue. We have to do 
something to fix this problem.
  My bill will bring everybody up to 92 percent. It would not bring 
down anybody. It would at least bring those 74-cents-on-the-dollar 
hospitals up to 92 cents on the dollar. They would still be well below 
the national average--and well below the people who are above the 
national average--but it would at least bring them out of poverty and 
allow them to provide the kind of quality health care we need.
  Mr. President, I appreciate the opportunity to make these remarks. I 
yield the floor and suggest the absence of a quorum.
  The ACTING PRESIDENT pro tempore. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. DAYTON. Mr. President, I ask unanimous consent the order for the 
quorum call be rescinded.
  The PRESIDING OFFICER (Mr. Edwards). Without objection, it is so 
ordered.
  Mr. DAYTON. Mr. President, I ask unanimous consent that I be 
permitted to speak as in morning business for 5 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (The remarks of Mr. DAYTON pertaining to the introduction of S. 1600 
are printed in today's Record under ``Statements on Introduced Bills 
and Joint Resolutions.'')
  Mr. DAYTON. Mr. President, I yield the floor and suggest the absence 
of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. SESSIONS. Mr. President, I ask unanimous consent the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER (Mr. BAYH). Without objection, it is so 
ordered.
  Mr. SESSIONS. Mr. President, I will just follow up on the remarks I 
made previously concerning the wage index and share with our fellow 
Members some of the information I have concerning this issue.
  I have a letter from the Mobile/Baldwin County area hospitals. It was 
sent to me, Senator Shelby, and Congressman Callahan. I will share some 
of the things that are in it supporting the legislation I have offered. 
They note this:

       Because of the huge discrepancy in the Area Wage Index 
     which applies in Mobile and Baldwin Counties, Alabama as 
     compared to our neighboring areas of Pascagoula, Mississippi 
     and Pensacola, Florida, not to mention the even greater 
     discrepancy with other parts of the country, we are beginning 
     to face a critical shortage of skilled registered nurses with 
     which to staff our hospitals. In the last three months alone 
     we have lost at least 87 registered nurses from our area 
     labor pool to traveling nurse agencies and to facilities in 
     adjacent states. Collectively, we have over 200 registered 
     nurse vacancies in the hospitals of Mobile and Baldwin 
     Counties. . . .
       We are literally unable to compete with the salaries that 
     are being offered these individuals because of the very low 
     (.80) Medicare Area Wage Index under which we must now labor.
       Already our ability to handle the volume of patients being 
     seen in our emergency rooms has been hampered and the waiting 
     time has increased significantly. Already this summer we have 
     had occasions where one or more of our hospitals have had to 
     declare a ``Code Red'' status, meaning that they could not 
     accept any more patients in their facility that would require 
     intensive care due to a lack of staffed intensive care beds.

  As a matter of fact, this weekend I was in an airport and talked to 
an administrator at one of our area hospitals. He told me for the first 
time in years, they cannot accept more patients. This is a great 
hospital. My mother has been there a number of times; other relatives, 
including my father, have been hospitalized there. I said: You mean you 
don't have beds or you don't have nurses?
  He said: We don't have nurses. We have the beds. We don't have 
nurses.
  This index situation is working in a perverse way so that when you 
economize, when you reduce your cost and cut your salary and negotiate 
toughly with nurses and pay them the most minimum salary you can get 
away with paying them, then they come back the next year and rate your 
wage

