[Congressional Record (Bound Edition), Volume 149 (2003), Part 12]
[Senate]
[Pages 15909-15935]
[From the U.S. Government Publishing Office, www.gpo.gov]




   PRESCRIPTION DRUG AND MEDICARE IMPROVEMENT ACT OF 2003--Continued


                           Amendment No. 969

  The PRESIDING OFFICER. Under the previous order, the hour of 2:15 
having arrived, there will now be 10 minutes evenly divided prior to a 
vote in relation to the Dodd amendment, No. 969.
  Mr. DODD. Mr. President, do I need to ask unanimous consent the 
present amendment be temporarily set aside?
  The PRESIDING OFFICER. That is unnecessary.
  Mr. DODD. Mr. President, in the 5 minutes I have, let me discuss it 
very briefly with my colleagues.
  This amendment would allow Medicare beneficiaries the freedom to move 
between plans for the first 2 years that this benefit is in effect, 
from 2006 to 2007. Under the present bill, you have to make a decision 
immediately and then you are locked into that decision for a year. Then 
you would have an open enrollment period for a month after that, and 
then you would be locked in for another year.
  What we are offering with this amendment is initially seniors be 
given a 2-year window in order to decide which plan works best for 
them. Then you would go to the 1 year with the 1-month open enrollment. 
But, initially, given the tremendous amount of potential confusion 
about which of these various alternatives would work best for people, 
they ought to be given a bit more time than to have to make an almost 
instantaneous decision about which of these plans is best suited for 
them.
  One of the hallmarks that has been used to describe this bill is it 
is to give people choice--flexibility and choice. All we are suggesting 
is an additional 2 years, if you will, not requiring an immediate 
decision but a 2-year window in order to make that choice so people are 
more well informed.
  There are a number of areas in the underlying bill that do not go 
nearly far enough, in my view, to serve Medicare beneficiaries. But I 
believe this is a good first step, at least as presently proposed. I am 
inclined to be supportive of this bill. These are some small points I 
think could help make this a better bill.
  If enacted, the underlying bill would require, as I mentioned, 
Medicare beneficiaries to choose a prescription drug plan and to stay 
with that plan for a minimum of 1 year. With the enactment of such 
broad and sweeping changes in the Medicare Program, I am fearful many 
Medicare beneficiaries will face great uncertainty trying to find the 
best plan to meet their particular needs. Beneficiaries would be faced 
with a menu of plans offering varying premiums, copayments or 
coinsurance, drug formularies, and all the other variables that make up 
a prescription drug benefit. It may not be immediately clear to people 
over the age of 65 which of these plans is going to best suit their 
needs. It is not difficult to imagine a scenario where this could 
become a significant problem, possibly even affecting the health and 
well-being of the beneficiary we are trying to assist with this 
legislation.
  A senior on a tight budget might enroll in a plan in an area that 
offers slightly lower premiums and coinsurance. Perhaps that 
beneficiary is on blood pressure medication and, after enrolling in the 
plan, discovers the particular medication--which she has been taking 
for years and has proven to be effective for a condition, with minimal

[[Page 15910]]

side effects--is not part of the formulary for the plan she chose 
immediately.
  What I am suggesting is, What are her options? As the bill is 
currently written, she is stuck with that plan for at least a year. So 
she can try to navigate the hurdles and obstacles that would allow her 
to take an off-formulary drug, or switch to another drug that might not 
be as effective or cause severe side effects. These are not optimal 
choices.
  One of our stated goals is to give seniors as much of a choice as 
possible, and I am firmly behind that goal, as I mentioned at the 
outset of these remarks.
  I do not want to suggest for a second that we should reduce choice or 
create simplicity, nor do I question the importance of cost-control 
mechanisms such as formularies. However, with choice and 
differentiation comes uncertainty. I believe we can greatly relieve 
this uncertainty by allowing those initially choosing prescription drug 
plans for the very first time the opportunity to move from one plan to 
another to determine which of these plans offers the best plan to fit 
their needs, and to give them the opportunity of doing that for a 2-
year period, and then go to the open enrollment period and a 1-year 
after that.
  I asked people in my own State to take a look at this proposal. In 
fact, this language comes from them. Their suggestion is this language 
I have on this chart. I will read from it:

       The amendment which you are proposing is essential to 
     ensure fair and informed access to the health plans which are 
     planned under the terms of S. 1.

  By the way, these people are very much supportive of what Senator 
Grassley is doing in this bill. They say:

       Our experience with Medicare beneficiaries in Connecticut 
     and nationally has shown that the ability of a Medicare 
     beneficiary to change from plan to plan, especially during 
     the period after initially choosing a plan, is of utmost 
     importance. Making choices about which health plan is best is 
     often confusing for a Medicare beneficiary, especially for 
     those who are elderly, frail or having medical problems. 
     Comparing plans and choosing the right plan can be a 
     complicated process, and Medicare beneficiaries who discover 
     they have not made the most informed choice, whose experience 
     with a plan demonstrates it is not adequate to meet their 
     needs, or who have changes in their life circumstances, need 
     to have some ability to change from one plan to another. Only 
     with this ability to change can they be assured the 
     opportunity to receive the kind of health care they want, and 
     the fullest health benefit they need, to meet their 
     individual circumstances under the Medicare program.

  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. DODD. Mr. President, I ask unanimous consent for 30 additional 
seconds.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. DODD. All we are asking is, instead of forcing people to make 
that initial decision, they be given that 2-year window to sort this 
out. And then you move into the 1 year and the window opens, and so 
forth. I do not think this has any significant financial implications. 
It is just allowing people to make intelligent, good choices which all 
of us want to provide people, particularly older Americans who could be 
terribly confused by choosing formularies and coinsurance and copayment 
plans. All that has to be done at the outset once this bill becomes 
law.
  I have used a little more time than I said I would to try to explain 
the amendment, but I want it to be clear to my colleagues why I think 
this is a very reasonable suggestion to make an improvement to this 
bill.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. DODD. I thank the Presiding Officer for his indulgence.
  The PRESIDING OFFICER. Who yields time?
  Mr. DODD. Mr. President, I ask unanimous consent that my colleague, 
Senator Lieberman, be added as a cosponsor of this amendment.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Who yields time?
  Mr. DODD. Mr. President, if they don't want to talk, I will be glad 
to take a little more time to explain this amendment.
  Mr. GRASSLEY. Mr. President, I will yield the man 1 minute of my 
time.
  Mr. DODD. Mr. President, I thank the man from Iowa for yielding the 1 
minute.
  The PRESIDING OFFICER. The Senator is recognized for 1 minute.
  Mr. DODD. The man from Connecticut appreciates the man from Iowa 
giving him 1 more minute.
  Mr. President, very briefly, the existing underlying bill says you 
have to make this choice about which plan you want to go into almost 
immediately once this proposal becomes law. We are suggesting that at 
the outset you give people a 2-year window to shop wisely. They may 
make the decision right away. They may make it within a month or two. 
But knowing how confusing this can be, knowing that different 
formularies provide for different medications, we ought to provide 
people at least some opportunity to get this right to the extent they 
can. So this is merely opening up that window from an immediate choice 
to a 2-year choice--anytime within that 2 years to make that right 
choice.
  There have been some who wondered, if you move from one plan to the 
next, what are the cost implications? I will be glad to respond to 
that. We do not think that is terribly complicated to figure out. If 
you have reached your deductible levels, obviously, the same would have 
to apply. You would not start all over in that 1-year period. So 
whatever costs you have incurred, whatever expenditures you have made 
or not made would move from one plan to the next, at least as far as 
the cost goes.
  So the additional time should not have any additional financial or 
fiscal implications but merely the choice of saying to people, who are 
older Americans: You get a little more time to sort this out. That is 
all I am suggesting with this amendment.
  I would hope the committee might support it. It is not a radical 
proposal.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mr. DODD. I thank the Senator.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. Mr. President, I yield myself such time as I might 
consume.
  I know the Senator from Connecticut has well-intentioned motivations 
behind his amendment. The reason why I oppose the amendment is not 
because of any ill intent. But we have very carefully crafted this 
product before us after the Federal Employees Health Benefits Plan and 
the open season and the practice there. As far as I know, we do not run 
into Federal employees complaining because they cannot change more 
often than once a year. So I am going to ask my colleagues to vote 
against this amendment.
  It has some costs. I will speak about that. The open enrollment 
period in S. 1, as I said, is modeled after the annual open enrollment 
period of the Federal Employees Health Benefits Plan. I believe this 
program has been in place for more than 40 years, so we have a lot of 
experience with it. Consequently, it is a good pattern for us to craft 
the legislation before us for senior citizens in retirement for their 
health benefits.
  Each year seniors would be able to examine the choice of plans and 
select the plan that is best suited to their needs. The amendment 
before us proposes to allow seniors to change plans more than once 
during a continuous open enrollment period that would last for 2 years. 
While this may seem a good idea on the surface, it is an invitation, I 
believe, to more expensive health care for our seniors. I think it is 
going to lead to chaos and plan instability.
  It is very important, at least in the opening years, as we get these 
new programs underway that there be some predictability in order to 
encourage more plans to compete. The more plans competing, the better 
benefits we ought to get for our seniors at a lower price.
  It seems to me that providing a long, continuous open enrollment 
period allows any and all seniors to wait until they are sick before 
enrolling in a more comprehensive plan. You can understand that we need 
to have a situation

