[Congressional Record (Bound Edition), Volume 148 (2002), Part 15]
[Senate]
[Pages 20876-20892]
[From the U.S. Government Publishing Office, www.gpo.gov]




                   UNANIMOUS CONSENT REQUEST--S. 3018

  Mr. BAUCUS. Mr. President, on October 1, Senator Grassley and I 
introduced a bipartisan Medicare package, the Beneficiary Access to 
Care and Medicare Equity Act. Our bill would address a number of 
Medicare payment changes--primarily reductions--that went into effect 
at the start of the fiscal year. At the beginning of the fiscal year, 
Medicare payment reductions automatically went into effect in many 
areas. What were they? Cuts to home health services. Cuts to nursing 
homes. Cuts to hospitals. One of the most damaging cuts of all, for 
Medicare physician payments, is scheduled to take place beginning 
January 1, 2003. This is the second year in a row such physician 
payment cuts would occur. Mr. President, these cuts threaten access to 
care for tens of millions of seniors across America.
  Sadly, since this bill was introduced, the Administration has 
indicated that preventing these cuts from going into effect is simply 
not a priority.
  Tom Scully, the administrator of the Center for Medicare and Medicaid 
Services made this clear last Tuesday. He said:

       It would be fine with the Bush administration if Congress 
     does not pass Medicare provider payment legislation this 
     year.
       If I had to guess right now--I guess there won't be any 
     give-back bill.

  The White House Office of Management and Budget Director, Mitch 
Daniels, also said he thinks ``the Federal Government cannot afford to 
pass a Medicare provider give-back bill.''
  Mr. President, the Administration says it cannot afford, after all 
the billions that have been spent elsewhere, to restore some of the 
cuts that have already gone into effect.
  The chairman of the House Ways and Means Committee has been equally 
unenthusiastic about addressing these cuts.
  The Administration and the chairman of the House Ways and Means 
Committee may believe this legislation is not a priority. I 
respectfully disagree. This bill is a priority. It is a priority for 
every senior who receives home health care. It is a priority for every 
senior who receives nursing home care. It is a priority for all 
Americans of all ages who depend on our teaching hospitals. And it is a 
priority to anyone who cares about ensuring our seniors receive access 
to physician services.
  Again, a large cut goes into effect for physician services after 
January 1. Last January, physicians saw their payments cut by 5.4 
percent. Already some doctors are talking about leaving Medicare. Why? 
Because they are concerned that Medicare payments may not be enough to 
allow them to pay for the costs of caring for seniors.
  If this legislation I have introduced with Senator Grassley does not 
pass, physician payments will be cut again by over 4 percent. This must 
be changed.
  Our bill also is a priority for our children. Under current law, 
funds for the Children's Health Insurance Program that have not yet 
been spent are scheduled to be returned to the Federal Treasury. I 
think this money should remain where it belongs--with the States, 
helping children. It is helping children who need health insurance 
benefits. We have about 9,500 Montana kids, and many more children in 
many other States, who are currently receiving coverage through CHIP. 
If our bill does not pass, America's kids stand to lose as much as $2.8 
billion.
  This bill is also a priority for States. We have all heard about the 
budget problems threatening States in every corner of our Nation, about 
the possibility of deep cuts to important programs and services, such 
as Medicaid. Our bill will send an extra $5 billion in fiscal relief to 
the States to forestall these cuts.
  This bill is a priority for rural America. From Montana to Maine, the 
Medicare payment system continues to discriminate against rural 
patients and rural providers. Our bill takes strong steps to address 
these regional inequities.
  This bill is a priority. I cannot imagine the administration saying 
this is not a priority, given all the other areas where we spend 
dollars. Defense, homeland security, and other issues are vitally 
important. But our Nation's health is also important, and we should 
invest in it accordingly.
  I cannot believe this administration is saying it is not a priority 
to prevent these cuts from taking effect. I cannot believe that. 
Nevertheless, that is what they say. This legislation tries to address 
that situation so those cuts do not go into effect.

[[Page 20877]]

  I said this bill is a priority. It is a priority for our seniors. It 
is a priority for our children. It is a priority for our State 
governments and rural areas in our country, for anyone who cares about 
preserving access to quality care in America.
  I might add, this is a bipartisan bill. Senator Grassley and I have 
worked very hard on this legislation. Senator Grassley is the ranking 
member of the Finance Committee. We worked together at every point to 
craft this bill. We sought input from our colleagues on both sides of 
the aisle. We met with our respective caucuses. We worked closely with 
members of the Finance Committee.
  When the Senator from Oklahoma objected to my unanimous consent 
request almost two weeks ago, he suggested this bill appeared out of 
nowhere on the Senate floor. That could not be further from the truth.
  The Senator also objected to this bill because we lack official CBO 
scoring. That issue has been cleared, as we received an official 
estimate of the bill on Friday. CBO estimates this bill would cost 
about $43.8 billion over 10 years. We guessed it would cost about $43 
billion. CBO said our guess is pretty close; it is $43.8 billion.
  I believe that is the minimum investment we should make to address 
the priorities I mentioned. So today as the Medicare payment cuts go 
into their 16th day, and as many more cuts loom on the horizon in 
January, I will again ask unanimous consent to pass S. 3018.
  Mr. President, I ask unanimous consent that the Senate proceed to the 
consideration of S. 3018, a bill to amend title 18 of the Social 
Security Act; that the bill be read a third time and passed; that the 
motion to reconsider be laid upon the table; and that any statements 
relating to the bill be printed in the Record.
  The PRESIDING OFFICER. Is there objection? The Senator from Oklahoma.
  Mr. NICKLES. Mr. President, reserving the right to object, 
unfortunately this bill did not go through committee. I ask the Senator 
if he would modify his request to refer the bill to the Finance 
Committee to be reported out within 48 hours. Will he be willing to 
modify his request?
  Mr. BAUCUS. I am sorry, I was distracted.
  Mr. NICKLES. Correct me if I am wrong, but the Senator is trying to 
pass his bill which never had a markup in the Finance Committee. I 
happen to be a member of the Finance Committee. I would like to offer 
an amendment. I know Senator Snowe has an amendment she would like to 
offer. Senator Sessions has an amendment he would like to offer, or 
myself or someone else on the committee to offer on his behalf.
  We would like other Members to have a chance to amend the bill. So 
will the Senator be willing to modify his request to request this bill 
be referred to the Finance Committee for 48 hours for a markup so all 
members on the Finance Committee would have a chance to have input on 
this particular bill?
  Mr. BAUCUS. Mr. President, in responding to my good friend from 
Oklahoma, I have a couple points. First, as my good friend well knows, 
since he is a member of the committee, this issue, the Medicare 
provider bill, has been discussed for many weeks. It was in the Finance 
Committee informally, with several discussions and meetings.
  In order to prevent the harm that these Medicare cuts represent, I 
believe, and I think Senator Grassley believes--we should check with 
him and make doubly certain--that we should pass this bill now. It 
makes more sense to pass this consensus bill than to go back and try to 
make it perfect in the view of some other Senators.
  Second, there are very few days remaining in the session. There are 
very few days remaining before the election occurs. What does that 
mean? It means under the Senate rules, anybody who wants to frustrate 
the will of the majority, frustrate the will of 99 Senators, can 
essentially do so by objecting or by offering amendments.
  The Senator knows this because we have had four separate votes on the 
issues he is indirectly referring to. Any attempt to refer legislation 
back to a committee for the purpose of offering amendments is really a 
veto tactic. It is an indirect way of accomplishing the same objective 
by objecting. As the Senator well knows, the amendments he is thinking 
of will not pass the Finance Committee, will not pass the floor, and 
will have the effect of preventing the Medicare provider bill from 
being enacted.
  So in good faith, in order to help millions of Americans, 
particularly the millions of seniors who need help right away, I could 
not agree to that modification. If there are other amendments on other 
issues such as prescription drug benefits, which I know the Senator is 
indirectly referring to, let us try at a later date to get that passed. 
We have tried for months, almost a year, to get prescription drug 
benefits passed, but there has been no breakthrough, there has been no 
agreement.
  But there has been agreement on this Medicare provider bill, basic 
agreement within the committee and basic agreement between myself, the 
chairman of the committee, and Senator Grassley, the ranking member of 
the committee. Let's not let perfection be the enemy of the good.
  Seniors need help. They need help right now. The cuts have already 
started to take effect. So let's pass this legislation, and then we can 
deal at a later date with the issues to which the Senator is referring. 
Let us get this bill passed so the seniors can get some help.
  The PRESIDING OFFICER. Is there objection?
  Mr. NICKLES. Mr. President, I object.
  The PRESIDING OFFICER. The objection is heard.
  The Senator from Oklahoma.
  Mr. NICKLES. Mr. President, I will repeat to my friend and colleague, 
the chairman of the Finance Committee, I will work with him to try to 
come up with a package that can pass this Congress this year. I want it 
to pass, and I want it to be signed into law. To come up with a package 
that the administration is opposed to means it will not become law.
  Some of us want to alleviate some of the problems. This particular 
bill the Senator has asked to pass by unanimous consent, which means no 
Senator gets to offer any amendment, flies in the face of Senate 
tradition.
  Senate tradition has always been--I did a little homework on 
Medicare. Twenty-two of twenty-three significant Medicare changes 
passed the Finance Committee in a bipartisan fashion and passed the 
Senate usually with overwhelming numbers--not all the time but usually 
with overwhelming numbers. So I was sincere in saying let us refer it 
back to committee, let us have some amendments, let us have some votes, 
and maybe we can come up with a bipartisan package that then will have 
momentum to pass on the floor.
  I might remind my friend and colleague from Montana, my suggestion 
was that is the way we should do the prescription drug bill. We did not 
do that on prescription drugs, and we ended up with no bill. Seniors 
got zero, and I am afraid if we continue going down this path on the 
so-called Medicare adjustment give-back bill, they will end up getting 
zero. I would like for us to provide some assistance by passing 
something that could become law.
  When I objected to this previously--I believe it was a week ago 
Friday, October 4--there was not a Congressional Budget Office scoring. 
The bill was just introduced, and I said: How much is it going to cost? 
To my colleague's credit, he said about forty-some-odd billion dollars, 
and it was forty-some-odd billions dollars. I said: How much will it 
cost the first 2 years? Because sometimes these 10-year estimates do 
not mean a lot but the first year or two does.
  He said that over the first 2 years it would be $10 billion. We did 
get CBO's estimate, and the first year's cost, 2003, was $10.1 billion. 
The second year's cost, 2004, was $11.8 billion. So the total cost is 
almost $22 billion the first 2 years, so it is twice as much as it was 
estimated in the original 2 years. That is real money. Can we do this 
right?
  We have a letter from AARP, and I ask unanimous consent that this 
letter be printed in the Record.

[[Page 20878]]

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


                                                         AARP,

                                  Washington, DC, October 9, 2002.
     Hon. Charles Grassley,
     U.S. Senate,
     Washington, DC.
       Dear Senator Grassley: The legislative session is drawing 
     to a close with no Medicare drug coverage in sight. Once 
     again, after years of waiting and with drug costs soaring, 
     beneficiaries and their families find that they get no help 
     from Congress. What they face instead is yet another round of 
     provider ``givebacks'' that will raise their Part B premiums.
       The provider pay hikes enacted in the Balanced Budget 
     Refinement Act of 1999 (BBRA) and the Medicare, Medicaid, and 
     SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) 
     are already costing beneficiaries $14 billion over ten years 
     in higher Part B premiums. The over $40 billion givebacks 
     package being considered by the Senate will raise Part B 
     premiums even higher--$6 billion in the first five years 
     alone. Less than 10 percent of that package would directly 
     benefit Medicare beneficiaries--the people the program is 
     supposed to be serving.
       These added costs to beneficiaries come in addition to 
     double-digit hikes in prescription drug costs for older and 
     disabled Americans, many of whom have little or no options 
     for drug coverage. Employers continue to reduce or eliminate 
     health care coverage. Medigap premiums continue to rise. And 
     now, nine more Medicare+Choice plans are pulling out of 
     Medicare.
       AARP opposes giveback provisions without drug coverage in 
     Medicare, and our 35 million members will not understand how 
     the Senate can take this course of action. Our members want 
     providers who treat Medicare patients to be paid fairly. 
     Errors or miscalculations in Medicare payment formulas should 
     be corrected. Fiscal relief to states to avoid drastic 
     Medicaid cuts should be addressed. Those can be done for much 
     less than $40 billion. And it must be done at a far smaller 
     cost to the millions of Medicare beneficiaries still waiting 
     for the Senate to fulfill its long overdue promise of 
     affordable prescription drug coverage.
           Sincerely,
                                               William D. Novelli.

  Mr. NICKLES. AARP, which I do not always agree with, basically says--
I will read this one sentence:

       AARP opposes give-back provisions without drug coverage in 
     Medicare, and our 35 million members will not understand how 
     the Senate can take this course of action.