[[Page 21179]]

costs lower. Then they want you to cut it again next year. This thing 
is getting out of sync.
  We have nurses in Alabama--and I have heard this all over the State 
in talking to administrators--who go off for a week or two. They work 
long hours at nearly twice the salaries they make in the State of 
Alabama. Then they quit working at the local hospitals where they have 
worked before. This is done because the majority of health care in 
hospitals in most areas of the country is Medicare/Medicaid work. So if 
you are not paying a living wage, if you are not paying a basic amount 
for those Medicare payments--this is our elderly who are most often 
hospitalized--then the net result of all that is the hospital gets 
squeezed badly.
  Last year, we made a good step in increasing the overall inflation 
index for hospitals. We had reduced that substantially as part of the 
Balanced Budget Act of 1997. It helped us create a surplus in this 
country, but we realized that it was beginning to cut deeper and deeper 
and deeper into hospitals. So this helped hospitals across the board.
  I know the hospitals in more rural areas are at a double disadvantage 
because 60 percent of their reimbursement cost is based on the wage 
index.
  Again, in Mobile, one of the larger cities in the State, a city on 
the coast, Mobile's wage index is 80. They get 80 cents on the dollar. 
The average in America is $1. Some hospitals in America are being 
reimbursed at $1.50. So this is really a huge difference. That is 
almost twice.
  In Montgomery, another sizable city in the State of Alabama--Alabama 
is a State of 4 million people, an almost average State in America--it 
is being reimbursed at 74 cents on the dollar. That is half what you 
are getting reimbursed in some other areas of this country.
  It is draining our qualified nursing personnel and endangering health 
care, causing the poor to be poorer and the rich, in a way, to get 
richer. At least the poor will get poorer. Nobody is getting rich on 
Medicare reimbursement today.
  I will share one more letter from the Baptist Health Care System of 
the State of Alabama. I talked with Dennis Hall a number of times. I 
have visited in several of his hospitals around the State of Alabama. 
He is passionately of the belief that the wage index is devastating 
their health care system. He said:

       The national crisis is affecting hospitals in Alabama in 
     dramatic ways. Most of the hospitals in Alabama, including 
     the very strong Baptist Health System, are losing money on 
     operations. We have counted on interest earnings on reserves 
     to offset losses. However, most institutions are now facing 
     losses on their reserves also.
       Our total losses in operations for our year ended June 30, 
     2001 will be in excess of $21 million. Charity, Medicaid and 
     Medicare played a big role in causing these losses. We simply 
     cannot continue to sustain these operating losses. We 
     certainly cannot be adequately prepared to respond to bio-
     terrorism should it strike one of our hospitals where we 
     serve.

  Mr. President, I have also a letter from the Coffee Health Group. I 
visited the Coffee Health Group. It is in Florence, AL, the Quad Cities 
area. There are a number of people in this area, a series of smaller 
communities in a fairly sizable metropolitan area.
  This is what Carl Bailey writes me:

       The wage index is a complicated issue that I truly believe 
     few understand. Nevertheless, you have asked us to help you 
     get some grasp of the problem by describing the impact of the 
     recruitment of a registered nurse from one of our Alabama 
     hospitals (``Hospital A'') to another institution (``Hospital 
     B'') that is already receiving higher Medicare payment due to 
     higher wage index.

  Hospital B will pay the travel, lodging, and higher wages to recruit 
the RNs. This additional cost to Hospital B actually increases the wage 
index for Hospital B.
  The hospital that is hiring a person at a higher wage and paying all 
these costs then bills that to create a higher wage index.
  This increase can only be paid from other areas because of budget 
neutrality.
  Get that? This increase for Hospital B that is paying a higher wage 
can only be paid from taking money from the other areas because of 
budget neutrality. We only have a certain pot of money.
  Therefore, Hospital A must share in the cost of paying for the 
increased wages of Hospital B. Since Hospital A cannot replace this RN, 
Hospital A's average wage decreases due to the loss of an employee with 
a higher than average hourly rate.
  You get that? Hospital A's, the losing hospital's wage index goes 
down because their wage rate goes down because they lost one of their 
higher paid people and one of their better people.
  This lowers the wage index for Hospital A and because of budget 
neutrality further increases the wage index gain for Hospital B. To 
respond to the shortage of staff, Hospital A then hires two or three 
nursing assistants to share the workload, reducing the number of 
nurses. This creates an even lower wage index for Hospital A which 
decreases the wage index even more. It also decreases the quality of 
care in Hospital A. Again, because of budget neutrality, the decrease 
in reimbursement to Hospital A is passed on as a higher wage index to 
Hospital B. Hospital B is now in a better financial position to hire 
additional employees from Hospital A than they were before, and the 
cycle continues.