[[Page 15911]]

where people are seen buying insurance and doing it in a way in which 
they manage their own risk as opposed to doing it in the case of only 
an emergency. This is where you get the insurance aspect that is so 
important in what we are trying to accomplish.
  So if you do that, as the Senator from Connecticut suggests, it is 
going to add costs to the program because it permits healthy enrollees 
to stay in the cheaper basic plan until an illness drives them to a 
generous plan. The generous plan then would become the plan just for 
sick enrollees.
  I have a statement here that the CBO says this would have a cost of 
$8 billion over the years 2004 to 2008, and $23 billion for the 10-year 
period 2004 to 2013.
  I am going to yield back the remainder of my time.
  The PRESIDING OFFICER. All time has expired.
  Mr. DODD. I ask unanimous consent for an additional 30 seconds.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  Mr. DODD. Mr. President, this is one time. Unlike Federal employees, 
who are 30 or 35 years of age, this plan is all new. What we are saying 
is, for the very first 2 years--that is all, just the first 2 years--
give seniors the flexibility so they do not have to sign up for a plan 
immediately. You get a couple years within that timeframe to make your 
choice, then you go into the 1-year cycle as all the rest of us do. But 
for older Americans, it is very confusing--very confusing--for them to 
have to make that choice at the get-go, right at the very beginning. So 
that 2-year window, to have some flexibility to make a choice that best 
serves your interest, I think is a reasonable request to make for our 
older Americans. That is the end of it.
  Mr. GRASSLEY. Mr. President, I ask unanimous consent for an equal 30 
seconds.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. GRASSLEY. Mr. President, I have some sympathy for what the 
Senator from Connecticut says because so many times I have said to my 
constituents, this is voluntary. You are going to have your choice to 
go into another plan or change plans. I emphasize the ability to change 
plans. In addition, we have to have some stability even in the early 
years. Most importantly, when we are developing a new prescription drug 
benefit, the most vast improvement in Medicare in 35 years, I think it 
demands more stability than when you get down the road a ways.
  I move to table the amendment and ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The question is on agreeing to the motion to table amendment No. 969. 
The clerk will call the roll.
  The bill clerk called the roll.
  Mr. REID. I announce that the Senator from Florida (Mr. Graham), the 
Senator from Massachusetts (Mr. Kerry), and the Senator from 
Connecticut (Mr. Lieberman) are necessarily absent.
  I further announce that, if present and voting, the Senator from 
Massachusetts (Mr. Kerry) would vote ``nay''.
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 55, nays 42, as follows:

                      [Rollcall Vote No. 234 Leg.]

                                YEAS--55

     Alexander
     Allard
     Allen
     Baucus
     Bennett
     Bond
     Breaux
     Brownback
     Bunning
     Burns
     Campbell
     Chafee
     Chambliss
     Cochran
     Coleman
     Collins
     Cornyn
     Craig
     Crapo
     DeWine
     Dole
     Domenici
     Ensign
     Enzi
     Fitzgerald
     Frist
     Graham (SC)
     Grassley
     Gregg
     Hagel
     Hatch
     Hutchison
     Inhofe
     Jeffords
     Kyl
     Lott
     Lugar
     McCain
     McConnell
     Murkowski
     Nelson (NE)
     Nickles
     Roberts
     Santorum
     Sessions
     Shelby
     Smith
     Snowe
     Specter
     Stevens
     Sununu
     Talent
     Thomas
     Voinovich
     Warner

                                NAYS--42

     Akaka
     Bayh
     Biden
     Bingaman
     Boxer
     Byrd
     Cantwell
     Carper
     Clinton
     Conrad
     Corzine
     Daschle
     Dayton
     Dodd
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Harkin
     Hollings
     Inouye
     Johnson
     Kennedy
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lincoln
     Mikulski
     Miller
     Murray
     Nelson (FL)
     Pryor
     Reed
     Reid
     Rockefeller
     Sarbanes
     Schumer
     Stabenow
     Wyden

                             NOT VOTING--3

     Graham (FL)
     Kerry
     Lieberman
  The motion was agreed to.
  Mr. GRASSLEY. I move to reconsider the vote.
  Mr. SANTORUM. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.
  The PRESIDING OFFICER. Who yields time?
  The Senator from Pennsylvania.
  Mr. SANTORUM. Mr. President, I ask unanimous consent that the 
remaining two votes in this series be limited to 10 minutes each.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                           Amendment No. 981

  The PRESIDING OFFICER. Who yields time on the Pryor amendment?
  The Senator from Arkansas.
  Mr. PRYOR. I thank the Chair.
  Mr. President, the United States may be the only country in the world 
that does not protect its population from price gouging when it comes 
to prescription drugs. Last week, the Senate took a very important step 
in eliminating that by adopting the Dorgan-Cochran amendment by a vote 
of 62 to 28 to allow the reimportation of prescription drugs from 
Canada.
  This amendment gives that amendment teeth. It gives HHS 2 years to 
act, and if they do not act within 2 years, then it becomes illegal for 
prescription drug companies to sell their products in the United States 
for more than they sell them in Canada.
  Some people call this price control. I respectfully disagree, but if 
you call it price control, that means 62 of us last Friday stood up for 
price controls. What it does in reality is introduce competition on 
prices.
  There is one drug called tamoxifen. Tamoxifen is a fantastic breast 
cancer drug. One could buy it before it became generic for $241 for 60 
pills in the United States, and for $34 for 60 pills in Canada. The 
difference between $241 and $34 is very significant, and that is what 
we are trying to fix.
  I thank the Chair.
  Mr. SANTORUM. Mr. President, I hope my colleagues can hear me. What 
the Pryor amendment does has nothing to do with reimportation. What it 
says is, if the Secretary does not certify that the drugs are safe 
coming from Canada after 2 years, we will adopt the Canadian pricing 
scheme for pharmaceutical products in this country. So the Government 
of Canada will set prices for pharmaceutical drugs in this country. We 
will be ceding to the Government of Canada the right to set prices for 
drugs in the United States of America.
  If we want to have price controls for drugs, we should have a debate 
to do that, but we should not be ceding to a foreign government the 
right to set drug prices in this country, and that is what this 
amendment does.
  Whether you are for reimportation, whether you are for price controls 
for drugs, do not give up the right to set the price controls to a 
foreign government who will set them for the United States. And that is 
what this amendment does. I urge an overwhelming negative vote.
  The PRESIDING OFFICER (Mr. Crapo). The question is on agreeing to the 
amendment.
  Mr. REID. The yeas and nays are not in order.
  Mr. SANTORUM. I move to table the amendment and I ask for the yeas 
and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The PRESIDING OFFICER. The question is on agreeing to the motion.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. REID. I announce that the Senator from Florida (Mr. Graham), the 
Senator from Massachusetts (Mr.

[[Page 15912]]

Kerry), and the Senator from Connecticut (Mr. Lieberman) are 
necessarily absent.
  I further announce that, if present and voting, the Senator from 
Massachusetts (Mr. Kerry) would vote ``nay''.
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 66, nays 31, as follows:

                      [Rollcall Vote No. 235 Leg.]

                                YEAS--66

     Alexander
     Allard
     Allen
     Baucus
     Bayh
     Bennett
     Biden
     Bingaman
     Bond
     Breaux
     Brownback
     Bunning
     Burns
     Campbell
     Carper
     Chafee
     Chambliss
     Cochran
     Coleman
     Collins
     Cornyn
     Corzine
     Craig
     Crapo
     DeWine
     Dodd
     Dole
     Domenici
     Ensign
     Enzi
     Fitzgerald
     Frist
     Graham (SC)
     Grassley
     Gregg
     Hagel
     Hatch
     Hollings
     Hutchison
     Inhofe
     Jeffords
     Kyl
     Landrieu
     Lott
     Lugar
     McCain
     McConnell
     Mikulski
     Murkowski
     Murray
     Nelson (NE)
     Nickles
     Roberts
     Santorum
     Sessions
     Shelby
     Smith
     Snowe
     Specter
     Stevens
     Sununu
     Talent
     Thomas
     Voinovich
     Warner
     Wyden

                                NAYS--31

     Akaka
     Boxer
     Byrd
     Cantwell
     Clinton
     Conrad
     Daschle
     Dayton
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Harkin
     Inouye
     Johnson
     Kennedy
     Kohl
     Lautenberg
     Leahy
     Levin
     Lincoln
     Miller
     Nelson (FL)
     Pryor
     Reed
     Reid
     Rockefeller
     Sarbanes
     Schumer
     Stabenow

                             NOT VOTING--3

     Graham (FL)
     Kerry
     Lieberman
  The motion was agreed to.