  They have stated they are opposed to doing a give-back bill on a 
stand-alone basis.
  The House passed a Medicare adjustment bill, or give-back bill, in 
addition to passing prescription drugs. I know the Senator from Maine 
has indicated an interest in trying to do that. Asking unanimous 
consent to pass it without amendment would deny the Senator from Maine 
the opportunity to offer an amendment either in committee or on the 
floor. It would deny the Senator from Alabama the chance to do more for 
a rural provider wage adjustment, which I know Senator Sessions has 
repeatedly said he wanted to address. He should at least have that 
opportunity, either in committee and/or on the floor. To do something 
strictly by unanimous consent denies them that opportunity.
  I make those points, but I am still willing to work with our 
colleagues to see if we can do an affordable bill, one that can pass 
both the House and the Senate and be signed by the President this year. 
Maybe that is this week, maybe it is next week, maybe it is the week 
after election, but I am willing to do that this year. I am willing to 
try to get all parties together so we can actually not make campaign 
statements but we can change the law and have that law changed by a 
signature of the President. I think that is doable, but we are going to 
have to get all parties together, and to my knowledge that has not 
happened at this point.
  I yield the floor.
  Mr. HATCH. Mr. President, today I rise to join my colleagues on the 
Senate Finance Committee in cosponsoring S. 3018, the Beneficiary 
Access to Care and Medicare Equity Act of 2002. Although this bill does 
not include all that I would have wanted, and indeed includes some 
provisions with which I disagree, on balance, I believe it is necessary 
to pass such a bill this year in order to provide needed assistance to 
both Medicare providers and beneficiaries.
  I would like to take this opportunity to express my strong support 
for provisions contained in S. 3018 which increase reimbursement rates 
for physicians, skilled nursing facilities and home health agencies. 
Physicians' Medicare reimbursements were reduced by approximately 5 
percent in 2002. Unfortunately, the estimates used by the Centers for 
Medicare and Medicaid Services, CMS, when calculating the physician 
payment formula were erroneous in some cases, and, regrettably, 
physicians will continue to be subjected to large cuts in future years 
if Congress does not take appropriate action. This is simply not fair 
to physicians or their patients.
  Doctors in Utah have been calling me about this issue since late last 
year and have explained to me over and over again that these reductions 
will have a lasting, negative impact on patient care. Some Utah 
physicians have told me that they will no longer accept Medicare 
patients or, even worse, are thinking about dropping out of the 
Medicare program all together. And what impact does that have on 
patients, especially those in rural areas? In my opinion, there is no 
question it could lead to reductions in the number of Medicare 
providers in rural areas. And, for those who are left, it will be 
virtually impossible to spend quality time with patients.
  Is this our goal? I do not think so. And I will be doing everything 
possible to increase reimbursement rates to physicians to help them 
continue to provide the high quality care that patients so deserve.
  Another important component of S. 3018 is the valuable assistance 
this bill provides to rural states, such as my home state of Utah. S. 
3018 incorporates many of the recommendations included in the Medicare 
Payment Advisory Commission's, MedPAC, 2001 report on rural health 
care. This report found that beneficiaries living in rural areas 
encounter more obstacles when receiving health care than those who live 
in urban areas, primarily due to cost barriers. In addition, the MedPAC 
report stated that rural hospitals have had lower Medicare inpatient 
margins than urban hospitals throughout the 1990s. This gap has widened 
from less than a percentage point in 1992 to 10 percentage points in 
1999. These statistics not only apply to inpatient care, but also to 
most Medicare services in rural regions of our country. In the end, the 
report states the obvious, current Medicare payment policy places rural 
communities at a distinct disadvantage and changes are necessary. S. 
3018 takes steps toward addressing these important concerns and 
attempts to provide equity between rural and urban Medicare providers 
and patients. In my book, this is sorely needed.
  In addition, it is important to me that Medicare funding for Skilled 
Nursing Facilities, SNFs, is included in S. 3018. I have heard from 
facilities across my State about the dire financial situation many SNFs 
are facing due to reduced Medicare spending in fiscal year 2003. SNFs 
care for our nation's most vulnerable seniors and provide valuable 
medical assistance to these Medicare beneficiaries and their families. 
I have been working with both Finance Committee Chairman Senator Max 
Baucus and Ranking Republican Chuck Grassley on this important matter. 
While I am pleased that the Senate Medicare provider give-back bill 
provides more money to SNFs than the House-passed bill, I believe that 
the funding level for SNFs should be even higher. I intend to continue 
to work with my House and Senate colleagues on improving the Medicare 
reimbursement rates for SNFs.
  I also am pleased that S. 3018 includes provisions that will 
eliminate the 15 percent reduction in home health payments. There is no 
question in my mind that home health services are among the most 
valuable Medicare provides. Home health agencies are providing 
compassionate, caring services which, quite simply, help keep 
beneficiaries out of more costly institutional settings. Home health 
agencies across my State have urged me to support the elimination of 
this cut. They have shown me how these potential cuts could cause many 
home health providers in Utah to go out of business. Over my Senate 
career, I have been extremely supportive of

[[Page 20879]]

home health services, and will continue my advocacy for this important 
program.
  The preceding things having been said, one great concern that I have 
with S. 3018 is the impact that this legislation could have on small 
durable equipment manufacturers in Utah. The bill contains provisions 
on competitive bidding which my constituents believe could drive them 
out of business. On the one hand, I do recognize the need to ensure 
efficiency in spending for scarce Medicare dollars. On the other hand, 
though, I am deeply concerned about the effect this legislation could 
have on these companies. I am working with CMS officials and my Utah 
manufacturers to resolve concerns that have been raised about the 
competitive bidding program included in this bill and will do 
everything possible to protect small durable medical equipment 
companies in Utah and across the country.
  Let me also mention the Medicaid program. There is no secret that the 
majority of States are running deficits in this program, expected to 
reach $58 billion during this fiscal year. Adding to the urgency is the 
fact that States have also used up two-thirds of their cash and their 
``rainy day'' funds. According to a recent survey by the National 
Conference of State Legislatures, more than 40 States had instituted 
some kind of spending freeze or an across-the-board cut and 22 states 
have cut Medicaid funds.
  Included in the Baucus-Grassley legislation is a provision that would 
direct some funds back to the States for their Medicaid programs. This 
legislation increases the Federal medical assistance percentage by 1.3 
pecent for 12 months. Additionally, it directs $1 billion in state 
fiscal relief grants for Fiscal Year 2003.
  In a perfect world, this is not the approach I would have preferred 
we take to address the issue of fiscal relief for States. I have doubts 
about the advisability of using an entitlement program to address a 
shortfall in State funds. The precedence for linking an entitlement 
program to the economy is unsound policy, in my opinion. If we had 
adopted that policy years ago and were consistent in following it in 
good times as well as bad, FMAP rates would have been lowered in the 
1990s when States were experiencing surpluses, resulting in the current 
FMAP rates being much lower than they are now. I am also very concerned 
that this ``temporary fix'' will end up becoming permanent. Both the 
Federal Government and the States do not have the best record when it 
comes to cutting off a funding source we may have come to rely upon. 
However, I do recognize that States are being forced to cut back 
essential services to low and middle income individuals and families as 
a result of States' considerable budget deficits.
  Additionally, this legislation includes a much-needed fix for the 
Children's Health Insurance Program, CHIP. Without this provision, some 
$2.8 billion of unspent CHIP funds are scheduled to revert back to the 
Treasury. It is critical that States are able to access these funds. 
Some States experienced significant challenges when implementing their 
CHIP programs. However, they are meeting that challenge and have 
``ramped up'' considerably. They now are in a position to draw down 
these dollars. Given these uncertain economic times, we should not 
deprive states of funding to help finance the social safety net.
  I also believe the provision prohibiting States from using their CHIP 
monies to cover childless adults is wise policy. While I am extremely 
sympathetic to the needs of the uninsured, it is important to note that 
Senator Kennedy and I worked very hard to pass the CHIP program as a 
way of helping the 10 million uninsured children in the country. As the 
title reflects, the bill was solely directed at ``Children.'' Indeed, 
it was not the health insurance program, HIP, nor the Adult Health 
Insurance Program, AHIP, but the Children's Health Insurance Program, 
CHIP.
  If we would like to help needy, uninsured adults, by all means, let's 
look at how we can accomplish that. In fact, Senator Wyden and I have 
recently introduced a bill to jump-start that discussion. However, in 
the meantime, we should not distort the focus of a program that is 
working well to help its intended participants and lose the sense of 
mission that has made it so effective.
  Finally, I have serious concerns about the provisions in S. 3018 on 
the Section 1115 waiver process for Medicaid and CHIP waivers. I will 
be submitting a separate statement for the record which will outline my 
thoughts on this issue in more detail.
  In conclusion, I believe that passage of S. 3018, the Beneficiary 
Access to Care and Medicare Equity Act, is critical for both Medicare 
providers and beneficiaries. This legislation, while not perfect, will 
provide access to quality and affordable health care to Medicare 
beneficiaries across the country. I urge my colleagues to support this 
bill and, in my opinion, we must pass this legislation before we 
adjourn. Partisan politics needs to be put aside because this issue is 
much too important to both Medicare beneficiaries and providers. 
Medicare providers, and most importantly, the beneficiaries they serve, 
are depending on us to get this job done, once and for all. Let's not 
let them down.
  The PRESIDING OFFICER. The Senator from North Dakota.
  Mr. DORGAN. Mr. President, the two most powerful words in the Senate 
are ``I object.'' The Senator from Oklahoma has demonstrated the power 
of that by just objecting to the request by the Senator from Montana to 
bring up the Medicare provider reimbursement legislation.
  Some seem to believe there is no urgency about this issue. The 
Senator from Montana has described bipartisan legislation that I 
support very strongly and that I think it is urgent we pass. This is 
bipartisan legislation addressing an urgent, serious, and difficult 
problem. Let me describe it from the standpoints of two different types 
of health care providers.
  First of all, with respect to nursing homes, on October 1, long-term 
care facilities experienced a cliff, or a sharp drop, in their Medicare 
reimbursement. As of October 1, skilled nursing homes face a 10-
percent, or $1.7 billion, reduction in their payment rates for the 
current fiscal year, and a 19-percent cut in 2004 unless Congress acts 
to respond to it.
  We can talk about numbers, this can all be about finances, but my 
colleagues know what it really is about. It is about the quality of 
care for people in our nursing homes. If the decision is made not to 
reverse these cuts for long-term care, the quality of care is going to 
be diminished for those folks who are in nursing homes.
  I suppose one of the saddest days of my life was when I took my 
father to a nursing home some months after my mother had been killed. I 
will never forget the moment we decided he had to go to a nursing home 
and then when I took him there. He did not want to go. The time he 
spent in that nursing home meant I spent a lot of time there as well, 
and I came to understand what long-term care was all about and what the 
quality of care for our senior citizens was about. I have deep 
admiration for the people who ran that nursing home. I do not know what 
my father would have done without the care he received in that 
facility.
  In my State, we rank right near the top in this country with respect 
to the number of nursing home beds per resident in the State are 
concerned. Yet, on October 1, at a time when nursing homes are already 
struggling and do not have the money they need, we find this cliff 
exists where they get a reduction in reimbursement--and a pretty 
substantial one at that.
  Now we are nearing the last few days of this session and my colleague 
Mr. Baucus brings to the floor legislation that I think makes great 
sense. It is bipartisan. The chairman and the ranking member of the 
Finance Committee are sponsors of this legislation. They say we need to 
get this done, it is urgent, but we have people who stand up and say, I 
object.
  There are a thousand reasons to object, but there is only one good 
reason to do what we need to do here to protect the quality of care for 
vulnerable