       Although this scenario takes three years to play out, the 
     mechanics are very real. We in Alabama have been living with 
     similar recruitment strategies and subsequent negative 
     reimbursement impact that has occurred in the past. Our loss 
     in the past cannot be recruited, but we must stop the flow of 
     Medicare funds from the ``have-nots'' to the ``haves.''

  Mr. President, those are the points we are making. This affects 
hospitals all over America, States such as New York. Both Senators from 
New York support wage index reform because their State has large 
numbers of hospitals that are being adversely affected. It is not just 
what State or what area of the State you are from; the gap has grown 
too great, and the gap is widening and accelerating. It is not good for 
quality of health care in America. We have to do something about it.
  Perhaps this is not the best bill to fix it, but I hope we can bring 
some increased attention to it. I look forward to working on it.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Iowa is recognized.
  Mr. HARKIN. Mr. President, I thank the Senator from Alabama for 
raising this very important issue. It is also an important issue to our 
providers in my State also, I might add. According to the Iowa Hospital 
Association, providers in Iowa would get about an additional $25 
million a year under this amendment. To put it simply, we are being 
discriminated against in our State and in a lot of rural areas, as I am 
sure Alabama is.
  This critical issue is at the center of States' like Iowa that are 
trying in vain to recruit and retain an adequate number of providers in 
rural areas. This is something of which I am very supportive. This is a 
point in time where I wish I were chair of the Finance Committee and we 
had a finance bill on the floor and we could take care of it right now.
  The Senator raised this issue in good faith. He is right on the mark. 
We have to change this wage index floor. We have to raise that floor. 
Also, I say to my friend from Alabama, since we are now talking about 
this issue, I ask him to look at another piece of legislation that I 
and others have introduced called the FAIR Act. The difference in 
States between Medicare reimbursement for Medicare patients on a per 
patient basis vary widely. Some States are as low as about $3,000 per 
beneficiary per year; some States are as high as $7,000 per beneficiary 
per year. In other words, if you are on Medicare in one State, the 
reimbursement rate for your State might be as high as $7,000; in 
another State, it may be less than half that amount. In Iowa, we are 
No. 50 out of the 50 States. I think Alabama is down pretty low with 
us. We need to close that gap. My bill would do just that as well as 
address the wage index floor problem this amendment seeks to address.
  My bill would take the national average and you say that no State can 
go

[[Page 21180]]