                           Amendment No. 1001

  The PRESIDING OFFICER. There are 2 minutes equally divided for 
consideration of the Boxer amendment.
  Mrs. BOXER. Mr. President, I would like to explain in 1 minute a very 
important amendment that will really improve this bill. This amendment 
is endorsed by the AARP--they feel very strongly about it--in addition 
to the other major seniors organizations to preserve Social Security 
and Medicare. In the bill right now, there is a benefit shutdown when 
you reach $4,500 worth of purchased drugs. That means seniors will face 
a $1,300 deficit before they start getting the benefit. I will just 
implore my colleagues, there is not any other prescription drug plan in 
this country that does this. This is a really terrible problem for our 
people. Just when they need help the most, they stop getting help.
  I conclude, since we have so little time, by reading what AARP says:

       AARP members find the notion of a gap in coverage to be a 
     major barrier to enrolling in a Medicare drug benefit. They 
     tell us that they are unaware of similar features in any of 
     the insurance products they routinely purchase.

  In closing, they say:

     . . . we urge the Senate to eliminate this coverage gap.

  Please make this bill better, friends. It is the least we can do for 
seniors.
  The PRESIDING OFFICER. The Senator's time has expired.
  The Senator from Pennsylvania.
  Mr. SANTORUM. Mr. President, I rise in opposition to make four 
points.
  First, we had an additional $30 billion when this bill was originally 
marked up in the Finance Committee. We put all $30 billion into filling 
the donut, so we have done as much as we can with the money allocated.
  Second, this amendment costs $64 billion. We would bust the 
agreement, which is to stay within the budget of $400 billion.
  Third, according to CMS, only 2 to 12 percent--depending on your 
estimates--are going to be affected by this ``coverage gap.''
  Finally, there is no standard benefit. This is sort of a mystery I 
don't know why we don't talk about more. This is a typical design of 
what a benefit would look like. But under this bill, the companies 
bidding on these pharmaceutical contracts can design the benefit any 
way they want. They can have a donut. They do not have to have a donut. 
The only thing they are required to do is have a $275 deductible for 
those plans of 160 percent of poverty and above and have $3,700 in 
total spending before the catastrophic kicks in. The donut is illusory, 
and I ask my colleagues to vote no on the amendment.
  Ms. MIKULSKI. Mr. President, I rise today in strong support of the 
amendment No. 1001 offered by my colleague from California, Senator 
Boxer.
  The Senate is debating legislation to provide seniors with 
prescription drugs that is a start but there are also many shortcomings 
with this bill. One of most glaring shortcomings is the gap in drug 
coverage. It doesn't make sense. As drug costs rise, benefits get shut 
off and seniors with high drug costs have to pay all of their drug 
costs from $4,500 to $5,800. I think that is cruel.
  How would this amendment address this shortcoming?
  It is simple. This amendment would let seniors continue to have 
continuous coverage until you hit the catastrophic cap of $5,800 so 
that means no gap. And, then your copay would drop to 10 percent just 
like in the bill. No figuring out when you hit the coverage gap. No 
figuring out how long you are going to be in the hole. No paying 
premiums and not getting benefits. You simply get drug coverage.
  Why is this amendment important?
  The coverage gap imposes a ``sickness tax'' on seniors. Once drug 
spending reaches $4,500 and this is a senior who clearly is facing 
serious health problems this senior would now have to pay $1,300 of 
their own money without any help from the Government even though they 
are still paying premiums to stay in the plan.
  What does this mean?
  Millions of our seniors will have no drug coverage for several months 
out the year. Their coverage will just stop and for many; it may not 
start back up again until the next year.
  This is wrong. I believe honor thy mother and father is not just a 
good commandment to live by, it is good public policy to govern by. 
That is why I feel so strongly about Medicare. Congress created 
Medicare to provide a safety net for seniors. I don't think there 
should be any holes in that net. That is why I support this amendment 
and urge my colleagues to also.
  The PRESIDING OFFICER. The Senator's time has expired.
  The yeas and nays have been previously ordered on this amendment.
  Mr. SANTORUM. Mr. President, I move to table the amendment and ask 
for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The question is on agreeing to the motion to table amendment No. 
1001.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. McCONNELL. I announce that the Senator from Colorado (Mr. 
Campbell) is necessarily absent.
  Mr. REID. I announce that the Senator from Florida (Mr. Graham), the 
Senator from Massachusetts (Mr. Kerry), and the Senator from 
Connecticut (Mr. Lieberman) are necessarily absent.
  I further announce that, if present and voting, the Senator from 
Florida (Mr. Graham) and the Senator from Massachusetts (Mr. Kerry) 
would each vote ``nay''.
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 54, nays 42, as follows:

                      [Rollcall Vote No. 236 Leg.]

                                YEAS--54

     Alexander
     Allard
     Allen
     Baucus
     Bennett
     Bond
     Breaux
     Brownback
     Bunning
     Burns
     Chafee
     Chambliss
     Cochran
     Coleman
     Collins
     Cornyn
     Craig
     Crapo
     DeWine
     Dole
     Domenici
     Ensign
     Enzi
     Fitzgerald
     Frist
     Graham (SC)
     Grassley
     Gregg
     Hagel
     Hatch
     Hutchison
     Inhofe
     Jeffords
     Kyl
     Lott
     Lugar
     McCain
     McConnell
     Miller
     Murkowski
     Nickles
     Roberts
     Santorum
     Sessions
     Shelby
     Smith
     Snowe
     Specter
     Stevens
     Sununu
     Talent
     Thomas
     Voinovich
     Warner

[[Page 15913]]



                                NAYS--42

     Akaka
     Bayh
     Biden
     Bingaman
     Boxer
     Byrd
     Cantwell
     Carper
     Clinton
     Conrad
     Corzine
     Daschle
     Dayton
     Dodd
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Harkin
     Hollings
     Inouye
     Johnson
     Kennedy
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lincoln
     Mikulski
     Murray
     Nelson (FL)
     Nelson (NE)
     Pryor
     Reed
     Reid
     Rockefeller
     Sarbanes
     Schumer
     Stabenow
     Wyden

                             NOT VOTING--4

     Campbell
     Graham (FL)
     Kerry
     Lieberman
  The motion was agreed to.
  Mr. GRASSLEY. I move to reconsider the vote, and I move to lay that 
motion on the table.
  The motion to lay on the table was agreed to.
  Mr. BAUCUS. Mr. President, I ask unanimous consent that all pending 
amendments be laid aside so that the Senator from New Jersey may offer 
an amendment.
  The PRESIDING OFFICER. Is there objection?
  Mr. SESSIONS. Reserving the right to object, is the Senator going to 
speak? I could not hear.
  Mr. BAUCUS. I withdraw the request. I ask unanimous consent that 
there be 30 minutes equally divided on the Lautenberg amendment and, 
immediately following that debate, the Senate vote on the Lautenberg 
amendment.
  Mr. SESSIONS. Reserving the right to object, I just want to call up 
an amendment and set it aside. Will the Senator agree we can do that?
  Mr. LAUTENBERG. I did not hear the request. Was the Senator asking a 
question of me?
  Mr. SESSIONS. Mr. President, I was asking unanimous consent that I be 
allowed to call up an amendment for 30 seconds and set it aside before 
the Senator from New Jersey commences his remarks.
  The PRESIDING OFFICER. The Senator from Montana has the floor.
  Mr. BAUCUS. I yield the floor and withdraw my request.
  The PRESIDING OFFICER. The Senator from Alabama may state his 
request.


                           Amendment No. 1011

  Mr. SESSIONS. Mr. President, I call up amendment No. 1011.
  The PRESIDING OFFICER. The Chair will interpret the Senator's request 
as a unanimous consent request to set aside all pending amendments. Is 
there objection to setting aside all pending amendments?
  Without objection, it is so ordered. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Alabama [Mr. Sessions] proposes an 
     amendment numbered 1011.

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

  (Purpose: To express the sense of the Senate that the Committee on 
  Finance should hold hearings regarding permitting States to provide 
health benefits to legal immigrants under medicaid and SCHIP as part of 
  the reauthorization of the temporary assistance for needy families 
                                program)

       Strike section 605 and insert the following:

     SEC. 605. SENSE OF THE SENATE REGARDING HEALTH INSURANCE 
                   COVERAGE OF LEGAL IMMIGRANTS UNDER MEDICAID AND 
                   SCHIP.