[[Page 20880]]

seniors in nursing homes, and that is because it is our responsibility.
  I have talked about nursing homes and how important they are. The 
same is true with hospitals. For hospitals in my State, and I suspect 
the States of Montana, Iowa, and many other States, the level of 
Medicare reimbursement is going to determine whether we have hospitals 
that are available to people who need acute care, who need emergency 
care, in the future.
  Now, we have the opportunity to do something to provide decent 
payment to these hospitals.
  Under the 1997 Balanced Budget Act, everyone in this Chamber 
understands we cut too deeply. We understand that. The fact is, we have 
hospitals and nursing homes on the brink of going out of business or 
cutting back services. Rural hospitals, just about all of the hospitals 
in my State, are disadvantaged by lower reimbursement rates. In my 
State, and many others, rural and small urban hospitals receive a 
standard payment that is woefully inadequate. We have to fix that. When 
you take a look at the standardized payment for hospital payments, you 
realize the standardized payment is not standard at all. This 
legislation fixes that concern.
  I know it is the eleventh hour. The fact is that Senator Baucus and 
Senator Grassley have offered a piece of legislation that everyone in 
this Chamber knows must be done. Yet we have people walking around as 
if to say this is not an urgent problem. Check yourself into a nursing 
home and tell me it is not an urgent problem. Check into a rural 
hospital and check the financial records as you walk through the front 
door and tell me it is not an urgent problem.
  We spend a lot of time in the Senate during the year on things not so 
serious. But there is a serious problem with Medicare reimbursement. We 
often treat the light too seriously and the serious too lightly. This 
is serious. We have a responsibility now to deal with this issue.
  I hope the Senator from Montana will come to the floor every single 
day we are in session and make the same unanimous consent request until 
at some point we will not see people standing up to object. I hope he 
will come tomorrow and I hope next week. At some point we will see this 
Senate and the other body on the other side of this Capitol say: Yes, 
let's do this. We have a responsibility to get this done for nursing 
homes, for hospitals, and for other providers.
  I did not mention physician reimbursement. I will mention that when I 
talk tomorrow about this subject.
  I appreciate the leadership of the Senator from Montana and the 
leadership of Senator Grassley. This legislation is the right thing for 
right now. Not next year, not the year after, but right now. It will 
have an impact on the quality of care for the American people in 
hospitals and nursing homes across this country.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Maine.
  Mrs. SNOWE. Mr. President, I am deeply disheartened by what I am 
hearing today, the refusal to refer the Medicare provider give-back 
legislation to the Finance Committee for the deliberation and the 
consideration it deserves. Time and again this Senate has circumvented 
the traditional and conventional procedures to undermine the 
possibility of enacting a prescription drug benefit for our Nation's 
seniors.
  It is clear to me if my colleague from the other side of the aisle 
wish to achieve and accomplish a victory for our Nation's seniors, they 
will work with me and others--the Senator from Oklahoma, those of us 
who worked on this legislation in the committee--who crafted a 
tripartisan package to provide comprehensive prescription drug coverage 
for our Nation's seniors. The Senator from Vermont, Senator Jeffords, 
Senator Breaux from Louisiana, Senator Grassley from Iowa, the ranking 
member of the committee, worked together. We could make it possible.
  I am deeply disappointed by what I am hearing today. Again, it gets 
back to the all-or-nothing proposition. Some have said, we have already 
had votes on this issue. What does that have to do with our Nation's 
seniors who are denied the possibility of having a prescription drug 
benefit included in their Medicare package? That is who we should be 
talking about today. It is not an all-or-nothing proposition. We can do 
both. It is possible to do the Medicare provider give-back package the 
Senator from Montana is referring to.
  It is also possible to do a prescription drug benefit for our 
Nation's seniors and include it in one package. There is no reason we 
have to be in any other situation than including and considering these 
issues in tandem. That is the desire of the Senator from Oklahoma, 
Senator Nickles. That is my desire. That is the desire of our Nation's 
seniors. In fact, it is the desire of the largest organization that 
represent our Nation's seniors, AARP.
  I know the letter has already been printed in the Record, but I will 
read it. It is important to read.

       The legislative session is drawing to a close with no 
     Medicare drug coverage in sight. Once again, after years of 
     waiting and with drug costs soaring, beneficiaries and their 
     families find that they get no help from Congress. What they 
     face instead is yet another round of provider ``givebacks'' 
     that will raise their Part B premiums.
       The provider pay hikes enacted in the Balanced Budget 
     Refinement Act of 1999 (BBRA) and the Medicare, Medicaid, and 
     SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) 
     are already costing beneficiaries $14 billion over ten years 
     in higher Part B premiums. The over $40 billion givebacks 
     package being considered by the Senate will raise Part B 
     premiums even higher--$6 billion in the first five years 
     alone. Less than 10 percent of that package would directly 
     benefit Medicare beneficiaries--the people the program is 
     supposed to be serving.
       These added costs to beneficiaries come in addition to 
     double-digit hikes in prescription drug costs for older and 
     disabled Americans, many of whom have little or no options 
     for drug coverage. Employers continue to reduce or eliminate 
     health care coverage. Medigap premiums continue to rise. And 
     now, nine more Medicare+Choice plans are pulling out of 
     Medicare.
       AARP opposes giveback provisions without drug coverage in 
     Medicare, and our 35 million members will not understand how 
     the Senate can take this course of action. Our members want 
     providers who treat Medicare patients to be paid fairly. 
     Errors of miscalculations in Medicare payment formulas should 
     be corrected. Fiscal relief to states to avoid drastic 
     Medicaid cuts should be addressed. Those can be done for much 
     less than $40 billion.

  The fact is AARP, our Nation's largest organization that represents 
the seniors' interest, is opposed to passing a give-back program 
without including a prescription drug benefit for our Nation's seniors.
  Mr. President, we have the opportunity. Yes, we have the time. Over 
the last month, there have been a number of hearings and markups that 
have been scheduled in the Finance Committee. They have then been 
canceled on a variety of pieces of legislation, including the Medicare 
give-back. I and others in the committee, and Senator Breaux, were 
planning to offer an amendment to the Medicare provider give-back more 
than a month ago again when that legislation was scheduled for markup 
in the Finance Committee which is appropriate because that is the 
committee of jurisdiction. We intended to offer an amendment to that 
legislation. Then the markup was canceled. There were a variety of 
other markups that were scheduled in the Finance Committee over this 
last month on various issues.
  Again, we were saying if we can have time to consider these other 
important pieces of legislation, clearly we should have the opportunity 
and we have the time to consider a prescription drug package.
  Now, you might say, we had votes in July on this issue in the Senate. 
That is true. Did the Finance Committee have a markup on the 
prescription drug bill? The answer is an unequivocal no. I can't state 
why. The Finance Committee, the committee of jurisdiction, did not have 
a markup on a bill I think virtually everybody in this Chamber would 
agree is one of our Nation's top domestic priorities. Everyone would 
agree with that. So you might ask, why didn't the committee have a 
markup, going through the conventional procedures, so that both sides 
have the chance to deliberate, to

[[Page 20881]]

amend, debate, and vote upon a package? It is a very good question, a 
question to which I do not have an answer. Yet I have never had an 
answer. This is close to a $400 billion package that would provide 
prescription drug coverage to our Nation's seniors. Yet we did not have 
a markup. That clearly undermined our ability to achieve a consensus on 
this legislation.
  You could take the tax-cut legislation in the year 2001. No one knew 
what the end result of that bill would be when it came before the 
Finance Committee. We had the ability over several days to amend it, 
debate it, and vote upon the various issues the Members had presented 
to the committee. Ultimately we voted on a package. It came to the 
floor. We had more amendments. We had more than 50 amendments to the 
tax cut bill because we had the right and the prerogative to express 
our positions and our views of the States that we represent. During the 
natural course of the legislative procedure, we had the ability to 
express ourselves on that very important piece of legislation and then 
ultimately vote for its enactment.
  The same was not true when it came to this significant issue that 
affects most of our Nation's seniors. So it became an either/or 
approach. What I am saying today is let's take the Medicare provider 
give-back legislation and let's have the opportunity to also consider 
an amendment--amendments to that legislation that would include a 
prescription drug package. I will make a unanimous consent request 
shortly on that issue.
  But I think we have the time, we have the ability to do both in this 
Chamber right now. The question is, Do we have the political will? Some 
people, as I said earlier, say we have voted on this issue. It is not 
about us. It is not about us. The last time I checked, Members of the 
Senate had health care coverage that included prescription drug 
coverage. It is about our Nation's seniors, and it is making this 
institution work on behalf of the people we represent. Each of us have 
an individual and collective responsibility to make that happen.
  It is a true failure on our part that we did not make this possible. 
We worked a year and a half ago--the Senator from Vermont is here, Mr. 
Jeffords, and Senator Breaux from Louisiana, Senator Grassley and I 
worked--more than a year and a half ago to begin the process of shaping 
a comprehensive package so we could include this significant benefit in 
the Medicare Program to avoid political collisions, to avoid the 
scenario that has now manifested itself in this institution on this 
particular issue.
  But what we got instead was denial and obstruction and circumvention 
of the conventional processes of this Senate--No. 1, because we did not 
have a markup in the Finance Committee; and, No. 2, it was an up-or-
down vote in the Senate floor on two packages, no amendments. So we did 
not have the ability to work through our differences, work through the 
concerns that each of us might have in terms of how do we shape this 
most significant benefit that nobody denies the seniors deserve and 
desperately need. No one is denying that. So what is impossible about 
doing it right here and now?
  If we have had time over the last few months to schedule markups in 
the committee on various initiatives, including the Medicare provider 
give-back, then why don't we have the time to also include, in 
conjunction with those bills, a prescription drug coverage?
  How can we fulfill our commitment to our Nation's seniors if we fail 
to do that in this session of this Congress? And to provide a provider 
give-back bill that I certainly support, but also one that raises Part 
B premiums? It raises Part B premiums. And that is not my estimate. 
That is the estimate of the Congressional Budget Office.
  What we are saying is, recognizing the impact that will have on our 
Nation's seniors and the costs to them directly, when you raise Part B 
premiums, you are obviously going to have to pay more of their out-of-
pocket costs for their Medicare coverage. So why then are we not also 
considering a prescription drug benefit to ease the impact of the cost 
to our Nation's seniors, if they can even pay? Even if they can afford 
to pay out-of-pocket costs for their drugs. But most, as we know, are 
forced to choose between food and paying for their prescription drugs 
prescribed by their doctors.
  I believe we have a greater obligation. We have a greater obligation 
to build upon the support of both goals here today. I hope we will be 
able to do that. That is why I think it is so clear that we do not have 
to end this session this way. If we had the ability to consider a $43 
billion package that provides reimbursements to our rural hospitals and 
home health care, to medical providers--and they, too, will acknowledge 
how imperative this benefit is to our Nation's seniors--they certainly 
would welcome the Senate's action on both pieces of legislation in 
tandem.
  The House of Representatives passed, months ago, both a prescription 
drug bill and a Medicare provider give-back. While some may have 
differences in this Chamber with what direction and what provisions 
they included in that package, they ultimately passed a package that 
included both initiatives. I happen to believe that we have a greater 
obligation to do the same.
  I don't think we can use the rationale that we are here at this point 
in time and that we do not have the time anymore. Let's send this back 
to committee. I regret the Senator from Montana objected to the request 
made by the Senator from Oklahoma to refer this back to the committee. 
We have the next couple of days. We are going to be here. We may be 
here next week. We have the ability to mark up this legislation, both 
the provider give-back and the prescription drug bill--we have the 
time--and then report it back to the floor so each of us have the 
opportunity again to debate and amend, if at all possible, on various 
issues, and have a final vote.
  I think we should try to work together to advance a viable, 
comprehensive prescription drug plan that warrants strong bipartisan 
support. We developed a tripartisan package beginning more than a year 
and a half ago. We announced our principles a year ago July, setting 
out the framework so we would avoid the political collisions and the 
polarization and partisanship that seem to be the monkey wrenches 
grinding this legislative process to a halt.
  But again, I guess it was not sufficient to overcome those 
impediments. Those negotiations we did have during the course of the 
summer, even in the aftermath of the votes that were taken, the up-or-
down votes on the two packages--one by Senator Graham, one that was 
offered by those of us who represented the tripartisan plan--we even 
had negotiations this fall. We all felt a breakthrough compromise was 
near.
  The foundation of that compromise was going to be, in fact, the 
tripartisan package. In fact, we had one of the meetings that was 
chaired by the Senator from Montana that included more than 14 
Senators, almost equally divided across the political aisle. We were 
really focusing on the several issues that really did represent the 
areas of disagreement. Somehow the meetings were canceled.
  No explanation was given. This is all the more unfortunate and 
disappointing because I think we did have a sense of agreement.
  The bottom line is we have never been closer than we were in 
September of providing this package--a universal, comprehensive 
Medicaid benefit for our Nation's seniors. The basis of a consensus 
package exists today.
  I hope we can agree today to do both. I am committed to doing that.
  I know there are others here who are committed in this Senate to do 
what is right for our Nation's seniors. We can argue about not having 
the time. Tell that to our Nation's seniors--that we just didn't have 
time. We have time for other issues, but we don't have time for our 
Nation's seniors when it comes to this vital benefit that can make the 
difference between life and death.
  We have all heard the traumatic stories and circumstances that many 
of our Nation's seniors have been placed in because they do not have 
the kind of

[[Page 20882]]

coverage that is extended to each of us here in this institution.
  I happened to come across a poll not too long ago. It says when 
asked, Should senior Americans have the right to choose between 
different health care plans with different benefits just like Members 
of Congress and Federal employees? Of course 90 percent said, yes, they 
want to have that choice. They want to be able to choose in their 
Medicare benefit package prescription drug coverage. They would have a 
choice under the tripartisan package. They could choose the traditional 
Medicare Program, the new enhanced fee-for-service program, or the 
Medicare+Choice. But whichever program they would choose, they would 
have the option of a prescription drug benefit. That is the way it 
should be.
  We all know the Medicare Program was developed almost 40 years ago. 
It needs to be reformed and overhauled in a way that modernizes and 
reflects the kind of health care that seniors are getting today. But 
some say the traditional program works, and they should have that 
option and benefit. If they want a new, enhanced fee-for-service that 
also includes prescription drug coverage, they should have that 
benefit. But the fact is they should have a choice.
  We are told, ``the next Congress.'' I have been hearing that every 
Congress. As far as I can check, we have been talking about this for 
almost the last 4 years or more--the next Congress; the next year. It 
is here and now that we have an obligation. We have an obligation to do 
it now.
  AARP is right in saying that you can't do one without the other--
especially because it has the impact on increasing our Nation's 
seniors' Part B premiums. That, of course, has been underscored by the 
Congressional Budget Office as well--that it will raise the cost of 
Part B premiums as a result of this give-back bill. If we are going to 
do the give-back--and I wholeheartedly support that--then we also have 
a responsibility to provide this most critical coverage to our Nation's 
seniors.
  It would be a terrible oversight if we fail to do what is right. This 
action is warranted. Seniors cannot put off their illnesses, and we 
must not put off a solution.
  I come to the floor to offer a proposal that we consider not only 
Senator Baucus' legislation and provide for his legislation but also 
the tripartisan prescription drug package. I made a commitment to our 
Nation's seniors that I would protect their interests and do everything 
possible to pass the Medicare prescription drug benefit this year.
  Now is the time to be giving that consideration. To say that we don't 
have time is really failing our Nation's seniors. We do have time. We 
have time because we are considering the Medicare-provided give-back. 
We have time because a number of markups were scheduled before the 
Senate Finance Committee, and they were canceled. But there was 
obviously time that was included on the schedule for the members of the 
committees to consider other pieces of legislation for markup in 
committee. I don't object to that. But what I object to is denying our 
Nation's seniors the ability to have a prescription drug benefit 
because we are denied the ability to give voice to that benefit and to 
express our will through the traditional procedures of the committee 
and here on the floor of the Senate.
  I regret that the majority leader will not allow a vote and a vote on 
an amendment and consideration on both issues in tandem. We could do it 
in the committee and bring it to the floor. That is certainly what I 
would prefer. But if not, we ought to be able to consider both of these 
initiatives before the full Senate. We should let the process work the 
way it is designed because our Nation's seniors deserve at least that.