over 105 percent and no State can go under 95 percent. You would leave 
some leeway for different problems, but no State could go over 105 
percent and no State could go below 95 percent of the average. I ask 
the Senator to take a look at that because that is something that would 
even out some of the problems we have in Medicare reimbursements. But 
the bottom line is simple. Any Medicare reform bill, whether it is 
attached to an appropriations bill or goes on its own, has to include a 
provision to level the playing field and fix a system that is currently 
unfair and inequitable. Again, I would like to accept the Senator's 
amendment and include it in this bill, but the Chair and Ranking Member 
of the Senate Finance Committee have made it clear that they will 
oppose any attempt to attach amendments that fall under the 
jurisdiction of the Finance Committee--including this amendment--to 
this appropriations bill.
  I wanted to mention that, and I thank the Senator for raising this 
issue. Count me on board to work with him to see what we can do.
  Mr. SESSIONS. I think it would take a point of order to do this. I 
wanted to raise this issue, and maybe others would like to speak on it. 
I would like to go on to another issue. I have had my say at this 
point. Perhaps a vote would not be necessary on this amendment or on a 
point of order. It is a health care bill.
  It is time to talk about one of the biggest problems we have in 
health care, which I believe is the wage index. I have been to 
hospitals and talked to administrators and CFOs, the people writing the 
checks, and the heads of nursing, and they see people leave, driving up 
the wage index at another hospital and reducing theirs even further. We 
have to fix this.
  Mr. HARKIN. The Senator is right on target on this issue.
  Mr. SESSIONS. I thank the Senator for his interest and leadership.
  I yield the floor.
  Mr. SPECTER. Mr. President, I commend my distinguished colleague from 
Alabama for raising this important issue. I believe it has national 
implications. There is certainly a problem in my state of Pennsylvania.
  For those who are watching on C-SPAN II and don't understand the 
procedures, it might be worth a word or two of explanation. This is a 
matter for the Finance Committee, and they have the jurisdiction over 
this matter and have lodged an objection to having it taken up on this 
bill.
  So what we have to do is look for an opportunity to raise it in a 
context where there is a Finance Committee bill on the floor. At that 
time, I think the Senator from Alabama will have a lot of support. I 
thank him for raising the issue at this time.
  Mr. President, in the absence of any Senator seeking recognition to 
introduce an amendment, I ask our colleagues to come forward. We have 
29 amendments on the list on one side and 32 on the other, for a total 
of 61. We need to proceed to conclude this bill. The conference is 
going to be very lengthy. If we are to have the appropriations for the 
National Institutes of Health, and the education bill, and the other 
matters, we are going to have to move ahead and not have this folded 
into a continuing resolution. I urge colleagues to come forward.
  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. DASCHLE. Mr. President, I ask unanimous consent the order for the 
quorum call be dispensed with.
  The PRESIDING OFFICER (Mr. Carper). Without objection, it is so 
ordered.


                           Amendment No. 2044

  Mr. DASCHLE. Mr. President, I ask unanimous consent the pending 
amendments be set aside and that an amendment I have just sent to the 
desk be considered.
  The PRESIDING OFFICER. Without objection, it is so ordered. The clerk 
will report.
  The legislative clerk read as follows:

       The Senator from South Dakota [Mr. Daschle] proposes an 
     amendment numbered 2044.

  Mr. DASCHLE. I ask unanimous consent the reading of the amendment be 
dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (The text of the amendment is printed in today's Record under 
``Amendments Submitted.'')
  Mr. DASCHLE. Mr. President, I rarely come to the floor to offer 
amendments on appropriations because, I have to say, especially in this 
case, the chair and ranking member have done a phenomenal job under 
very difficult circumstances to get us to this point. I admire their 
work and their leadership and appreciate very much their extraordinary 
efforts as we have attempted to accelerate consideration of the 
appropriations bills.
  I come to the floor to offer this amendment in part because I believe 
this provides perhaps the only vehicle we will have to consider 
legislation that I believe ought to have the opportunity to be 
considered before the end of this year. I offer the amendment on this 
bill in part because of the importance I think this legislation holds, 
not only for firefighters but for the country as a whole.
  When the planes crashed into the World Trade Center on September 11, 
the shift had just changed at fire houses all across the country. In 
New York, firefighters who had just worked through the night could have 
gone home, but they didn't. Without a moment's hesitation, they rushed 
to what we now call Ground Zero to try to save lives.
  They climbed on the first pumper or ladder truck they saw. One group 
of firefighters even commandeered a city bus to get to the World Trade 
Center as quickly as they could. Retired firefighters who heard what 
had happened rushed from their homes. Within hours, we now know, 343 
New York City firefighters had lost their lives in the greatest 
terrorist attack in our Nation's history.
  More than 7 weeks later, other firefighters, police, and rescue 
workers continue to comb through the still smoldering pile at Ground 
Zero, still risking their lives.
  We have heard many words of praise for these heroes, and for their 
extraordinary efforts and for their first responders who risked their 
lives at the Pentagon, and in western Pennsylvania. They deserve every 
word of that praise, and far more.
  As we honor them, it is important to remember that they are not 
alone.
  Every day, in every State in America, firefighters, police officers 
and other emergency workers risk their lives to protect our safety. But 
in 18 States, they don't have the legal right to sit down with their 
employers and talk about their own health and safety.
  That is wrong, and I believe the time has come for those 
circumstances to change.
  That is why Senators Dodd and Gregg, and I are offering this 
bipartisan amendment today: the Public Safety Employer-Employee 
Cooperation amendment.
  Our amendment extends the basic right of collective bargaining to 
firefighters, police officers, paramedics, and emergency medical 
technicians.
  It guarantees public safety officers the right to form and join a 
union, and the right to bargain collectively over hours, wages, and 
conditions of employment.
  That is it.
  There are things this amendment does not do, and I want to clarify 
and emphasize that.
  It expressly forbids strikes or ``lockouts'' by public safety 
workers. It exempts all States with State bargaining laws for public 
safety workers that are equal to or greater than this proposal. And it 
preserves all management rights.
  We know the essential role firefighters, police and other first 
responders played on September 11.
  We know the role Capitol Police played on October 15. When a member 
of my staff opened a letter containing anthrax, Capitol police officers 
were immediately notified and were there immediately as well. They 
risked their lives to protect us. As a result, six law enforcement 
officers were exposed to the deadly bacteria. Today, every one of them 
is on the job.