       (a) Findings.--The Senate makes the following findings:
       (1) In 1996, in the Personal Responsibility and Work 
     Opportunity Reconciliation Act of 1996 (Public Law 104-193; 
     110 Stat. 2105)(commonly referred to as the ``welfare reform 
     Act''), Congress deliberately limited the Federal public 
     benefits available to legal immigrants.
       (2) The Personal Responsibility and Work Opportunity 
     Reconciliation Act of 1996 allows a State the option of 
     electing to offer permanent resident legal aliens that have 
     been living in the United States for at least 5 years the 
     same benefits that their State citizens receive under the 
     temporary assistance for needy families program (commonly 
     referred to as ``TANF'') and the medicaid program.
       (3) As of the date of enactment of this Act, 22 States have 
     elected to give the permanent resident legal aliens who 
     reside in their States the same TANF and medicaid benefits as 
     the States provide to the citizens of their States.
       (4) This Act, the Prescription Drug and Medicare 
     Improvement Act of 2003, is not a welfare or medicaid reform 
     bill, but rather is a package of improvements for the 
     medicare program that is designed to provide greater access 
     to health care for America's seniors.
       (5) The section heading for 605 of this Act as reported out 
     of the Committee on Finance, was titled ``Assistance with 
     Coverage of Legal Immigrants under the medicaid program and 
     SCHIP,'' and, as reported, related directly to the provision 
     of benefits under the medicaid and State children's health 
     insurance programs, not to benefits provided under the 
     medicare program.
       (6) The reported version of section 605 would have directly 
     overturned the reforms made in the 1996 welfare reform Act.
       (7) The reported version of section 605 would have greatly 
     expanded the number of individuals who could receive benefits 
     under medicaid and SCHIP.
       (8) No hearings have been held in the Committee on Finance 
     of the Senate concerning why the 5-year residency requirement 
     for legal aliens to obtain a Federal public benefit 
     established in the welfare reform Act needs to be overturned 
     or why the reported version of section 605 should be included 
     in a medicare reform package.
       (9) Congress must reauthorize the temporary assistance for 
     needy families program later this year and should hold 
     hearings regarding whether the 5-year residency requirement 
     for legal aliens to obtain a Federal public benefit should be 
     overturned as part of the reauthorization of that program.
       (b) Sense of the Senate.--It is the sense of the Senate 
     that the Committee on Finance of the Senate should hold 
     hearings in connection with the reauthorization of the 
     temporary assistance for needy families program, or in 
     connection with reform of the medicaid program, regarding 
     whether the 5-year residency requirement for legal aliens to 
     obtain a Federal public benefit that was established in the 
     1996 welfare reform Act should be overturned for purposes of 
     the medicaid and State children's health insurance programs.

  Mr. SESSIONS. Mr. President, I ask unanimous consent that the 
amendment be set aside for consideration at the appropriate time.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. SESSIONS. I yield the floor.
  The PRESIDING OFFICER. The Senator from New Jersey.
  Mr. LAUTENBERG. Mr. President, I want to be certain of the order. My 
amendment is at the desk. What I want to do is in the time allocated to 
me--which I understand is 15 minutes per side; is that correct?
  The PRESIDING OFFICER. At this point, no such order has been entered.
  Mr. LAUTENBERG. I thank the Chair.


                           Amendment No. 982

  Mr. LAUTENBERG. Mr. President, I call up my amendment which is at the 
desk.
  The PRESIDING OFFICER. Without objection, the pending amendments will 
be set aside. The clerk will report.
  The legislative clerk read as follows:

       The Senator from New Jersey [Mr. Lautenberg], for himself, 
     Mr. Reed, Mr. Reid, Mrs. Clinton, and Mr. Corzine, proposes 
     an amendment numbered 982.

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

  (Purpose: To make prescription drug coverage available beginning on 
                             July 1, 2004)

       At the end of title I, insert the following:

     SEC. __. IMPLEMENTATION OF TITLE.

       Notwithstanding any other provision of this Act, the 
     amendments made by this title shall be implemented and 
     administered so that prescription drug coverage is first 
     provided under part D of title XVIII beginning on July 1, 
     2004.

  Mr. LAUTENBERG. Mr. President, I rise to talk about my amendment 
which is designed to change the effective date of this bill.
  My amendment is cosponsored by Senators Reed of Rhode Island, Reid of 
Nevada, Clinton, and Corzine.
  My amendment is very simple: Let's give our seniors a prescription 
drug benefit just as quickly as we can. They need it now. Let's not 
delay any longer than practicable to get it into place.
  Under the current proposal, comprehensive drug coverage does not 
start until July 2006. Imagine that, 2006. It is not fair to seniors 
who are expecting a benefit almost immediately. They will have seen 
President Bush sign a bill with some fanfare and will have seen lots of 
Members of Congress crowding the stage with him, and everyone will say: 
We have put a prescription drug benefit into place. When

[[Page 15914]]

seniors learn that the benefit begins in 2006, they are going to feel 
deceived, tricked, and angry.
  My amendment changes the effective date of the coverage to July 1, 
2004. There is not any reason to have our seniors wait any longer for a 
prescription drug benefit.
  The original Medicare plan was signed into law by President Johnson 
on July 30, 1965, and 11 months later, July 1, 1966, all persons 
eligible were enrolled. The entire system for Medicare was created in 
just 11 months.
  When we look at this chart, we see what is planned with the Bush/
Senate prescription drug benefit. We are looking at 30 months, and we 
are looking at the creation of an entire Medicare system which took 
just 11 months to put in place. That was done without the luxury of 
today's high-speed computers. It was just President Johnson and his 
administration getting the entire system in place in 11 months.
  My amendment essentially follows the same timetable. If President 
Johnson was able to create the entire Medicare system in just 11 
months, then surely President Bush should be able to add a drug benefit 
in the same amount of time.
  Look at the timeline the President has set for this Medicare drug 
proposal: 30 months. Why so long? Our clue is, what? Election day. That 
is illustrated on this chart. Sixteen months from now, this prolonged 
effective date is conveniently well past election day.
  The administration's Medicare agency, CMS, says it needs 30 months. 
That is very convenient timing for political purposes, but it is 
terrible timing for America's seniors.
  President Johnson, a true Texan, had a can-do attitude, and there is 
no reason this administration cannot dedicate itself to completing this 
task in 11 months. We need to give seniors meaningful drug coverage as 
soon as possible, not 2006.
  The reality is that 5.5 million seniors currently on Medicare will 
not be alive in 2006. If there are insufficient funds in the budget for 
this amendment, then it is the result of choices made by the President 
and his party. They chose to provide a massive tax cut to the 
wealthiest among us, and they chose it at the price of Medicare.
  The issue is simple: If we give a prescription drug benefit, why 
would we want to withhold it? This bill is about fooling the American 
people about the mission here. It is more about elections than 
correcting the problems associated with a prescription drug program. I 
urge my colleagues to support this amendment.
  Mr. President, we have some time remaining. How much time remains on 
our side?
  The PRESIDING OFFICER. There is no set amount of time. The Senator 
has consumed 5 minutes.
  Mr. LAUTENBERG. Mr. President, I yield the floor. I know the Senator 
from Nevada is interested in speaking.
  Mr. GRASSLEY. Mr. President, I yield myself such time as I may 
consume in opposition to the Lautenberg amendment.
  The PRESIDING OFFICER. The Senator has the floor.
  Mr. GRASSLEY. Maybe I should ask, are we under time constraints?
  The PRESIDING OFFICER. There are no time constraints.
  Mr. GRASSLEY. What the Senator from New Jersey wants to do I wish we 
could do. I personally was somewhat astounded when we asked experts at 
the Congressional Budget Office, experts at the Office of Management 
and Budget, experts in the Department of Health and Human Services, how 
much time it would take to get this new prescription drug program 
underway. We were advised to start it in the year 2006.
  In an ideal world, all seniors would have access to our comprehensive 
prescription drug benefit next year. But our plan, I am sorry to say, 
cannot go into effect until 2006. Therefore, we need to do something to 
help our seniors right now. Part of S. 1 does that. They have been 
doing it because seniors, as I am sure the Senator from New Jersey is 
trying to respond to, have been waiting a very long time for Congress 
to act and pass a prescription drug benefit, in the end, helping them 
with the tremendous costs they are paying for prescription drugs.
  This obviously is not satisfying to the Senator from New Jersey who 
would like to get this plan underway much sooner. Because of the 
waiting period until the year 2006 to get the very comprehensive 
program underway, we included in our plan a temporary prescription drug 
discount card. This is a voluntary program that all seniors can partake 
of next year. It is available for an annual fee costing no more than 
$25. Since our low-income seniors need extra help, this fee would be 
waived. It provides for a 10-percent to 25-percent discount on all 
costs of prescription drugs. There are some seniors for whom even a 10-
percent to 25-percent discount is still a hardship to purchase 
prescription drugs. So we have added to this for really low-income 
seniors to receive a $600 annual help in purchasing prescription drugs 
during this interim period of time, 2004 and 2005. They will be 
required to pay a minimal copayment of 10 percent when the spending of 
the $600 subsidy is in place. Spouses who receive the low-income 
benefit are also allowed to pool share their deposits.
  When the comprehensive drug program begins January 1, 2006, the 
discount card program automatically ends. However, low-income seniors 
will be able to use their allotment of $600 until June 2006.
  Almost 10 million Medicare beneficiaries with significant 
prescription drug needs will realize savings from this endorsement 
program. The Center for Medicare Services projects that the Medicare 
beneficiaries will save between $1.2 billion and $1.6 billion in the 
program the very first year.
  As I said, I feel, not for reasons I like to give to my fellow 
Senators, that we cannot expect this comprehensive new prescription 
drug program for seniors, which happens to be the first major 
improvement in strengthening of Medicare since 1965, to go into effect. 
Maybe we can push and push and push, but this first major expansion of 
Medicare in 38 years ought to be carefully done and done right. 
Consequently, that is why we have deferred to the judgment of the 
Congressional Budget Office, Office of Management and Budget, as well 
as the Secretary of HHS. We have tried to compensate for the long 
period of phasing with the discount card and the $600 subsidy.
  I wish I could do more. I wish I could vote for the Senator's 
amendment but I cannot. I ask my colleagues to vote against it.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from New Jersey.
  Mr. LAUTENBERG. I say to our friend from Iowa, the discount card 
allows somewhere between 10 and up to 25 percent. With seniors spending 
an average $2,300 a year on medication, even a 20-percent discount does 
not provide nearly enough relief. Frankly, it is hard to understand why 
it has to take 2\1/2\ years to get the program into place. I rather 
suspect it has less to do with the perfection of the program than it 
has to do with some other cause. It cannot take that long. We have all 
of these seniors on record. They are medical enrollees now. Why can't 
we get this going?
  As a matter of fact, my colleague from Minnesota, who is going to say 
something, thinks it should be done in an even shorter period of time 
than my amendment provides.
  I ask my colleague if he would like to say something. I yield the 
floor.
  The PRESIDING OFFICER. The Senator from Minnesota.
  Mr. DAYTON. Mr. President, I join with my Senator from New Jersey. He 
persuaded me to be reasonable. This is the reasonable alternative 
proposal, July 1 of 2004. I have great respect for the chairman of the 
Senate Finance Committee, the Senator from Iowa. I sense his difficulty 
because I don't believe the senior citizens of anywhere else in America 
will be any different from the senior citizens of Minnesota who will 
be, I believe, absolutely beside themselves to learn this program they 
have waited years for Congress to enact will be enacted but it will not 
be ready for 2\1/2\ years.
  I suggest perhaps one of the reasons is that this is not a system 
that can be