                       Unanimous Consent Request

  I ask unanimous consent that the Senate immediately turn to the 
consideration of S. 2; that following the reporting by the clerk, a 
substitute amendment at the desk which contains the text of S. 3018, 
the Beneficiary Access to Care and Medicare Equity Act of 2002, and S. 
2, the 21st Century Medicare Act, be considered and agreed to, the 
motion to reconsider be laid upon the table, and the bill then be open 
to further amendment and debate.
  The PRESIDING OFFICER. Is there objection?
  Mr. REID. Mr. President, reserving the right to object, I say to my 
friend from Maine, the distinguished senior Senator, that maybe she 
protesteth too much.
  The fact is the prescription drug package that she talks about did 
not get a majority vote in the Senate. The one that received a majority 
vote of 51 Senators was the Gramm-Miller amendment prescription drug 
plan. That received a majority vote of the Senate.
  I think her idea is a good idea--that we go ahead and adopt what the 
Senator from Montana, the chairman of the Finance Committee, has come 
to the floor twice today and talked about doing the Medicare give-
back--have that and have the prescription drug bill have a majority 
vote. Graham of Florida and Miller--51 votes.
  That would let the will of the Senate work where the majority of the 
Senate determines what happens. The problem was we didn't get 60 votes. 
We had 51 votes.
  I also say my friend from Maine talks about protecting the interests 
of seniors. I know she wishes to protect the interests of seniors. I 
think the best way to do that is with the best prescription drug 
package that has surfaced in the Senate--the one that received the 
majority vote of the Senate. Let us pass that. That would protect the 
interests of seniors.
  I would also say this: I say it with a smile on my face. To have the 
minority talk about us having enough time to do things is about as 
close to being ridiculous as anything I have heard. I have sat on this 
floor--not for minutes but hours, days--I have sat here for weeks while 
the minority has prevented us from doing anything. We can't pass our 
appropriations bills because they won't let us. We can't pass homeland 
defense because they won't let us. We can't pass the conference report 
on terrorism insurance because they won't let us. We can't pass the 
prescription drug bill because they won't let us. We can't pass the 
generic drug bill because they won't let us. I could go on and on.
  So don't tell me that we do not have enough time to do things. We are 
not having enough time to do things because the minority won't let us.
  So I object, unless my amendment is accepted.
  I move to amend the unanimous consent request to accept the 
language----
  The PRESIDING OFFICER. Objection is heard.
  The Senator from Maine has the floor.
  Ms. SNOWE. Thank you, Mr. President.
  In response to what the majority whip mentioned, the fact is that we 
had the opportunity and the time. The motion that I offered with 
respect to the Medicare-provided give-back legislation and the 
prescription drug benefit is including further amendments and debate.
  That is all we are asking, to have the opportunity to debate and 
amend a package on the floor of the Senate that gives our Nation's 
seniors the option of having a prescription drug benefit in the 
Medicare program. It is not a question of whether I protest too much. I 
can assure you, our Nation's seniors will protest when they learn about 
the failure of this institution to pass any prescription drug benefit.
  We were close to working out our differences on the few issues that 
really did separate us on the two packages that were before the Senate 
back in July. It really came down to several different issues. We had 
ongoing negotiations, even including additional Members who had been 
working on this issue before, because we were reaching out. We were 
close to reaching an agreement, whether it was on the cost or the 
fallback, to ensure every senior had the option and the access to a 
prescription drug benefit that was designed in that program, regardless 
of where they lived in America, so no one would be denied.
  We were close to reaching that consensus. But for some unexplainable 
reason, further negotiations were suspended. That was regrettable 
because

[[Page 20883]]

we could have been at a point where we could have enacted a 
prescription drug benefit in the Medicare program.
  When I asked for this unanimous consent, it was to also include the 
opportunity for the Senate to amend and debate this legislation. We do 
have the time. If we have the time to bring up Medicare provider give-
back legislation of more than $43 billion, then clearly we also have 
the time to consider a prescription drug bill. Then, I would argue, we 
are even further along in this institution in examining all of the 
components and provisions and the issues surrounding the development of 
a comprehensive universal package. We are much further ahead because we 
did have debate on the two proposals on the floor, but we didn't have 
the opportunity to amend our various packages. It was up or down, all 
or nothing, either/or, take it or leave it, get the 60 votes or not--
not expressing our will through the conventional procedures of this 
institution.
  I cite again the example of the tax-cut measure we ultimately adopted 
in the Senate back in May of 2001. It required several days. In that 
case, there were 50 amendments. But we expressed ourselves. We had the 
opportunity to offer amendments and then ultimately vote on a final 
package, yes or no. That is not the same opportunity that has been 
given to this issue.
  Our Nation's seniors deserve to know that. They also deserve to 
consider both of these initiatives in tandem. I have yet to hear a 
reasonable argument as to why we can't do that, why we cannot include 
both of these initiatives in one package, similar to what the House of 
Representatives did months ago. We should be able to do the same thing 
in the Senate, send the package to the conference, and work out the 
issues.
  Believe me, there is great urgency to obviously resolve both of these 
initiatives to reach a final conclusion. I think there is genuine 
interest on both sides of the political aisle here in this institution 
and on the other side to work these issues out in the final and 
remaining days of this Congress. But to say it can't be done, tell that 
to our Nation's seniors.
  Voting on an issue means nothing unless you produce results. Results 
means taking final action on a piece of legislation that is sent to the 
President of the United States. The President is eager to have 
legislation that can be signed into law to give this much-needed 
benefit to our senior citizens.
  We can do it. I hope the Senate will recognize it is a very 
reasonable unanimous consent request. I hope they will reconsider their 
objection to this request.
  Mr. REID. Would the Senator repeat herself? I was speaking to one of 
my staff.
  Ms. SNOWE. I hope the Senator would reconsider his objection to my 
unanimous consent request because this motion really is asking to 
include both issues in one package in tandem and to be able to further 
amend and debate. I think it is a reasonable request, and it is one 
that should not be denied.
  Mr. REID. Will the Senator allow me to respond?
  Ms. SNOWE. I am glad to have the Senator respond.
  Mr. REID. The Senator has asked if I would respond or reconsider. I 
have the greatest respect for the Senator from Maine. We have worked 
together on many issues. She is a fine legislator, but she is simply 
wrong.
  It seems somewhat unusual to me that in the waning hours of this 
congressional session, suddenly we want to have a debate on Medicare 
give-backs and prescription drugs. We have fought the minority all year 
long on many issues. On the list, of course, is prescription drugs. 
That is the second one we have here. We were forced to pass something 
that is good, but certainly not what we wanted with the generic drug 
bill. It is buried in the dark hole of the Republican-led House of 
Representatives because they will not go to conference.
  We have the Medicare give-backs, which is so important for the people 
of the State of Nevada and Maine and Vermont, West Virginia and 
Montana, any State in the Union, a very important piece of legislation. 
That is ready to move. We could pass that in a matter of minutes.
  The prescription drug bill I referenced, the Graham-Miller 
legislation, had extended debate on the floor. We have heard enough 
about that. People understand the issue. It got a majority vote. We 
don't need another amendable item on which we have, frankly, your side 
stall, stall, stall, as you have done all year long.
  I have reconsidered. The only thing I would suggest we do is adopt 
the proposal of the Senator from Montana, the proposal of the Chairman 
of the Finance Committee, on Medicare give-backs and stick in that, if 
we have so many on the other side who suddenly found religion and want 
to do something to help seniors with prescription drugs; that we pass, 
as a majority of the Senate has already said we should do, the Graham-
Miller prescription drug bill.
  The PRESIDING OFFICER (Mr. Feingold). The Senator from Maine.
  Ms. SNOWE. Mr. President, in response to the points made by the 
Senator from Nevada, obviously the minority do not design the floor 
schedule. That is the prerogative of the majority. The minority did not 
preclude the Finance Committee from marking up this legislation. We did 
not choose to postpone the consideration of a prescription drug package 
in the Finance Committee. The Senator from Nevada would acknowledge a 
markup in the Finance Committee was important and essential to 
achieving the consensus that is so critical in passing any significant 
piece of legislation.
  In this instance, we are discussing a package that represents more 
than $400 billion over the next 10 years.
  Mr. President, I think everybody would agree the Finance Committee 
should have had the opportunity to consider that initiative. I cannot 
think of the last time that creating a new benefit, a new package, or a 
new program that represents close to $400 billion over the next 10 
years, has not had the benefit of a markup in the committee--at least, 
if you are thinking about enhancing the ability to create the consensus 
for the final passage of that legislation. So the process was 
circumvented, for whatever reason, I do not know.
  But what I do know is what is possible today. I do know if we had the 
political will, we could resolve the few differences between the 
positions that were offered on the floor back in July that, 
regrettably, we didn't have the opportunity to amend or further amend. 
It was, again, as I said, up or down, either/or, all or nothing. Well, 
you cannot achieve cooperation and consensus on a major package of this 
kind without working through the various issues.
  So all I am asking is we have the opportunity to consider a 
prescription drug benefit in tandem with the Medicare provider give-
back. If we have time to provide $43 billion in additional assistance 
to Medicare providers--and I would wholeheartedly support that, but I 
also would support providing prescription drug coverage to our Nation's 
seniors. How can we do one without the other? I have not heard an 
explanation I think would be acceptable to the senior citizens of this 
country.
  We didn't have time? Well, where have we been over the last 2 years? 
We didn't have time, Mr. President? I don't think that is acceptable. 
How does anybody go home and say to their constituents we didn't have 
time--especially because that has been the rationale given for the last 
4 years: we will put it on to the next Congress.
  We are elected to do what is important here and now. That is our 
obligation. If we have to stay here day and night, through the weekend, 
what greater obligation do we have than to do what is important to the 
people we represent? This is an issue that has been acknowledged by 
both sides to be one of our top domestic priorities, and we are saying 
we don't have time. We don't have time in the committee. We didn't have 
time in the committee last July. We didn't have time in the committee 
last spring. We have not had time. When do we have time around here, 
Mr. President? When do we have time to do what is right in this 
institution? When do we have time? How do we do it?