[[Page 21181]]

  Capitol Police are all working 12-hour, 14-hour days, 6 days a week, 
to protect us all; and they are all union members.
  People who say that protecting public safety workers' basic rights 
will somehow jeopardize the public safety simply do not understand the 
dedication of the men and women who take these jobs.
  We owe them our thanks. We owe them the basic right to collective 
bargaining. We owe them this opportunity to look out for themselves in 
the best way they know how, in their health, in their work, and in 
their lives.
  So, Mr. President, I hope that our colleagues will look favorably on 
this amendment. I commend the extra effort made by Senators Kennedy and 
Dodd in particular, and Senator Gregg, who has been an outspoken 
advocate and proponent of this legislation. I am grateful to them. I am 
especially grateful for the opportunity this afternoon to offer this 
amendment with their support.
  Mr. KENNEDY. Mr. President, I thank our leader, Senator Daschle, for 
the introduction of amendment No. 2044 to this Health and Human 
Services appropriations. I welcome the opportunity to cosponsor this 
with him.
  So much of the Labor, HHR appropriations bill addresses the well 
being of our Nation's workers. We must meet the needs of all our 
workers, including our public safety workers, who do so much for us. 
The firefighters tell us that this amendment is their highest priority. 
This amendment is the least we can do for them, in light of the 
sacrifices they have made for our country.
  This amendment is an important bipartisan effort to help protect our 
Nation's public safety officers on the job. I have been pleased to work 
with my Republican cosponsors, Senator Gregg, Senator DeWine, and 
Senator Snowe. This amendment will measurably add to the caliber of our 
defense against threats to the security of our communities. It will 
also further this country's historic commitment to collective 
bargaining. I can point out to the Senate the substance of this 
amendment, in legislation, passed overwhelmingly from our Senate Labor 
and Human Resource Committee.
  I know that no one in this room needs to be reminded of the heroic 
efforts made by the country's public safety officers in the last 10 
days. The pictures of tired, dust covered firefighters confronting 
unimaginable horror are permanently emblazoned in our minds.
  The courage and dedication of those who died--including Peter Ganci, 
the chief of the New York Fire Department; William Feehan, the first 
deputy commissioner; and Mychal Judge, the chaplain of the Department--
set a shining example for all of us. There were 344 firefighters and 
paramedics who died in the World Trade Center rescue effort. They were 
members of locals 94 and 854 of the International Association of 
Firefighters. And, just miles from the Capitol, hundreds of 
firefighters risked their lives in the rescue efforts at the Pentagon. 
America needs these men and women, now more than ever, and it is no 
exaggeration to say that we owe our lives to them.
  This amendment will ensure that firefighters, police officers, 
correctional officers, and emergency medical personnel will be afforded 
the fundamental right to bargain collectively with their employers. The 
amendment guarantees the basic rights that are necessary to meet that 
goal--to form and join a union; to bargain over hours, wages, and 
working conditions; to sign legally enforceable contracts; and to deal 
with an impasse in negotiations.
  This proposal follows in the honorable traditions of our country's 
labor laws, by recognizing the importance of collective bargaining to 
improve job conditions, increasing worker safety, and improving 
productivity. Most importantly, this amendment will lead to safer 
working conditions for public safety officers and to enhanced safety 
for the public that they serve.
  As we now know all too well, firefighters, police officers, and 
emergency medical personnel serve in some of the country's most 
dangerous, strenuous, and stressful jobs. They are frequently asked to 
risk--and sometimes give--their lives to protect the safety of others. 
We have a moral obligation to do whatever we can to increase the safety 
of these critical jobs--and thereby to add to the Nation's defense 
against threats to the public's health and safety.