[[Page 15915]]

easily put in place or administered. The chairman is trying to 
accommodate, if I understand his remarks correctly, the administration, 
the Office of Management and Budget, and the Secretary of Health and 
Human Services. They said this program as designed cannot be put 
together and administered and operational until January 1, 2006.
  I suggest that is pretty strong evidence that is not a very good 
system for delivery of these services. We have insurance companies that 
are going to be providing policies--they are in the business of 
providing insurance for people. It can't take them 2\1/2\ years to 
design this program. Regarding CMS or HHS, the Department itself, we 
hear from this administration how their management of Government is so 
much improved over their predecessor's. Is it going to take them 2\1/2\ 
years to design this program when, as my colleague from New Jersey, 
Senator Lautenberg, pointed out, 40 years ago they were able to take 
the whole Medicare Program and put that in effect in 11 months?
  Not only do I support the amendment offered by Senator Lautenberg, 
but I have to say for those who are advocating this as the preferred 
alternative to extending Medicare to cover prescription drugs, if they 
cannot get the program up and running in a lot less than 2\1/2\ years--
either 6 months as I would propose, or a year--then this is the wrong 
program because this is not a viable alternative, and it is not viable 
for the senior citizens of Minnesota or anywhere else, in my judgment.
  To say people are going to get a discount card--they can get discount 
cards already. They don't need Congress to do anything more than that 
for 2\1/2\ years.
  Just taking the figure the Senator from Iowa offered, if I understand 
it correctly, of savings for seniors in America, Medicare 
beneficiaries, of $1.26 billion the first year, it sounds like a lot of 
money--it is a lot of money--but there are 40 million Medicare 
beneficiaries in the country. If you divide $1.26 billion in savings by 
those 40 million, that is about $30 per Medicare beneficiary in the 
first year.
  We are going to go back with this to the senior citizens of 
Minnesota, and those with disabilities who are being crushed by these 
prices, who see them going up all the time due to the greed and 
profiteering of the pharmaceutical industry. We are told here we have a 
bill, because it is the only one the majority of the Senate will agree 
to, that is not going to do anything--nothing at all, under our 
Government, on behalf of seniors and on behalf of all American 
consumers of prescription drugs, to bring these prices down. Instead, 
they are going to get a discount card that is going to save them on 
average $30 a year? We ought to be ashamed of ourselves, first of all. 
This bill is not what it is purporting to be, which is real relief for 
anybody who needs it now, not January 1, 2006.
  If my colleagues do not support this, I think we are sending a very 
strong message to America that this is not a viable program to begin 
with, and the pharmaceutical industry has, one more time, succeeded in 
putting their profits ahead of the needs of people in America.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Montana.
  Mr. BAUCUS. I know the Senator from New Hampshire would like to go 
ahead. I will speak for just a minute or 2 before he does.
  I very much agree with the Senator. It seems absurd that we have to 
wait until 2006 before this program goes into effect. I very much 
understand the concern of the Senator.
  Let me say this to all of us who are concerned. Before the conference 
report comes back, I am going to do my level best by pushing the CBO 
and CMS, asking a lot of tough questions of these agencies, to see if 
there is some way we can get this put together earlier. It is my hope 
we could bring back a conference report that has an earlier date, 
significantly earlier date. My guess is the private sector could get 
this done pretty quickly. It would not take a full 2 years to get it 
done.
  I just pledge to my colleagues, this is one Senator who is going to 
do his level best to try to get an earlier date. The current date just 
doesn't make sense. We need to ask some tough questions and get some 
answers.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. If the Senator from New Hampshire will just give me a 
minute, I have a unanimous consent request on votes coming up I would 
like to propound.
  I ask unanimous consent that at 4:20 the Senate proceed to a vote in 
relation to Dayton amendment No. 957, to be followed by a vote in 
relation to the Lincoln amendment, No. 1002; to be followed by a vote 
in relation to the Lautenberg amendment, No. 982, with 2 minutes 
equally divided for debate for each succeeding vote after the first; 
further, that no amendments be in order to the amendments prior to the 
votes; and finally that the second and third votes be limited to 10 
minutes in length.
  I ask unanimous consent that prior to the first vote, Senator Sununu 
be recognized for up to 5 minutes in order to offer an amendment.
  Mr. REID. Reserving the right to object, I ask the vote occur at 4:25 
and I be given 5 minutes after Senator Sununu.
  Mr. GRASSLEY. I modify my unanimous consent request accordingly.
  The PRESIDING OFFICER. Is there objection?
  Mr. DAYTON. Reserving the right to object, I ask the Senator, in 
terms of the motion, that 2 minutes be evenly divided for my amendment, 
the first amendment. Is there something different for that?
  Mr. GRASSLEY. You would have 1 minute and I would have 1 minute.
  Mr. DAYTON. I object to that. I was told by the Senator's staff I 
would have 2 minutes, 4 minutes equally divided.
  Mr. REID. He can take a minute of my time.
  Mr. GRASSLEY. You will get 2 minutes, one from your leader. Can we go 
ahead?
  Mr. DAYTON. I have no objection.
  The PRESIDING OFFICER. Is there objection? Without objection, it is 
so ordered.
  The Senator from New Hampshire.


                           Amendment No. 1010

  (Purpose: To improve outpatient vision services under part B of the 
                           medicare program)

  Mr. SUNUNU. Mr. President, I ask unanimous consent that all pending 
amendments be set aside for purposes of offering an amendment.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. SUNUNU. Mr. President, I have an amendment at the desk. I ask for 
its immediate consideration.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from New Hampshire [Mr. Sununu] proposes an 
     amendment numbered 1010.

  Mr. SUNUNU. I ask unanimous consent the reading of the amendment be 
dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  (The amendment is printed in today's Record under ``Text of 
Amendments.'')
  Mr. SUNUNU. Mr. President, I rise to offer an amendment that 
effectively mirrors a piece of legislation I introduced earlier this 
year. This amendment will extend benefits under Medicare for vision 
rehabilitative services; that is, rehabilitative services for those 
seniors with a vision impairment.
  As we debate this important prescription drug legislation, I think 
one of the cornerstones, one of the principles that is at stake is the 
objective of giving seniors more options and more choices for their 
health care and, in doing so, to create an option for a more holistic 
approach to their health care that perhaps focuses, to a greater 
extent, on preventive measures and other services that improve 
independence and improve a senior's quality of life.
  This legislation is very much in keeping with that objective and that 
goal. This will extend coverage for vision rehabilitative services 
under Medicare, but it does this under the existing physician fee 
schedule. It does it

[[Page 15916]]

without creating a new provider network or a new fee schedule. As a 
result, the cost of this legislation is estimated, over a 5-year 
period, to be just $8 million. That was an independent estimate that 
has been done. Of course, I will seek scoring under the Congressional 
Budget Office for the purpose of this bill.
  It is legislation and a set of services that is geared toward 
improving the level of independence and quality of life for those 
seniors who are affected by a vision impairment. For the sake of 
reference, there are over 3.5 million Americans who are affected by 
vision impairment in the United States. That means vision loss that 
cannot be treated with eye glasses, that cannot be treated with surgery 
or other techniques. These seniors need help in learning how to 
navigate in their own homes, how to deal with the obstacles of daily 
life, and how to learn to live and work with that vision impairment.
  The cost of vision impairment to America and to our seniors can be 
huge. The CDC estimates over $20 billion in costs annually due to falls 
and due to injuries that have occurred as a result of vision loss. Hip 
fractures alone, due to vision loss, are estimated to cost our country 
over $2 billion per year.
  For those reasons, I envision under this legislation cost savings in 
the long term to be quite significant for the modest cost of improving 
coverage for these vision rehabilitative services.
  This is a piece of legislation I introduced earlier this year for 
which I was pleased to receive bipartisan support. We have 14 
cosponsors--seven Republicans, seven Democrats--and among them a number 
of the members of the Finance Committee.
  I certainly believe this takes the right approach toward 
strengthening Medicare in a way that gives more focus to the kind of 
preventive care and the kind of medical maintenance that improves the 
independence and quality of life for our seniors.
  I urge my colleagues to support the amendment.
  I yield the floor.
  The PRESIDING OFFICER. The Democratic whip is recognized.
  Mr. REID. Mr. President, under the consent we obtained, I was to have 
5 minutes to speak. I would ask that 1 minute of that time be given to 
Senator Dayton, so he can have his 2 minutes. I ask the Chair to notify 
me when I have used 3 minutes.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                           Amendment No. 982