[[Page 20884]]

  We had a tripartisan group from the Senate Finance Committee begin to 
work on this issue a year ago--I would say in June, and we announced 
our principles a year ago July--to avoid this type of political 
showdown, to avoid the all-or-nothing confrontation that seems to 
pervade this institution. Guess what. We are denied the ability to mark 
up this bill in the Senate Finance Committee.
  Well, I might be protesting too much, but, frankly, I think our 
Nation's seniors deserve better. I know they are protesting. Tell them 
we don't have time. Explain to them why we didn't have a markup in the 
committee that would have increased the likelihood of the passage of 
this legislation.
  Now we are hearing we should have this Medicare provider give-back. I 
endorse that, but I don't believe these are mutually exclusive issues. 
I want to make that clear. These are not mutually exclusive items. 
Obviously, AARP agrees because of the letter they sent to the 
legislative leadership, the committee leadership, and the ranking 
member of the Finance Committee, that you should not do one without the 
other. I am speaking on behalf of the seniors I represent in my State 
of Maine. They deserve better.
  I hope the Senator from Nevada will reconsider, so we have the 
ability here and now to consider the provider give-back benefit, and if 
the Senator indicates there is general unanimous agreement to provide 
that, then we can focus on the prescription drug benefit and on the few 
areas we have identified to be the issues in disagreement between what 
was offered by Senator Graham and the tripartisan package offered by 
the Senator from Iowa, Senator Breaux from Louisiana, Senator Jeffords 
from Vermont, and myself. We can do that. I hope I will hear that 
message today. Let's begin here and now.
  Mr. REID. Mr. President, I try to be very patient; sometimes I am and 
sometimes I am not. But I have to tell you the statement of my dear 
friend, the senior Senator from Maine, is really trying my patience. 
She has stated numerous times she likes the tripartisan piece of 
legislation. More power to her. The fact is, it could not get a 
majority vote in the Senate. We had a piece of legislation that got a 
majority, but she refuses to talk about that. She talks about 
committee, committee, committee. We recognize how the Senate works. The 
committee structure, I support. I have great respect for the traditions 
of the Senate. But there are times when the committees don't have full 
hearings on pieces of legislation.
  The minority should become consistent because, on the one hand, they 
are telling us if the committee works and they don't like what the 
committee does, the matter should come to the floor anyway. Let's see 
how that would work here. If something happens in the Senate Judiciary 
Committee and they make a determination and the minority doesn't like 
what happens in the committee, then it should come to the floor anyway. 
It would seem to me if you are consistent, you have to recognize we 
have a situation where we have had extensive debate that took place 
over a period of many weeks on prescription drugs. The only one that 
got a majority vote is the one I talked about--on two separate 
occasions--by Senators Graham and Miller. Let's pass that now. I think 
that is fine.
  I see the Senator from Michigan, who spent weeks of her time working 
on prescription drugs. We didn't get a prescription drug bill because 
we could not get 60 votes. But we had a majority. We passed a generic 
drug bill--not a perfect bill but a good one--that would lower the cost 
of drugs in America, not only for seniors but for everybody. It allows 
reimportation from Canada.
  Where is that bill? It's buried over in the dark hole of the 
conferences of the Republican-led House of Representatives. They won't 
even let us do that. Here we have somebody telling us we have lots of 
time. Let's do another prescription drug bill, but we want to start 
this one in the committee. When it comes to the floor, we want to have 
a lot of amendments, or a few amendments.
  We know that is a prime-time word for the big stall. That is all this 
is. I have great respect for the AARP. It is a great organization, but 
they don't run the Senate or this country. There are many people in the 
State of Nevada, and all over the country, who badly need this Medicare 
give-back. So I am willing to take my chances with AARP because the 
Republicans would not let us pass a prescription drug bill, a generic 
drug bill. I will take my chances with AARP and go with the Senator 
from Montana. Let's pass the Medicare give-back bill to help millions 
of people in America--rural America and urban America--people who badly 
need this. I am going to have convalescent centers going broke in 
Nevada, filing bankruptcy.
  Is that what we want? We had a convalescent center in rural Nevada. 
They had all kinds of problems. They did not know what to do with the 
people in the center because they were going broke. What do they do 
with them? It was the only center in town. This legislation would 
direct money to that situation.
  AARP is a great organization, but they can take that letter and 
carpet floors with it because that is not how we run the Senate. We do 
what is best for the people of our States, and the best for our States 
is to do what the Senator from Montana said to do. We tried to pass all 
kinds of legislation, and we have had the big stall. So do not have 
anyone lecture me on enough time to do things. I have spent days, 
weeks, and probably months of my life sitting here doing nothing 
because they would not let us do anything.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. Mr. President, I am thankful the Senator from Maine is 
still on the floor. I wish to respond to a couple points she made.
  I do not know that there is anybody in the Senate who wants to get a 
prescription drug benefit for seniors more than the Senator from Maine. 
Believe me, I understand that. I have been at many meetings with the 
senior Senator from Maine where she has made that very clear.
  There is also no one on the floor who wants to pass a prescription 
drug bill more than the senior Senator from Montana. The same is true 
of the Senator from Michigan, the Senator from Nebraska, and the 
Senator from West Virginia, as well as the current occupant of the 
chair, the Senator from Wisconsin. We all want to get a prescription 
drug benefit passed.
  On the one hand, there is the so-called tripartisan bill, which the 
Senator from Maine supports, and which is basically the insurance 
company model. On the other hand, there is the bill that would use 
pharmacy benefit managers, or PBMs, to administer a drug benefit. This 
is essentially the Medicare model. Reducing it to its basic simplicity, 
that is the argument.
  The Senator says she wants a prescription drug benefit passed, but 
she slyly indicates she wants hers passed. But her bill did not get a 
majority vote in the Senate. There are others who want to get 
prescription drug benefits passed who have a different view of what a 
prescription drug benefit should be, and that is the problem. Neither 
side wants to give in. Both sides think they are right.
  We just witnessed a good example of that. The Senator from Maine 
says: Bring up a prescription drug bill, but bring up hers, the way she 
wants it. She does not agree to bring up the other bill, apparently, 
that the Senator from Nevada suggested, the one that received a 
majority vote. That is the problem. Neither side agrees. Each side 
wants its bill passed.
  I say to my good friend--and she well knows this--I have worked so 
hard with her to get a prescription drug benefit passed. I called the 
meeting in my office with the Senator from Maine and with other 
Senators who were key Senators on this subject as a last-ditch effort 
to get a bill passed because I share with her the view we owe it to our 
seniors to get a prescription drug benefit bill passed. I understand 
that.
  But the Senator knows well that there are huge differences of 
agreement. The issue is basically, should we have a more privatized 
system or not? That is basically the argument.

[[Page 20885]]

  The Senator from Maine suggests the approach that privatizes 
prescription drugs to seniors with insurance companies. That is 
basically her bill. There are others who say: No, do not do that; that 
is wrong because insurance companies will take too much for themselves; 
the insurance companies will not give the benefits to the seniors, and 
besides that, insurance companies are not sure they want to do it, 
anyway.
  It is very easy for a Senator to stand up and say: Let's do 
prescription drug benefits. The hard part is actually coming up with a 
compromise so we can reach a solution and pass a bill that does give 
benefits to our seniors.
  To be frank, I have not heard the Senator from Maine come forth to me 
or anybody with a reasonable compromise. She has been pushing for this 
insurance company model, and she is not coming up with a compromise. I 
say that because that indicates the degree of separation and the 
division in this Senate over how to get prescription drug benefits to 
seniors.
  But while we all want to pass a benefit, we also want to make sure it 
is done right. If we are going to pass legislation on the order of $400 
billion over 10 years, we have to make sure it is done right and that 
it works for seniors. It does not make sense just to pass a bill. It 
makes sense to pass a bill that works.
  I could not agree more with the Senator that we should pass a bill, 
but in all candor, at this late moment, coming up to the Chamber 
without first suggesting an honest-to-goodness compromise sounds as if 
this is obfuscation. On the surface, it sounds good: Let's pass a 
prescription drug benefit. I know she means well, but there are others 
on her side of the aisle for whom this is an obfuscation, a desire not 
to get an underlying give-back bill passed.
  The reason the Medicare give-back bill is here is because there is 
agreement. There is agreement on almost all of the provisions: an 
agreement that we should not allow the home health cut go into effect; 
agreement on what the restoration for physicians should be; agreement 
on hospital payments, the so-called standardized amount. There is 
agreement.
  But there is not agreement on how to provide prescription drug 
benefits, and the Senator from Maine well knows that. Her argument is: 
Let's just try; let's try it.
  Sometimes we have to tell it like it is. The fact is, both sides are 
so stuck in their ways that I have made the judgment that it is nearly 
impossible in the remaining days to reach agreement because we are in 
such a political season.
  If the Senator from Maine wants to come forth and give me a 
legitimate compromise, then maybe we can get a bill passed. She says 
she wants the tripartisan bill up for consideration. She does not say: 
let's sit down and work out a legitimate agreement and see if we can 
put something together.
  I would like to sit down with the Senator from Maine and see if we 
can reach agreement. I know the Senator from Maine would like to do so. 
To be honest, she has not suggested anything except the tripartisan 
insurance company model. And that plan did not even get a majority vote 
in the Senate. The approach by Senator Graham received a majority of 
votes in the Senate.
  Mr. President, if we don't pass this bill to restore Medicare 
payments, we should consider all of the seniors who may get less care 
in nursing homes, and seniors who may get less care because doctors 
will no longer provide Medicare services to patients.
  My good friend from Maine points out that the Medicare payment bill 
will increase costs to seniors. She does not tell us that of the 
increased cost to seniors 90 percent is caused by a restoration of 
payments to physicians. This restoration is needed to ensure that 
physicians will still provide care to seniors.
  If she wants doctors to continue to withdraw from Medicare, that is 
her right, that is her choice, when she complains about the amount of 
the increase seniors will have to pay. It is true that they will have 
to pay a little more. We have to figure out a solution to that. I am 
hopeful we can do it next year, and I am hopeful there will be more of 
a bipartisan mood around here.
  I know the Senator's motives are pure. Hers are pure, but I cannot 
say that for the majority of the Members on the other side of the aisle 
on this issue at this moment. I have been around here a while and know 
how this place works. I have the utmost respect for the Senator from 
Maine. She has pure motives, but her offering this unanimous consent 
request at this time is clearly an effort on the part of others--not 
her--on the part of others to try to slow down and prevent the Medicare 
give-back bill from passing.
  Mr. HATCH. Mr. President, as my colleagues are aware, I have agreed 
to cosponsor S. 3018, the Beneficiary Access to Care and Medicare 
Equity Act of 2002, because I believe it is imperative we act this year 
to correct deficiencies in Medicare payment levels that are certain to 
create hardships for providers and those they serve, beneficiaries.
  I want to take this opportunity to underscore concerns I have with 
Section 706 which deals with the process for development and 
implementation of Medicaid and CHIP waivers.
  I am sympathetic to the underlying concerns expressed by the sponsors 
of this provision, especially as they relate to coverage of childless 
adults under the CHIP program. CHIP was designed to address the needs 
of children of working parents who made too much money to qualify for 
Medicaid, but, many times, could not afford private health insurance. I 
believe that the integrity of the CHIP program must be maintained. For 
this reason, I have even opposed attempts to expand CHIP to cover 
pregnant women, because I believe funding should be devoted to 
providing coverage to uninsured children, preserving the original 
intent of this legislation. It should come as no surprise to my 
colleagues that I oppose expanding CHIP under a waiver to cover 
childless adults.
  However, there are those who do not share my views on this issue and 
I believe that they should be heard. There are those who believe that 
CHIP enrollment is not as high as it could be because parents are not 
covered by the program. They believe that one way to capture children 
under CHIP is to offer family coverage. I do not agree with that 
approach, but I do believe that there should be a debate on the issue.
  Before Congress adopts provisions which could limit both the Federal 
and State governments' ability to adopt innovative approaches to 
address the problem of the uninsured, we ought to have a thorough and 
comprehensive debate. The Senate Finance Committee should hold hearings 
on these important waiver issues prior to enacting legislation which 
could be detrimental to State flexibility and innovation. I strongly 
object to including a provision which is opposed by the Secretary of 
Health and Human Services and the National Governors Association in an 
attractive package of Medicare reimbursements and fiscal relief for the 
states. Both HHS and NGA have concerns with this provision because it 
limits a State's flexibility to provide expanded health coverage 
tailored to the specific needs of its residents.
  I believe that, as drafted, Section 706 would deter a state's attempt 
to provide health insurance coverage to those who are currently 
uninsured. Additionally, it is my view that Section 706 would not 
improve the waiver process, but would actually function as a 
disincentive for States to undergo an open dialogue with stakeholders 
as they go through the process of securing a Medicaid or CHIP waiver.
  Section 706 would require that 60 days prior to the date that a state 
submits a waiver or amendment application to the Secretary, the state 
must publish, for written comment, a notice of the proposed waiver that 
contains at least the following: projections regarding the likely 
effect and impact of the proposed waiver on any individuals who are 
eligible for receiving medical assistance or health benefits coverage. 
In addition, a State must make a statement regarding the likely effect 
and impact of the proposed waiver on any