  It is clear that this amendment will help us to meet these goals. The 
men and women who serve on the front lines in providing firefighting 
services, law enforcement services, and emergency medical services know 
what it takes to create safer working conditions. Ensuring that these 
professionals have a right to collective bargaining will give them a 
voice in decisions that can literally make a life-or-death difference 
on the job. Making such a difference for our country's public safety 
officers will, by definition, improve our collective safety.
  Available data prove that collective bargaining enhances safety. 
These data show that States that lack collective bargaining laws have 
death rates for firefighters that are nearly double that of States in 
which bargaining takes place.
  In States with collective bargaining, there were 1.5 firefighters 
killed in the line of duty for every 10 thousand firefighters. In 
States without collective bargaining, 2.5 out of every 10 thousand 
firefighters were killed on the job. Similarly, in 1993, firefighters 
in 9 of the 10 States with the highest firefighters death rate lacked 
collective bargaining protection.
  This amendment will also save money for States and local communities. 
A study by the International Association of Fire Fighters shows that 
States and municipalities that give firefighters the right to discuss 
workplace issues have lower fire department budgets than States without 
such laws.
  When workers who actually do the job are able to provide advice on 
their work conditions, there are fewer injuries, better morale, better 
information on new technologies, and more efficient ways to provide the 
services.
  The amendment also accomplishes its goals in a reasonable and 
moderate way. The amendment requires that public safety officers be 
given the opportunity to bargain collectively; it does not require that 
employers adopt agreements.
  Nor does it regulate the content of any agreements that are reached. 
Where States have collective bargaining laws that substantially provide 
for the modest minimum standards set forth in the bill--as a majority 
of States already do--moreover, those States will be unaffected by the 
legislation.
  Where States do not have such laws, they may choose to enact them or 
to allow the Federal Labor Relations Authority to establish procedures 
for bargaining between public safety officers and their employers. This 
approach respects existing State law and gives each State the authority 
to choose the way in which it will comply with the requirements set by 
this amendment. States will have full discretion to make decisions 
regarding their implementation and enforcement of the basic rights set 
forth in this proposal.
  This approach respects existing State law and gives each State the 
authority to choose the way in which it will comply with the 
requirements of this proposal. States will have full discretion to make 
decisions regarding the implementation and enforcement of the basic 
rights in this amendment.
  This amendment will not supersede State laws which already adequately 
provide for the exercise of--or are more protective of--collective 
bargaining rights by public safety officers. This amendment is intended 
to ensure that public safety officers have a role in addressing their 
wages, hours, and terms and conditions of employment; and to improve 
the safety and welfare of public safety officers and the communities 
they serve.
  It is a matter of basic fairness to give these courageous men and 
women the same rights that have long been enjoyed by other workers. 
They put their lives on the line to protect us every day. They deserve 
to have an effective voice on the job, and improvements in

[[Page 21182]]

their work conditions will benefit their entire community.
  I commend my cosponsors for their leadership on this important 
proposal, and I urge the Senate to approve it.
  I yield the floor and suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. HOLLINGS. Mr. President, I ask unanimous consent the order for 
the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (The remarks of Mr. Hollings are printed in Today's record under 
``Morning Business.'')
  Mr. HOLLINGS. I yield the floor.

                          ____________________