  Mr. REID. Mr. President, my first elective job was when Medicare came 
into being. I was the chairman of the board of trustees at a place 
called Southern Nevada Memorial Hospital. It is now called the 
University Medical Center. At that time it was the largest medical 
facility, hospital facility in Nevada.
  At that time 40 percent of the seniors who came into that hospital 
had no insurance, and children, other relatives, and friends had to 
sign a piece of paper before they came into the hospital that they 
would be responsible for the bills. Medicare changed all that.
  In 1965, when Medicare was created by Congress, it took 11 months 
after the bill was signed to put a new program in place. That was back 
in the days of slide rules and adding machines. That was, of course, 
before we had computers that had any ability to function.
  Today our senior citizens need help with soaring drug prices. They 
deserve the security of knowing they will be able to buy the medicines 
that can keep them alive and healthy.
  So today if we are telling our seniors to wait for that help and that 
security until the year 2006, I do not think they are going to accept 
that. It will be too late for millions of seniors, people who have 
worked hard all their lives to make this the greatest and richest 
country in the world--the only superpower left in the world. Certainly, 
if that, in fact, is the case, we should have a prescription drug 
benefit for senior citizens.
  It might be too late for Alice and Frederick Williams of Reno. They 
worked hard all their lives and raised four children. But Alice 
contracted hepatitis C from a blood transfusion. Today she is also 
battling heart disease and a thyroid condition, and Frederick is 
recovering from prostate cancer. Together, they have to spend $350 
every month on prescription drugs. That is $4,200 a year. They don't 
have it.
  Jackie Ridley, it might be too late for her. She is a retired 
teacher, who spoke at a Committee on Aging hearing in Las Vegas. She 
and her husband had all kinds of problems: heart disease, high blood 
pressure, diabetes, and emphysema. Between them, they had 25 
prescriptions. Before Jackie's husband passed away, they faced out-of-
pocket expenses of more than $1,000 every month. And sometimes, to make 
it to the next month, they cut back on some of their medicine. We have 
heard that before.
  These Nevada seniors, and millions more like them in every single 
State, need help now, not 3 years from now. They deserve security now, 
not in 2006. That is why I rise to support the Lautenberg amendment. It 
would make this prescription drug benefit effective sooner rather than 
later.
  The bill is confusing enough without asking some senior citizens to 
apply for one benefit now, and then come back in 2 years to apply 
again. Our seniors have enough to worry about without wondering if they 
will be ruined financially before the benefit takes effect.
  The American people know that when Congress really wants to get 
things done, we can take action quickly. Now they are looking for us to 
help them, seniors who have worked hard to make this country strong and 
prosperous.
  I urge the support of the Lautenberg amendment.
  I yield back whatever time I have.
  The PRESIDING OFFICER. The Senator has used 3 minutes.
  Mr. REID. I yield back.
  The PRESIDING OFFICER. The Senator from Minnesota.


                           Amendment No. 957

  Mr. DAYTON. Mr. President, I understand, under the previous order, I 
have 2 minutes.
  The PRESIDING OFFICER. The Senator has 2 minutes.
  Mr. DAYTON. Mr. President, I call up amendment No. 957 and ask the 
clerk to report it.
  The PRESIDING OFFICER. The amendment is pending.
  Mr. DAYTON. Thank you, Mr. President. I will proceed.
  Mr. President, this amendment is a matter of simple fairness. It says 
that whatever prescription drug coverage we in Congress vote for for 
senior citizens and other Medicare beneficiaries in this legislation, 
then the Members of Congress will get for ourselves, our coverage, 
under prescription drugs for the life of this particular legislation.
  I have heard many of my colleagues say we want to give seniors 
coverage that is as good as we get ourselves. I heard a lot of senior 
citizens in Minnesota say they want coverage as good as Members of 
Congress get for themselves. Well, unfortunately, the bill that is 
before us this week is not even close to that parity.
  If you calculate the total benefits provided, the value of this bill 
is about half of what Members of Congress get, what we pay as part of 
the Federal Employees Health Benefits Plan system. But, nevertheless, 
it is about twice as good as what the seniors of America and those with 
disabilities and others are going to be able to obtain from what we are 
likely to pass.
  Furthermore, as we have been discussing earlier, this does not even 
begin until January of 2006. Medicare beneficiaries will get a discount 
card instead. Well, then, Members of Congress should get a discount 
card--and nothing more--as well. I think after what I heard the Senator 
from Iowa say, I would include a few members of the administration 
since they are the culprits in this delay, but I will save that for 
another time. With the premiums, deductibles, and the absence of any 
coverage at all from $4,500 to $5,800, if it is good enough for the 
seniors of America, then it is good enough for the Members of Congress.
  I point out to my colleagues who would like to keep the benefit level 
they have today----

[[Page 15917]]

  The PRESIDING OFFICER. The Senator has used 2 minutes.
  Mr. DAYTON. Mr. President, I ask unanimous consent for 30 seconds to 
conclude my remarks.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  Mr. DAYTON. The amendment Senator Durbin has offered, which we will 
have a chance to vote on and discuss later this week, would provide 
seniors with a comparable package to what we have in Congress. So I 
urge the support of that amendment, for that reason among many others. 
But if we are not going to be as generous to senior citizens as we are 
to ourselves today, then we are going to have to, in my view, bring 
ourselves down. I would rather bring everyone else up, but what is fair 
for them is fair for us.
  I thank the Chair. I yield the floor.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. I yield back my time and wish to vote now.
  I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be.
  The question is on agreeing to amendment No. 957.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. McConnell. I announce that the Senator from Colorado (Mr. 
Campbell) is necessarily absent.
  Mr. Reid. I announce that the Senator from Florida (Mr. Graham), the 
Senator from Massachusetts (Mr. Kerry), and the Senator from 
Connecticut (Mr. Lieberman) are necessarily absent.,
  I further announce that, if present and voting, the Senator from 
Florida (Mr. Graham) and the Senator from Massachusetts (Mr. Kerry) 
would each vote ``yea''.
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 93, nays 3, as follows:

                      [Rollcall Vote No. 237 Leg.]

                                YEAS--93

     Akaka
     Alexander
     Allard
     Allen
     Baucus
     Bayh
     Bennett
     Biden
     Bond
     Boxer
     Brownback
     Bunning
     Burns
     Byrd
     Cantwell
     Carper
     Chafee
     Chambliss
     Clinton
     Cochran
     Coleman
     Collins
     Conrad
     Cornyn
     Corzine
     Craig
     Crapo
     Daschle
     Dayton
     DeWine
     Dodd
     Dole
     Domenici
     Dorgan
     Durbin
     Edwards
     Ensign
     Enzi
     Feingold
     Feinstein
     Fitzgerald
     Frist
     Graham (SC)
     Grassley
     Gregg
     Hagel
     Harkin
     Hatch
     Hutchison
     Inhofe
     Inouye
     Jeffords
     Johnson
     Kennedy
     Kohl
     Kyl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lincoln
     Lott
     Lugar
     McCain
     McConnell
     Mikulski
     Miller
     Murkowski
     Murray
     Nelson (FL)
     Nelson (NE)
     Nickles
     Pryor
     Reed
     Reid
     Roberts
     Rockefeller
     Santorum
     Sarbanes
     Schumer
     Sessions
     Shelby
     Smith
     Snowe
     Specter
     Stabenow
     Stevens
     Sununu
     Talent
     Thomas
     Voinovich
     Warner
     Wyden

                                NAYS--3

     Bingaman
     Breaux
     Hollings

                             NOT VOTING--4

     Campbell
     Graham (FL)
     Kerry
     Lieberman
  The amendment (No. 957) was agreed to.