[[Page 20886]]

provider or suppliers of items or services for which payment may be 
made under the Medicaid or CHIP program.
  It would seem to me, that we are putting the cart before the horse 
here. Isn't it the purpose of a public comment period to determine the 
effects and impacts on individuals and providers? Aren't we setting the 
States up to be criticized for coming to pre-determined conclusions 
about the effects of a proposed waiver by requiring them to effectively 
develop these conclusions before the public has had a chance to weigh 
in on the matter?
  Section 706 goes on to require that the State must have one meeting 
with the state's medical care advisory committee and two public 
hearings on the waiver. I am somewhat confused by these provisions. It 
seems to me that rather than encouraging an open and comprehensive 
dialogue in the state over a proposed waiver, Section 706, if enacted, 
would curtail and truncate the process, effectively limiting input from 
the very individuals and groups which would be affected by the waiver. 
In short, to comply with Section 706, a State could conclude what the 
effects of the waiver would be prior to public comment, hold two 
perfunctory public hearings and be done.
  Officials in my State of Utah, in developing their waiver, did not 
need the Federal Government to come in and tell them how to reach out 
to stakeholders on this issue. I am informed that the state held 
meetings for 10 months prior to getting approval for their waiver with 
low-income advocates, providers, insurance companies, employers and 
state legislators. The state held a series of work conferences and 
community meetings on issues associated with Utah's waiver. The State 
had several legislative task force meetings which were open to the 
public as well as several budget hearings, also open to the public. 
Officials from my State who were overseeing the waiver process attended 
monthly meeting of advocate groups and met repeatedly with their 
medical care advisory committee.
  Now, it might be that other States contemplating a waiver might not 
need such a comprehensive public outreach effort. Other states could 
determine they should emulate such an approach. Is it really the role 
of the Federal Government to micro-manage this process?
  Section 706 would also require states to file copious records 
documenting detailed descriptions of the public notice and input 
process; copies of all notices, dates of meetings and hearings; a 
summary of the public comments; and, a certification that the state 
complied with any applicable notification requirements with respect to 
Indian tribes.
  If we are looking for ways to encourage unwilling states to reach out 
to the public for input, one of the least effective ways to do so, in 
my opinion, is to require States to jump through a bunch of 
bureaucratic hoops. This will not foster open debate nor will it 
encourage the states to try and draw a buy-in from stakeholders. 
Instead, in my opinion, it will create an atmosphere where the state 
will do the bare minimum in order to meet the requirements and no more. 
This is not the way to promote outreach efforts and a free-flowing 
exchange of ideas. In fact, I believe that if enacted, Section 706 will 
stifle such an approach.
  In considering the role of HHS relative to the waiver process, I am 
informed that HHS Secretary Tommy Thompson has written in opposition to 
Section 706. I share the Secretary's concerns that, as drafted, this 
section would leave HHS vulnerable to costly and burdensome lawsuits. I 
agree with Secretary Thompson that State and Federal resources should 
be spent addressing the issue of the uninsured and should not go, 
instead, to fending off legal challenges from every national advocacy 
group who did not get exactly what they wanted.
  Finally, one of the facts that gets overlooked in these waiver 
discussions is that we have 41 million uninsured Americans and states 
are trying to cover them. This is really the bottom line, here, the 
states are trying to find ways to get some coverage to Americans who 
would otherwise have no coverage. Rather than looking for ways to 
inhibit the states from accomplishing this, we should be making it 
easier for them.
  I look forward to working with my colleagues on the Finance Committee 
to accomplishing this important goal.
  The PRESIDING OFFICER. The Senator from West Virginia.
  Mr. ROCKEFELLER. Mr. President, I find myself in total agreement with 
the Senator from Montana, sadly so but nevertheless very much so. But 
this situation strikes me as ironic.
  I support the position of the Senator from Montana and what he is 
trying to do with the give-back. The Senator from Maine talked about 
resolving a few minor differences, and the Senator from Montana said 
they are not minor. They have to do with whether or not a State such as 
West Virginia, which this Senator represents, will have any 
prescription drug benefits at all because there are no insurance 
companies that have any intention of coming into the State of West 
Virginia and making those available.
  I am not so sure that any would be willing to go to Maine. I do not 
think they would be willing to go to Montana. I do not think they would 
be willing to go to--well, I don't know. They probably would be willing 
to go to Florida, probably Nevada a little bit, Michigan a little bit, 
but Nebraska not very much; Wisconsin, I do not know.
  Basically, all rural States--and 81 percent of all counties in the 
United States of America are rural--will be shut out by this 
prescription drug bill which the tripartite approach embraces. I hope 
the Presiding Officer does not think for one moment the Senator from 
West Virginia is going to contemplate working out a compromise on the 
floor of the Senate, with only a few days left, when we have been 
filibustered on every single thing we have brought up, especially 
something as complicated as a difference between a pharmacy benefit 
manager and an insurance model.
  There is a lot of educating that has to go on on the Senate floor 
that has taken place in the Finance Committee. There was a vote on the 
floor. The vote said one thing and the Senator from Maine says she 
wants something else.
  I am extremely disappointed we are not able to get the unanimous 
consent that was sought to proceed to the Beneficiary Access to Care 
and Medicare Equity Act of 2002.
  I have heard nonstop from those in my State concerning the effects of 
the declining Medicare reimbursement on access to critical care 
services. The reality is we will also be unable to enact a Medicare 
prescription drug benefit for this year. Why? Because of the huge 
ideological gap which I have just finished describing.
  People can describe it as a minor difference. It is the Grand Canyon 
of difference, and it is the difference between whether people from 
populated, wealthier areas get a prescription drug benefit and 
everybody else does not.
  If that is what one wants, fine; but that is not what the Senator 
from West Virginia wants, and it is not what my people want. It is not 
what the majority of the people in this country want. Yes, they want 
something called a prescription drug benefit. But there is a question 
of saying how do they get it and who gets it? The mechanism is 
important.
  I want a prescription drug benefit. I dare say the income of Medicare 
beneficiaries in the State of West Virginia is lower--about $10,800--
than the Medicare beneficiaries in the State of Maine.
  People spend $4,000, $5,000, to $6,000 out of their pockets on 
prescription drugs. Do I want a prescription drug benefit? You better 
believe I do, but I want one which will actually get to the people I 
represent and which are represented across America in rural States.
  We do not have a choice of being able to say let's do both. We cannot 
finish that debate on this floor. We cannot reach agreement on this 
floor. Not the Senator from Maine, but there are many on the other side 
of the aisle who do not want to see that happen in some respects 
because they do not want to see the Graham-Miller bill pass because 
that would be deemed a victory for the wrong people, or something like 
that.

[[Page 20887]]

  However, one priority that cannot wait until next year is providing 
States with fiscal relief. That would include the State that the 
Presiding Officer is from.
  On July 25, 75 members--talk about a consensus. The Senator from 
Maine, Ms. Collins; the Senator from Nebraska, Mr. Nelson; and this 
Senator put forward a compromise plan, and it got 75 votes. It got half 
the Senators on the other side of the aisle to vote to provide States 
with $9 billion in assistance. That has since been somewhat cut down in 
an agreement with the Republican leader on the Finance Committee to $5 
billion, but that is still substantial relief--$4 billion in Medicaid 
and then $1 billion in Social Security's block grant. That is a lot of 
money. It will help all States.
  Since we passed that amendment by an overwhelming vote, the situation 
in the States has, in fact, gotten much worse. The last time States 
faced a budget crisis this bad was in 1983. I happen to remember that 
because I was Governor of West Virginia and our unemployment rate was 
about 21 or 22 percent. One does not forget those things quickly.
  At least 46 States struggled to close a combined budget gap of $37 
billion in the past fiscal year. This year's gap is even wider. This 
year it is going to be a combined $58 billion deficit. Most States are 
required by law to balance their budgets, something we did up until a 
year and a half ago. Then a variety of things happened, and it is no 
longer balanced. So they are being forced to slash their spending. The 
Governors do not want to, but they have to.
  This year coming up, 18 States are planning to cut families from 
Medicaid coverage, and 15 States are eliminating important health care 
benefits. Twenty-nine States are cutting or freezing provider payment, 
further jeopardizing access to health care. As a result, thousands of 
Americans, at the least, will join the ranks of the uninsured and 
countless more will find access to needed benefits reduced or 
eliminated altogether.
  Amy Goldstein reported in the Washington Post on October 11, 2002 
that in this tough fiscal climate, ``a new survey of Medicaid programs 
shows an increasing number of States are dropping certain groups of 
patients, curtailing some services, requiring poor people to help pay 
for their own care when they can, limiting access to expensive drugs 
and then cutting or freezing payments to hospitals, doctors, nursing 
homes, and other providers of care.'' Is that kind of important? You 
bet your bottom dollar it is. Fundamental access to health care.
  In Massachusetts, the legislature had to stop covering about 50,000 
unemployed adults. In California, children spent longer in foster care 
because of cuts in adoption services.
  In New Jersey, the working poor will lose access to State-funded 
health care. In Louisiana, there will not be future hospital beds 
available for low-income patients. The Kaiser Commission on Medicaid 
and the Uninsured, which nobody disputes, in a new study found that 18 
States are planning to tighten their eligibility rules in the coming 
fiscal year, compared with 8 States last year.
  As Goldstein pointed out, the most common strategy that States are 
using to cut costs is to limit their expenditures on prescription drugs 
by reducing pharmaceutical payments or making it more difficult for 
doctors and patients to select expensive but necessary medicines. Forty 
States are trying to cut costs by limiting their drug expenditures. In 
Illinois last month, Medicaid officials began requiring patients who 
need the popular antidepressant drug Zoloft to get tablets that are 
twice as strong as they need and then break the pills in half. I do not 
know if that makes a tragedy, but it sure is a lousy way to do 
business.
  Goldstein also noted that ``in a subtler strategy, some States are 
curtailing recent innovations that were designed to find more people 
who are eligible for public insurance and then make it easier for them 
to stay covered once enrolled. Delaware stopped a very good initiative 
which had been paid through an outside grant to publicize Medicaid and 
the Children's Health Insurance Program and to help clients fill out 
applications.'' They had to stop that because they had no money.
  So the ``decision being made by Governors, legislators, and Medicaid 
administrators,'' Goldstein concludes, ``underscores the pressure that 
States are confronting in a weakened economy, which I dare say will 
stay weakened for some time. Their revenues are plunging. Increases in 
unemployment and poverty are prompting more people to sign up for 
government help. As a result, States are reversing the trend that 
lasted nearly a decade when they added money and changed rules so the 
public insurance programs could help more Americans who lack health 
coverage and pay for more kinds of care.''
  The fiscal crisis has a direct impact on the families in our States 
but it also has a direct impact on local economies. Medicaid is the 
largest purchase of maternity care in the United States of America. It 
pays for half of all nursing home care which everybody faces at some 
point in their life.
  Medicaid provides significant support for local hospitals and for 
nursing homes. Providers in some instances are struggling to stay in 
business, and in many instances have stopped. Eight out of 10 hospitals 
in West Virginia are losing money. How long can they continue in small 
rural counties? The bottom line is that means Medicaid plays a critical 
role in sustaining local economies as well as people's lives and health 
care. For every dollar a State cuts from Medicaid--and that is what is 
happening--it loses between $1 and $3.31 in Federal assistance. That is 
one large loss. That loss would have otherwise gone to hospitals, to 
home health services, nursing homes, and health clinics tied into our 
local economy.
  For this reason, the legislation introduced last week in the Senate 
to increase payments to providers under Medicare, which we just failed 
to get unanimous consent on, also includes a billion dollars in fiscal 
relief for States. In many ways, States are the largest providers of 
health care, and ensuring their stability is the best way to maintain 
access.
  If Congress does not act to provide a temporary boost to Medicaid 
funding for States to help them meet their responsibility to protect 
the most vulnerable citizens, and all citizens, since a great majority 
of Medicare citizens are vulnerable, the situation will get worse.
  We have made significant progress over the last 10 years in expanding 
access to health insurance. This year, 50 million Americans are 
expected to receive health insurance through two programs: Medicaid and 
the Children's Health Insurance Program which was started in the Senate 
Finance Committee. These programs provide health coverage to more than 
10 percent of all Americans.
  In closing, this coverage is now at risk unless, as the Senator from 
Montana wants, the Congress refuses to act. This is one priority that 
cannot wait until next year. We should pass the Senate's proposal to 
reduce the current law cuts to critical Medicare providers. Even if we 
fail to do that, we must enact a provision to provide additional relief 
to the States that struggle to provide our Nation's people with the 
crucial safety net.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Maine.
  Ms. SNOWE. Mr. President, I respond to some of the issues raised by 
the Senator from Montana, for whom I have a great deal of respect. It 
is important to clarify some of the issues suggested by the Senator 
regarding the legislation I and others have proposed, the tripartisan 
legislation.
  The Senator from Montana did schedule meetings in his office with 
Senators from both sides of the political aisle, Senators who were very 
concerned about the legislation. Obviously, there were differences 
among all the Senators. We were trying to narrow the areas of 
differences.
  I was surprised by the characterization suggested by the Senator with 
respect to those meetings. He had established the agenda. In fact, he 
asked everyone at the meetings, what should be the basis for 
negotiations? What should

[[Page 20888]]

be the starting point for discussions? It was agreed by those in the 
room, when he initiated the question, that the tripartisan legislation 
should be the basis for the discussion and negotiation. The staff had 
been given instructions to develop language with respect to the three 
areas in which we had identified to be the major areas in disagreement.
  One was the assets test, one was the cost, and one was the fallback 
provisions as to whether or not the provision included in the 
tripartisan package was in and of itself sufficient to guarantee 
prescription drug coverage to a senior, regardless of where they lived 
in America. We thought our language certainly met the conditions for 
ensuring that our Nation's seniors, regardless of whether they lived in 
an urban or rural area, would have the benefit of a prescription drug 
coverage as designed in our legislation. But we were certainly amenable 
to additional language, additional protection in the legislation to 
absolutely guarantee we would provide seamless coverage in the event 
that an insurer was not providing the options for prescription drug 
coverage to seniors in a particular area of the country for whatever 
reason. So no matter what, a senior would have the benefit of the 
coverage, regardless of where they lived, and they would have a choice 
of at least two plans, so we were more than amenable. We were amenable 
even on the price tag. We were considering language on the acid test.
  The chairman did not reconvene meetings after assigning the staff 
with the responsibility of drafting the new legislation. We were never 
given reasons no additional meetings were scheduled.
  In the meantime, markups were scheduled in the Finance Committee this 
fall on various issues, including the provider give-back. We said we 
intend to offer the tripartisan package because that had the support of 
Senator Grassley, who worked on it a year and a half ago; Senator 
Jeffords from Vermont, a member of the committee; Senator Breaux from 
Louisiana; and myself as a member of the Finance Committee. We would 
offer that as an amendment and see where the process takes us in 
Finance Committee. The markups were canceled.
  If our bill was not going anyplace, as the chairman suggests, then 
why were the markups canceled? If our bill had no opportunity to go 
anyplace, why were the markups canceled? Is it because these four 
members of the Finance Committee had at least offered a basis for a 
bipartisan--in this case a tripartisan--comprehensive prescription drug 
package? We did not say it was all or nothing. We did not suggest 
inflexibility or intransigence on our part. We say let's offer this as 
a basis for amendment, further consideration, and debate and votes.
  The same was true in the unanimous consent request I presented on the 
floor that was ultimately rejected. It says ``be open to further 
amendment and debate.'' That does not suggest inflexibility. I didn't 
say take tripartisan package or nothing. I am saying the only way you 
work things out is being able to bring up the bill and offer amendments 
and debate and vote on the amendments and reach a final conclusion. Now 
we are talking about July.
  Mr. BAUCUS. To be honest, I think if all Members of the Senate were 
like the Senator from Maine, we would have an agreement. The Senator 
well knows there are a lot of other Senators in this body who were dug 
in and who very much wanted their points of view.
  We had the last meeting. We were working on five issues: Assets test, 
benefit design, Medicare reforms, consumer protections, and how to 
design a viable fallback mechanism, which would take effect in the 
event of private plans not entering a particular market. Roughly 
speaking, we were working off the basis of the so-called tripartisan 
view, but is it not also true at that time that was very loose and 
there were an awful lot of issues to work out?
  Ms. SNOWE. I would like----
  Mr. BAUCUS. It was my judgment after that meeting and checking with 
Senators on both sides of the aisle, that discussions were going 
backwards on prescription drugs. I basically made a decision that 
Senators were digging in so much that they were not going to agree.
  Ms. SNOWE. I would like to pose a question to the Senator from 
Montana as to why we didn't have any additional meetings based on your 
instructions to the staff to work out language in the various areas? I 
didn't sense there was inability to reach a consensus. It might well 
have been, after we considered and pondered the legislative language 
they were drafting, language over the weekend. We didn't have the 
opportunity to talk about those issues.
  Mr. BAUCUS. That is correct.
  Ms. SNOWE. We didn't have an opportunity to talk about the language 
the staff was instructed to draft in these three areas.
  Mr. BAUCUS. I might ask the question--the reason is because I checked 
with Senators who were at that meeting and they said: No, sorry, I am 
not going to agree with that. They are going backwards. They were going 
in the other direction. They didn't want to meet. It is unfortunate, it 
is so unfortunate. To be candid, Senator, you and I know you and I were 
the last two standing on this issue. Basically you are the last one 
standing on this issue trying to find agreement.
  But it is clear there are not enough Senators in this body who also 
want agreement at this time. That is why I think we cannot let the 
Medicare provider legislation be held hostage to another bill which 
does have an agreement.
  It is very unfortunate we could not get agreement. But it is partly 
because the Senate, as well as the House, is still a bit too partisan 
on all matters--not all matters, but most matters. Particularly on this 
issue, because it gets to a very fundamental question which this body 
and the other body will have to address, the whole country is going to 
have to address, and that is: What is the future of health care in this 
country? To what degree is it going to be privatized, to what degree 
not? That is a huge question. The prescription drug benefit debate is 
really the opening shot of that larger debate.
  I wish that were not so. I wish we could pass the prescription drug 
benefit quickly this year, but it is the judgment of this Senator, and 
I think it is the judgment of virtually every other Senator in this 
body, that it is not going to happen now. I wish that were not true.
  Therefore, I think let discretion be the better part of valor and let 
this Medicare payment bill pass.
  Ms. SNOWE. In response to what the Senator from Montana indicated, 
let me say this. Obviously I am not privy to his private conversations, 
but we were sitting in those meetings in good faith, and I didn't hear 
from anybody around that table--more than 14 Members--who resisted the 
idea we should not proceed, that we should not work out these areas, 
that it was impossible.
  Maybe in the final analysis, it might have been impossible, but that 
certainly was not the expression of the sentiment in that meeting 
during that course of time. The fact is quite the contrary. I think 
most of the Senators--as I said, it was equally divided between 
Republicans and Democrats, including Senator Jeffords from Vermont. 
There was an indication of strong interest to proceed to try to see if 
we could work through and resolve the identified areas in disagreement.
  Those are the ones I mentioned previously.
  So I didn't hear any indication there was a ``can't do'' attitude. In 
fact, just the contrary. They were suggesting we could proceed and 
instructed the staff to work over the weekend on those various areas.
  Suffice it to say we didn't have the process in the committee to work 
these through. Obviously, for whatever reasons, it did not work out as 
a result of those negotiations. But they were, I think, very close. I 
think we were very close.
  I know if those individuals sitting around the table had agreed in 
these areas, we certainly could have overcome any political obstacles 
and impediments here in the Chamber because

[[Page 20889]]

I think there is virtually unanimous desire to get something done on 
behalf of our Nation's seniors.
  I cannot imagine anybody here in the Senate would want to tell their 
seniors that somehow it could not be done. We are elected to get things 
done. We are responsible for ensuring this institution functions in a 
way that does dignity to the process. Unfortunately, I think in this 
instance we failed.
  I happen to believe on the Medicare provider give-back, if we were 
somehow to be able to resolve those differences behind closed doors, 
without a markup and on the floor, then clearly we should be able to do 
what has been deemed to be the impossible--the impossible in this 
institution--in advancing this legislation in the interests of our 
Nation's seniors. In fact, we invited the AARP to be part of our 
negotiations this fall to talk about some of the issues.
  Yes, they had concerns with the tripartisan bill, as they did with 
the bill that had been offered by Senator Graham, in providing an 
unfunded mandate on States. But the fact is, who is to say any 
legislation is perfect? We certainly didn't indicate ours was. This is 
the agreement we had reached. We were prepared to accept amendments and 
to consider different ideas. That is where we were in these meetings 
that were scheduled by the Senator from Montana in his office.
  Ultimately, there were not additional meetings, even though the staff 
had been instructed to draft language in the three areas I mentioned 
originally. The fact is, this failure is at whose expense? It is at our 
Nation's seniors' expense. As prescription drug prices go up each and 
every year by more than 15 percent, it is 2\1/2\ times faster than the 
cost of additional health care components. By 2011, the prescription 
drug spending is expected to be 15 percent of all health care spending 
in America. Rising prescription drug costs have made prescription drug 
coverage for Medicare beneficiaries less available and more expensive. 
We have seen employer-sponsored retiree health plans provide 28 percent 
of Medicare beneficiaries with prescription drug coverage, more than 
any other source. It is a major source of prescription drug coverage 
for our Nation's seniors.
  Now what are we finding? Far fewer employers are offering coverage to 
their employees. Those employers who continue to do so are requiring 
seniors to pick up a larger share of the costs. That is what we are 
talking about. The proportion of larger employers offering retiree 
health benefits dropped from 31 percent to 23 percent between the years 
1997 to 2001. Those who were requiring Medicare-eligible retirees to 
pay the full cost of their coverage rose from 27 percent to 31 percent.
  Those are not my figures. Those are the figures that have been given 
by the GAO, that have been certified. Certainly I think they underscore 
the costs of prescription drugs to our Nation's seniors and, I think, 
the challenges we face in this country if we fail to address this most 
serious problem.
  As AARP indicated in its own letter, the costs of prescription drugs 
are going up, as was said, more than 15 percent on an annual basis. 
These added costs to beneficiaries, as we have seen, because the 
Medicare provider give-back is going to increase part B premiums. There 
is no question about that. So that is going to raise the premium $6 
billion in the first 5 years alone. These added costs, as they said in 
their letter recently, come in addition to double-digit hikes in 
prescription drug costs for older and disabled Americans, many of whom 
have little or no options for drug coverage.
  Employers continue to reduce or eliminate health care coverage. 
Medigap premiums continue to rise. And now, nine more Medicare+Choice 
plans are pulling out of Medicare.
  So, you see, we do have an obligation to do what is right. I would 
not be standing here today insisting on getting this done if I didn't 
think it was possible. That is because I have had a number of 
conversations with colleagues on both sides of the aisle, on different 
sides of the issues, different philosophies. Many have indicated they 
are prepared to make concessions and develop compromise and consensus 
on this issue to get it done here and now.
  I agree with the statement that was made by the Senator from West 
Virginia with respect to the provider give-back legislation, I think it 
is necessary for our Nation's hospitals and home health care. So is 
this. They are not mutually exclusive. They go hand in glove for our 
nation's seniors.
  I have toured many of the hospitals in my State.
  I have heard firsthand from seniors in my State about the plight of 
some who have gone without prescription drug coverage.
  I was told a story about a man who had diabetes and was supposed to 
take his medication and couldn't take his medication. He knew what that 
would lead to. He didn't have prescription drug coverage. So he was 
unable to take the medication prescribed by his doctor after he was 
released from the hospital. He had diabetes which ultimately led to 
amputation and ultimately to his death.
  Those are the kinds of tragic stories we hear over and over again. 
Those are choices our seniors shouldn't have to make.
  We have the time. We have the time to do what is right.
  Mr. KYL. Mr. President, I rise in support of S. 3018, the Beneficiary 
Access to Care and Medicare Equity Act, which was recently introduced 
by the Chairman and Ranking member of the Finance Committee.
  This act would provide more than $40 billion over the next 10 years 
to improve benefits for Medicare beneficiaries, guarantee that Medicare 
beneficiaries continue to receive the high quality health care they 
deserve, and increase reimbursements to Medicare providers.
  I would prefer that we address these issues as part of comprehensive 
Medicare reform, reform that includes a new prescription-drug benefit. 
Unfortunately, the process the Majority Leader used to bring a 
prescription drug benefit to the Senate floor guaranteed its defeat, 
and no drug proposal put forward won the 60 votes necessary for 
passage. While the Senate was unable to pass a prescription drug bill, 
we still have an opportunity to address other critical Medicare issues.
  And it is critical. In 1997, Congress passed the Balanced Budget Act. 
This act made significant cuts in Medicare provider reimbursements and 
implemented new payment systems. In many cases, these cuts made sense. 
However, in some cases they went too far. Moreover, the process of 
implementing these new payment systems for home health care, hospital 
outpatient services and skilled nursing-facility services has not been 
a smooth one.
  One key area where we see this is in payments to physicians. 
Physicians are reimbursed for providing services to Medicare 
beneficiaries under a fee schedule. The fee schedule is updated 
annually under a very complex formula. The formula considers the 
sustainable growth rate which is based on four factors: the estimated 
changes in fees; the estimated changes in the average number of 
Medicare Part B enrollees, not including Medicare+Choice beneficiaries; 
estimated projected growth in real gross domestic product growth per 
capita; and estimated change in expenditures due to changes in law or 
regulations.
  On November 1, 2001, the Center for Medicare and Medicaid Services 
(CMS) announced that the annual update of the fee schedule in 2002 
would result in a 5.4 percent reduction in reimbursements. A number of 
factors led to this decline, including the adjustment by the 
sustainable growth rate. But the sustainable growth rate is flawed 
because of mistakes made by CMS. In the late 1990's, CMS overestimated 
the number of Medicare beneficiaries in the Medicare+Choice program and 
underestimated gross domestic product growth. These errors resulted in 
reimbursements greater than what they should been if CMS had not made 
them. As more accurate data came about CMS has corrected its previous 
errors. This correction has partially led to the -5.4 percent update 
this year. Additionally, physicians are looking at future payment cuts 
next year and the two years following that. Overall, physicians could 
see a 17 percent reduction