                           Amendment No. 1002

  The PRESIDING OFFICER. Under the previous order, there are 2 minutes 
equally divided prior to the vote on the Lincoln amendment.
  The PRESIDING OFFICER. Who yields time?
  The Senator from Arkansas. The Senator has 1 minute.
  Mrs. LINCOLN. Mr. President, I plead with my colleagues to take a 
very serious look at the amendment before us. I know they are hearing 
differently from downtown perhaps, but I want them to take a look at a 
recent CBO study that has indicated to us there is negligible impact in 
giving parity to the fallback plan.
  CBO has given us a recent study that indicates there is negligible 
impact on the private plans in allowing parity with the fallback plans 
that may be needed in some of our rural areas to ensure that all of our 
citizens across this great land get the same benefit in a prescription 
drug package.
  Fifteen of our States have no Medicare+Choice or private plans 
currently. We know it is going to be difficult. Let's make sure a 
fallback plan is there for seniors, that the continuity is there for 
them. All we want to do is make sure they will have the same 2-year 
contract cycle that the private plans will have.
  Again, approximately 80 percent of the people in this country are in 
fee-for-service plans. Let's make sure those who are in our rural 
States are going to see the parity in these two plans. Just remember, 
if the private plans are not there or happen to be there, there will be 
no fallback plan, so you do not have any problem with that.
  I thank the Chair.
  The PRESIDING OFFICER. The Senator's time has expired.
  Mrs. LINCOLN. I encourage my colleagues to vote for this amendment.
  The PRESIDING OFFICER. Who yields time?
  The Senator from Pennsylvania.
  Mr. SANTORUM. Mr. President, I oppose the amendment. First off, it is 
bad enough to have one fallback, which I believe will dramatically 
discourage private plans from participating in a stand-alone drug 
benefit. To have two is even worse.
  The fact is, the Secretary has the authority under this legislation 
to balance the risk. With a fallback plan, there is no risk on the 
private sector. All the risk for a plan is on the public sector. We 
give the Secretary the ability to dial back the risk to everything but 
zero, and the fallback plan is zero. We believe giving the Secretary 
the discretion will at least encourage the private sector to come in, 
which they will under this bill, and take some risk, which means they 
will have some incentive to control costs. If they have no risk, they 
have no incentive and, thereby, the cost of the program goes up.
  Having one fallback plan is a very bad idea. Expanding this very bad 
idea is a worse idea, and I hope we vote against the amendment.
  I ask unanimous consent that the remaining two votes in this series 
be limited to 10 minutes each.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. SANTORUM. Mr. President, I move to table the amendment and ask 
for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be a sufficient second.
  The question is on agreeing to the motion.
  The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. McCONNELL. I announce that the Senator from Colorado (Mr. 
Campbell) is necessarily absent.
  Mr. REID. I announce that the Senator from Florida (Mr. Graham), the 
Senator from Massachusetts (Mr. Kerry), and the Senator from 
Connecticut (Mr. Lieberman) are necessarily absent.
  I further announce that, if present and voting, the Senator from 
Florida (Mr. Graham) and the Senator from Massachusetts (Mr. Kerry) 
would each vote ``no''.
  The PRESIDING OFFICER (Mrs. Dole). Are there any other Senators in 
the Chamber desiring to vote?
  The result was announced--yeas 51, nays 45, as follows:

                      [Rollcall Vote No. 238 Leg.]

                                YEAS--51

     Alexander
     Allard
     Allen
     Baucus
     Bennett
     Bond
     Breaux
     Brownback
     Bunning
     Burns
     Chambliss
     Cochran
     Coleman
     Cornyn
     Craig
     Crapo
     DeWine
     Dole
     Domenici
     Ensign
     Enzi
     Fitzgerald
     Frist
     Graham (SC)
     Grassley
     Gregg
     Hagel
     Hatch
     Hutchison
     Inhofe
     Jeffords
     Kyl
     Lott
     Lugar
     McCain
     McConnell
     Murkowski
     Nickles
     Roberts
     Santorum
     Sessions
     Shelby
     Smith
     Snowe
     Specter
     Stevens
     Sununu
     Talent
     Thomas
     Voinovich
     Warner

                                NAYS--45

     Akaka
     Bayh
     Biden
     Bingaman
     Boxer
     Byrd
     Cantwell
     Carper
     Chafee
     Clinton
     Collins
     Conrad

[[Page 15918]]


     Corzine
     Daschle
     Dayton
     Dodd
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Harkin
     Hollings
     Inouye
     Johnson
     Kennedy
     Kohl
     Landrieu
     Lautenberg
     Leahy
     Levin
     Lincoln
     Mikulski
     Miller
     Murray
     Nelson (FL)
     Nelson (NE)
     Pryor
     Reed
     Reid
     Rockefeller
     Sarbanes
     Schumer
     Stabenow
     Wyden

                             NOT VOTING--4

     Campbell
     Graham (FL)
     Kerry
     Lieberman
  The motion was agreed to.
  Mr. GRASSLEY. I move to reconsider the vote.
  Mr. BAUCUS. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.


                           Amendment No. 982

  The PRESIDING OFFICER. Under the previous order, there are now 2 
minutes for debate prior to a vote in relation to the Lautenberg 
amendment, No. 982.
  Who yields time?
  The Senator from New Jersey.
  Mr. LAUTENBERG. Madam President, my amendment is very simple. It 
says, if you are going to give, then don't take it away. If you are 
going to give a prescription drug benefit, then, by golly, start it in 
a timely manner, and start it, let's say, by July of 2004 instead of 
2006.
  What kind of a benefit is this when 5.5 million of our present living 
seniors, I am sorry to say, will not be here at that time, 30 months 
hence. In 11 months, President Lyndon Johnson initiated the idea of 
Medicare and had it passed and in place--11 months. Why in the world is 
it going to take 30 months?
  I do not believe we ought to be looking at these discount cards, 
which are available generally in the community today, as the stopover 
until 30 months have gone by. It is an outrage that this date is 
chosen, I think not because they want to delay the benefit for seniors 
but, rather, because it coincides with an election. I do not think we 
ought to stand for it.
  The PRESIDING OFFICER. The Senator's time has expired.
  The Senator from Iowa.
  Mr. GRASSLEY. Madam President, I sympathize with those who feel a 
need to get this program going sooner than we have it in this 
legislation. But the fact is, CMS has told us it is physically 
impossible to get this benefit up and running in the year 2004. Now, 
knowing that, we have provided a prescription drug discount card, 
starting on January 1, 2004, in order to get immediate relief from the 
high cost of prescriptions for our seniors.
  The amendment would spend close to $24 billion in fiscal year 2004--
the amendment that is before us--and that is money that is not in the 
budget. We deal with the needs of our seniors in a fair way with this 
bill, the discount card, and the $600 help for them for each of the 
next 2 years. So I urge my colleagues to take all this into 
consideration and oppose the amendment.
  Madam President, I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be a sufficient second.
  The question is on agreeing to amendment No. 982.
  The clerk will call the roll.
  The assistant legislative clerk called the roll.
  Mr. McCONNELL. I announce that the Senator from Kansas (Mr. 
Brownback) and the Senator from Colorado (Mr. Campbell) are necessarily 
absent.
  I further announce that if present and voting the Senator from Kansas 
(Mr. Brownback) would vote ``no''.
  Mr. REID. I announce that the Senator from Florida (Mr. Graham), the 
Senator from Massachusetts (Mr. Kerry) and the Senator from Connecticut 
(Mr. Lieberman) are necessarily absent.
  I further announce that, if present and voting, the Senator from 
Massachusetts (Mr. Kerry) would vote ``yea''.
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 41, nays 54, as follows:

                      [Rollcall Vote No. 239 Leg.]

                                YEAS--41

     Akaka
     Bayh
     Biden
     Bingaman
     Boxer
     Byrd
     Cantwell
     Carper
     Clinton
     Conrad
     Corzine
     Daschle
     Dayton
     Dodd
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Harkin
     Hollings
     Inouye
     Johnson
     Kennedy
     Kohl
     Lautenberg
     Leahy
     Levin
     Lincoln
     Mikulski
     Murray
     Nelson (FL)
     Pryor
     Reed
     Reid
     Rockefeller
     Sarbanes
     Schumer
     Stabenow
     Talent
     Wyden

                                NAYS--54

     Alexander
     Allard
     Allen
     Baucus
     Bennett
     Bond
     Breaux
     Bunning
     Burns
     Chafee
     Chambliss
     Cochran
     Coleman
     Collins
     Cornyn
     Craig
     Crapo
     DeWine
     Dole
     Domenici
     Ensign
     Enzi
     Fitzgerald
     Frist
     Graham (SC)
     Grassley
     Gregg
     Hagel
     Hatch
     Hutchison
     Inhofe
     Jeffords
     Kyl
     Landrieu
     Lott
     Lugar
     McCain
     McConnell
     Miller
     Murkowski
     Nelson (NE)
     Nickles
     Roberts
     Santorum
     Sessions
     Shelby
     Smith
     Snowe
     Specter
     Stevens
     Sununu
     Thomas
     Voinovich
     Warner

                             NOT VOTING--5

     Brownback
     Campbell
     Graham (FL)
     Kerry
     Lieberman
  The amendment (No. 982) was rejected.
  Mr. GRASSLEY. Madam President, I move to reconsider the vote.
  Mr. REID. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.
  Mr. REID. Madam President, the two leaders have met and talked to the 
managers. We will have, in approximately 30 minutes, two votes. Senator 
Dodd has agreed to take 20 minutes on his two amendments. He can divide 
it however he deems appropriate. Following that, the Senate will still 
be in session. People will offer amendments, if they desire, but it is 
contemplated these two votes will be the last votes of the evening.
  The PRESIDING OFFICER. The Senator from Connecticut is recognized.
  Mr. DODD. Madam President, I ask unanimous consent that the pending 
amendment be temporarily laid aside.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                           Amendment No. 998

  Mr. DODD. Madam President, I call up amendment No. 998.
  The PRESIDING OFFICER. The clerk will report.
  The legislative clerk read as follows:

       The Senator from Connecticut [Mr. Dodd] proposes an 
     amendment numbered 998.