[[Page 20890]]

in reimbursements from Medicare over these four years.
  The key concern, of course, is really not so much Medicare 
reimbursements for physicians, but Medicare beneficiaries' access to 
medical care. There is increasing evidence that doctors are not taking 
new Medicare beneficiaries, are retiring early or accepting 
administrative positions. According to a report in the March 12, 2002 
edition of the New York Times, 17 percent of family doctors are no 
longer taking new Medicare patients. The Beneficiary Access to Care and 
Medicare Equity Act would increase reimbursements to physicians over 
the next three years, and, in turn, help stem the tide of doctors 
refusing to treat new Medicare patients.
  Of course, physicians are not the only health-care providers that 
this legislation would help. The legislation would eliminate a 15 
percent reduction in home health-care reimbursements mandated by the 
Balanced Budget Act of 1997. As it turns out, the Balanced Budget Act's 
original change in the payment system for home health care services 
helped save money. But it is no longer necessary to implement the 15 
percent cut. Additionally, this legislation would help smooth out the 
transition to a new payment system for skilled nursing facilities. S. 
3018 would also provide both urban and rural hospitals with increases 
in reimbursements. It has many provisions to help alleviate the 
reimbursement differences between rural and urban hospitals. Of 
particular note, S. 3018 contains a technical change that will allow 
publicly-funded safety net hospitals to negotiate for lower drug 
prices. These hospitals bear a disproportionate burden in caring for 
the uninsured in our country; allowing them to negotiate lower prices 
will save them millions of dollars.
  Another provision of note is section 805, which would provide $48 
million annually for two years to States and other providers that offer 
federally-required emergency medical treatment to illegal aliens. A 
congressionally-commissioned study by the U.S.-Mexico Border Counties 
Coalition estimates that the 24 counties along the southwest border 
incur uncompensated costs of over $200 million per year in connection 
with the provision of emergency health treatment to undocumented 
aliens. The non-border counties in southwest States, and other states, 
including New York, Florida, Illinois, New Jersey, Massachusetts, 
Washington, Colorado, and Maryland, also incur tremendous costs. The 
entire state of Arizona, for example, incurs unreimbursed costs of 
approximately $100 million per year to provide such treatment.
  These southwest States and counties, many of which have very small 
tax bases and small annual budgets, and other States should not be 
forced to bear the responsibility of providing emergency health 
treatment to undocumented aliens. These unreimbursed costs have helped 
put Arizona's and other States' affected hospitals in a state of dire 
fiscal emergency. Many hospitals have closed, or are in danger of 
closing, their emergency rooms either temporarily or permanently.
  The Balanced Budget Act of 1997 provided funding to states to help 
defray some of these uncompensated costs; however, this provision 
expired at the end of fiscal year 2001. Section 805 would specifically 
extend and refine the Balanced Budget Amendment Act of 1997 to provide 
$32 million in each of fiscal year 2003 and fiscal year 2004 to the 17 
States with the highest number of undocumented aliens, as defined by 
the U.S. Department of Justice. Additionally, in fiscal year 2003 and 
fiscal year 2004, $16 million would also be allotted to the six highest 
undocumented alien apprehension States, as defined by the U.S. 
Department of Justice.
  Forty-eight million dollars per year is just a fraction of the 
unreimbursed costs that the States incur each year, but this funding 
will at least begin to defray some of the costs.
  Although, I strongly support most of the provisions contained in S. 
3018, I do have concerns about others. For instance, section 707 of S. 
3018 provides States with a temporary 1.3 percent point increase in 
their Federal Medical Assistance Percentage, FMAP, payments, the amount 
that the Federal Government supplements States' Medicaid spending.
  Under FMAP, Medicaid funds are distributed to States based upon a 
formula designed to provide a higher Federal matching percentage to 
those States with lower relative per capita income, and a lower Federal 
matching percentage to those States with higher per capita income. This 
formula, although not perfect, is justified because States cannot 
manipulate it for their own gain; the data are periodically published 
and can be estimated with reasonable accuracy. Additionally, the use of 
per capita income is a proxy for state-tax capacity which, in turn, 
relates to a State's ability to pay for medical services for needy 
people. To put it simply: poorer States get more help than wealthier 
States.
  Unfortunately, S. 3018 ignores the Medicaid formula and gives each 
State a 1.3 percent point increase. Under this section, States that 
have been determined by the Medicaid formula to receive the lowest FMAP 
of 50 percent receive the greatest percentage increase in FMAP. States 
with the highest FMAP receive the lowest percentage increase. This is 
the exact opposite of how the funds should be allocated. The Medicaid 
formula, whatever its faults, does indicate a relative sense of need. 
It would be wrong to give the least needy States the largest percentage 
increase.
  Even though I have concerns about how funds are distributed under 
this section, I urge my colleagues to support S. 3018. It is vitally 
important that Congress enact changes to Medicare payment policies 
before we adjourn. I also support the passage of a Medicare 
prescription-drug benefit, preferably the tripartisan modernization 
proposal; but we should not allow our inability to reach a consensus on 
that matter to stop us from making the appropriate changes to 
Medicare's payment policies. Medicare beneficiaries need guaranteed 
access to high quality care, and S. 3018 is a means to that end.
  Mr. JEFFORDS. Mr. President, I first want to salute the Senator from 
Montana, Mr. Baucus, as well as my good friend and colleague, Senator 
Grassley, for their bipartisan effort and leadership in crafting S. 
3018, the Beneficiary Access to Care and Medicare Equity Act of 2002.
  As the chairman and the ranking member of the Senate Finance 
Committee, they have worked long and hard on legislation that is 
critically important to the future of health care for our citizens that 
rely on Medicare. I am proud to be a cosponsor of S. 3018, and I urge 
all of our colleagues to support its passage as soon as possible.
  In the closing days of the 107th Congress, there will be many bills 
that on their way to consideration and passage will enjoy the unanimous 
consent of the Senators. There are few of these many bills more worthy 
of our consideration and unanimous consent than this measure.
  Vermont, like so many of our States, has a healthcare system that is 
facing reductions in levels of Medicare reimbursement that are 
untenable. In some cases, these reductions took effect on October 1 and 
others will occur at the end of this month. The cuts have already led 
to fewer physicians and services being available to care for our 
elders.
  The list of cuts and reductions is long. Physicians and other 
healthcare professionals, home health agencies, critical access 
hospitals, skilled nursing facilities, sole community hospitals, and 
others are being affected. And make no mistake, these cuts translate as 
cuts in access to healthcare for our elders.
  But it is not too late. We can pass this legislation, engage in a 
conference with our colleagues in the other chamber, and have a bill 
for the President to sign before the end of this Congress.
  Once again, I want to commend Senator Baucus and Senator Grassley for 
their work on this bill and for this chance to speak to its merits 
today. It is needed legislation, it is balanced, and it is well 
crafted. Our elders need it passed. Our providers need it passed. 
Children depending on SCHIP need it passed, and our States need it 
passed.

[[Page 20891]]

We should not let this opportunity to enact this legislation go by, and 
so I urge our colleagues to support its passage.
  Also I want to commend the Senator from Maine for her statement with 
which I agree and commend her.
  The PRESIDING OFFICER. The Senator from Nebraska.
  Mr. NELSON of Nebraska. Mr. President, the Senator from Maine has 
told us what the Baucus-Grassley unanimous consent request to move the 
legislation forward won't do, what it has been said is included, what 
has not been included in it, and, therefore, as a result it shouldn't 
be considered at this point.
  I will concede the point to my friend from Maine that it is a 
tremendous shame we didn't somehow pass a prescription drug benefit for 
our seniors. I have worked with her. We even shared an amendment on the 
Patients' Bill of Rights. I know of her passion for health care and for 
the benefits for our seniors. I share those values, and I share the 
concern we all have today everywhere that we don't have a prescription 
drug benefit for our seniors.
  I have to go back to Omaha and face George and Lee, who have spent so 
much time telling me about the importance of having a prescription drug 
benefit. But you know we had three shots at it this session. One was it 
was too expensive, one was it didn't provide enough benefits, and the 
one my friend from Maine supported--the insurance model--failed by 
getting only 48 votes.
  But I come from an insurance State. And not one insurer that I spoke 
to told me they planned to offer this benefit anywhere, let alone in 
the State of Nebraska.
  There were a lot of reasons why that particular bill didn't make it. 
There were reasons why the other two bills didn't make it.
  I would like to have us pass a prescription drug benefit before we 
leave, but I don't want to do it at the expense of this legislation 
that is so necessary.
  When I go back, if we don't pass it because we try to pass a 
prescription drug benefit that causes the failure of this legislation 
which I am going to describe in a minute, I will have to face George 
and Lee. Not only will they tell me we didn't get a prescription drug 
benefit, but their physician Medicare rates are down and their doctor 
doesn't want to provide the care for them anymore. Or I have to go back 
and find out the skilled nursing facilities are not going to be funded 
or the State fiscal relief that Senators Rockefeller and Collins and I 
worked so hard to get through is now cut back from $9 billion to $5 
billion and that is not going to be available to the State.
  I agree with the passion of the Senator from Maine and her concern 
about the fact we didn't get a prescription drug benefit done yet this 
session. But I don't agree we ought to pull this legislation which is 
before us back into committee so they can attach to it a bill that 
failed, only got 48 votes, and which I don't think will work. I think 
we have to separate these two issues--and they have been separated.
  Let us talk about the bill that is now before us, the Baucus-Grassley 
bill, a bipartisan effort. The ranking Member from Iowa is pushing to 
have this considered on the floor rather than to go back and be delayed 
in committee.
  Under current law, Medicare's physician payment rates are projected 
to fall by 12 percent over the next 3 years. In Nebraska, physicians' 
losses due to the 2003-2005 cuts will total about $63 million or 
$17,230 per physician. This comes on top of a 5.4 percent payment cut 
which cost Nebraska doctors a total of $12.9 million or about $3,875 
per physician in 2002.
  An AMA survey conducted earlier this year found that one in four 
physicians either has restricted or plans to restrict the number or 
type of Medicare patients treated. One in three has stopped or intends 
to stop delivering certain services to Medicare beneficiaries.
  Additional payment cuts of an extra year will only exacerbate these 
problems and cause significant access problems in the State of 
Nebraska--a State that is already challenged geographically to be able 
to provide access to our residents.
  Let us talk for just a moment about skilled nursing facilities and 
what will happen there.
  Our skilled nursing facilities are also in jeopardy. If action isn't 
taken and if this legislation does not pass, then Nebraska's facilities 
will lose $28.48 per patient per day next year, for a total of $10 
million. There are just some that aren't going to make it. They are 
going to be in small communities that will be left out when it comes to 
skilled nursing facilities.
  When it comes to State fiscal relief, my colleague from West Virginia 
and I--both former Governors from our States--know very well what the 
impact is going to be on the States of Nebraska and West Virginia, as 
well as the rest of the States. Forty-nine out of 50 States must 
balance their budgets by law.
  It is no secret the economy is hurting. States are facing a number of 
difficult decisions as a result of that. When States have to make 
budget cuts, let me assure you it affects real people. There may be 
line items in a budget, but there are faces associated in every case.
  In a special session in Nebraska in August, the legislature made some 
drastic cuts. It wasn't pretty. Thirteen thousand kids were cut from 
Medicaid.
  That is why we have been working so closely, Senators Rockefeller, 
Collins, and I, to pass State fiscal relief, which is part of this 
legislation. Seventy-five of our Senate colleagues agreed with us when 
they supported our amendment in July. Senators Baucus and Grassley have 
included State fiscal relief in this very important provider package, 
and it is extremely important to the people in the State of Nebraska 
and the States of every one of our colleagues here in the Senate.
  If I were one of my residents of Nebraska, or one of my constituents 
watching or listening to the debate today and heard about unanimous 
consent requests, objections, sending this back to committee for 
further consideration, trying to deal with what cloture is, how many 
times, what person did what, and how many of us are all interested in 
making sure we get not only this legislation through but also a 
prescription drug benefit, they have to be confused.
  Their only question is, Why don't you just get this legislation done 
and work also on a prescription drug benefit? What has one got to do 
with the other? Don't, for heaven's sake, deny us our prescription drug 
benefit because you can't get it through, and at the same time now come 
along and make sure our doctors aren't going to get reimbursed enough, 
or our skilled nursing homes aren't going to have enough money, and our 
States are going to continue to cut back on Medicaid benefits. Separate 
the two issues and get them done.
  Three tries, and I don't think we are out. That is true in baseball. 
I don't think it is true here. I think we can dust off one of these 
versions and make it work well.
  I have met with Senator Snowe on a prescription drug benefit. I have 
met with everybody I can in the interest of finding a prescription drug 
benefit. I know it is possible. I also know it is difficult. But I 
think it is extremely important for us to first fulfill our obligations 
with the Baucus-Grassley effort. Let us let this come to a vote. Let us 
stop the objections. Let us withdraw the objection from the other side. 
Let us get a vote. Then let us see if a bunch of us can come back 
together--and we should--and get a prescription drug benefit.
  But, for heaven's sake, even in the greatest and most sincere effort 
in the world, we should not think about one bill here because we are 
trying to save another, when we know very well it is not going to work. 
We have not run out of time. We can do this. We should bifurcate them. 
We should separate them, get the Baucus-Grassley bill done, withdraw 
the amendment, and let us work on a prescription drug benefit so I can 
go home and I can talk to Lee and George and tell them something more 
than: Well, we tried.
  I sure don't want to have to go back and say: Well, we didn't get 
anything on prescription drugs. But that isn't

[[Page 20892]]

where the bad news ends. There is worse news. We also didn't get the 
give-back bill through, and that means if you have to go to a nursing 
home, there may not be one. Your doctor may decide he is not going to 
treat you because he has had a reimbursement dropped or if, heaven 
forbid, they have to go on Medicaid, there will not be any benefits to 
provide for seniors as well.
  I don't want to have to tell the children of Nebraska there are 
further cuts coming because we could not get the State relief, the 
FMAP, as it is called, back to the States to take care of the short 
budgets so that people are not going to be further disadvantaged by 
these unfortunate economic conditions in these times.
  I agree with my friend from West Virginia, there is more passion in 
this Senate body to pass a prescription drug benefit than you can 
imagine. The problem is very simple. We just cannot agree on how to do 
it. It cannot cost too much, the benefits cannot be too little, and we 
cannot pass something that will not work.
  I think we have the collective wisdom to find a way to do it, but it 
is going to require the collective will to do it. But this mechanism is 
not the mechanism on which to do it. And let's not sink it trying to do 
something noble for those who are the most vulnerable among us, our 
seniors. I think they can understand why we do not want to sink one 
trying to do the other.
  Mr. President, I yield the floor.
  The PRESIDING OFFICER (Mr. Dayton). The Senator from West Virginia.

                          ____________________