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

(Purpose: To modify the amount of the direct subsidy to be provided to 
               qualified retiree prescription drug plans)

       On page 129, strike lines 3 through 20, and insert the 
     following:
       ``(2) Amount of payment.--The amount of the payment under 
     paragraph (1) shall be an amount equal to the monthly 
     national average premium for the year (determined under 
     section 1860D-15), as adjusted using the risk adjusters that 
     apply to the standard prescription drug coverage published 
     under section 1860D-11.

  Mr. DODD. Madam President, this first amendment is intended to 
address one of the major problems with this bill, and that is the 
impact the legislation could have on Medicare beneficiaries who are 
currently receiving prescription drug coverage under the employer-
sponsored retiree benefit plans.
  I will quickly point out to my colleagues who may be saying we voted 
on this with the Rockefeller amendment that this is very different. The 
Rockefeller amendment was designed to provide encouragement to 
employers to supplement the existing prescription drug benefit. This 
amendment is designed to provide that encouragement only to employers 
who would be picking up the total cost of the prescription drug 
benefit, not just acting as a supplement. So it is very different. It 
is not the wraparound. This is an optional choice by the retiree or the 
employer.

[[Page 15919]]

If they are the primary provider of the drug benefit, they would be 
covered by this amendment.
  For employers intending to act as a supplement to the coverage, we 
decided that today; unfortunately, it was voted down. With that in 
mind, clearly in this bill most of us believe what we ought to be 
trying to do is support, not supplant, the valuable efforts of 
employers already providing prescription coverage to retirees.
  As presently written, I am concerned the bill would lead many retiree 
benefit plans to scale back or drop entirely the prescription drug 
coverage they presently provide. However, this amendment would provide 
an increased subsidy to employers, because we want to encourage them to 
provide this benefit to retirees. It seems to me it is in our interest 
to encourage them to stay involved. They would get a subsidy, as long 
as they continue to offer prescription drug coverage to retirees only 
as the primary provider, not as a supplement--not as a wrap around the 
new Medicare benefit.
  The scope of this problem is not small at all. In fact, I was 
surprised to learn how many seniors would be impacted by the unintended 
change to retiree benefit coverage. About one-third of all Medicare 
beneficiaries receive prescription drug coverage through an employer-
sponsored health care plan. That is by far the largest source of 
prescription drug coverage for seniors.
  These plans have played a very critical role in providing security to 
seniors, while Congress has been unable over the last number of years 
to pass a prescription drug benefit plan under Medicare. Retiree 
benefit plans should continue, in my view, to play that role even after 
a drug benefit plan is enacted. In many cases, the drug coverage 
provided by retiree benefit plans is significantly more generous than 
the plan we are debating here.
  Furthermore, many seniors have become familiar and comfortable with 
the coverage offered by their former employers.
  Understandably, they do not want to give it up for a plan about which 
they are confused and uncertain or may not be as beneficial to them.
  We should be doing, in my view, everything in our power to provide 
these seniors with a choice, with the option of staying with their 
employer-sponsored plan. Thus, this amendment.
  Unfortunately, the option may not be available for many seniors. That 
is why I put up this chart. I wish to focus the attention of those who 
may be following this debate to the left side of this chart. The right 
side I will talk about briefly, but the most significant numbers are on 
the left side of the chart. I will get to them in a minute.
  While the numbers vary slightly, depending upon which study one 
consults, they come to the same conclusions, roughly the same numbers, 
and they are very disheartening. Between 1993 and 2001, the percentage 
of large employers, those who employ more than 500 people, offering 
coverage to Medicare-eligible retirees dropped from 40 to 23 percent, 
almost in half over 7 or 8 years. In the last 2 years, 13 percent of 
all employers offering future retiree coverage have elected not to do 
so. Those retaining coverage are experiencing annual cost increases on 
the order of 14 percent. It has been tremendously expensive. As a 
result, they are substantially raising the cost-sharing burdens for 
individuals enrolled in these plans.
  The chart on the left-hand side illustrates the crisis that employer-
sponsored plans are facing today and are going to continue to face in 
the future. The numbers are based on a survey conducted by the Kaiser 
Family Foundation and Hewitt Associates in December of 2002.
  The graph shows that the actions large employers have taken over the 
last 2 years to deal with the rapidly increasing retiree health care 
cost--these numbers may not be clear to everyone, so I will recite 
them--a large number of employers have increased individual costs in 
some way. Forty-four percent have increased retiree contributions to 
premiums, while 36 percent increased cost sharing. In addition, 14 
percent have shifted all costs to the individual retiree, and 13 
percent have eliminated the plans altogether. Finally, nearly half of 
employers surveyed increased cost sharing for prescription drugs, as 
shown by the bar depicting 49 percent.
  The numbers on this chart do not bode well, is the point I am trying 
to make, for those seniors who currently receive health care benefits 
from their former employers. Given the enormous financial pressures 
being felt by employers and the encouragement this bill already 
provides--in the form of a 64 percent subsidy--to keep employers from 
dropping coverage, it seems to me that if the employees decide to stay 
with their existing coverage, we believe that subsidy ought to go from 
64 percent to 100 percent of the national average premium. That is what 
we are trying to do with this amendment.
  The Congressional Budget Office has estimated that almost 40 percent 
of seniors who currently have their prescription drug medicines covered 
by retiree benefit plans would lose their coverage under the plan 
before us. So even with the 64 percent subsidy, 37 percent of retirees 
would be dropped from these plans. We are raising through this 
amendment that subsidy to 100 percent which we think will do a lot to 
keep these employer-based plans in place so that retirees would have 
that option of sticking with those retiree plans.
  I supported the Rockefeller amendment. I mentioned that earlier. This 
is different. This is very different. If you are just supplementing the 
benefit plan, then you would not be covered by the Dodd amendment. That 
was the Rockefeller amendment, and the Senate voted it down. My 
amendment says only if you are the primary provider of the prescription 
drug benefit would you get the kind of subsidy we are talking about, 
from 64 to 100 percent. That would mean approximately an additional 
$400 a year per retiree paid to the employer. This would encourage 
employers to retain the full prescription drug coverage they presently 
provide rather than cutting back coverage and simply supplementing a 
new Medicare benefit.
  The underlying bill has a provision that would provide a subsidy to 
employers for every Medicare-eligible retiree who elects to remain in 
an employer-sponsored plan as an alternative to the Medicare 
prescription drug plan. That subsidy would be approximately, as I 
mentioned, 64 percent of the national average premium for prescription 
drug coverage.
  This amendment would very simply increase that subsidy to the full 
national average premium. This would mean an additional $35 a month per 
beneficiary or roughly $400 a year paid directly to employer-sponsored 
plans as long as they continue to offer an alternative to Medicare 
prescription drug coverage, bringing the total subsidies to almost $100 
per month when we combine the 64 percent that is in the bill and what 
we are adding with this amendment.
  To receive this subsidy, employers would have to offer a prescription 
drug plan that is competitive with the Medicare benefit because the 
subsidy would only be paid for beneficiaries who remain in the 
employer-sponsored plan and do not enroll in Medicare Part C or D.
  We simply cannot allow retiree benefit plans to disappear. That would 
be a great mistake, in my view. This amendment is designed to keep them 
if we can. It is a modest amendment considering the benefits that could 
accrue to the retirees, giving them the option of sticking with an 
employer-based plan.
  If CBO is right, under the plan before us, almost 40 percent of these 
retirees will lose that prescription drug coverage under their 
employer-based plans. I do not think we want to have that happen. I 
urge the adoption of this amendment, and I hope my colleagues will be 
supportive of it.
  I see the chairman of the committee who I know wants to respond to my 
amendment.
  The PRESIDING OFFICER (Mr. Alexander). The Senator from Iowa.
  Mr. GRASSLEY. Mr. President, I wish to propound a unanimous consent 
request.
  I ask unanimous consent that Senator Dodd have up to 20 minutes and

[[Page 15920]]

Senator Grassley up to 10 minutes for debate on amendment Nos. 970 and 
998 concurrently. I further ask unanimous consent that following that 
debate, the Senate proceed to a vote in relation to the amendment No. 
970, to be followed by a vote in relation to amendment No. 998, with no 
second-degree amendments in order to the amendments prior to the vote. 
Finally, I ask unanimous consent that at 10 a.m. tomorrow the Senate 
proceed to a vote in relation to the Grassley, or his designee, 
amendment, regarding the benchmark, with no amendments in order to the 
amendment prior to the vote; provided further, that this vote be 
subject to the approval of both leaders.
  The PRESIDING OFFICER. Is there objection?
  Mr. REID. Reserving the right to object.
  The PRESIDING OFFICER. The Senator from Nevada.
  Mr. REID. Mr. President, it is my understanding the Senator from 
Connecticut has graciously indicated the time he has used would be 
counted toward this time.
  Mr. DODD. That is correct.
  Mr. REID. That being the case, the vote will occur around 6:15 p.m., 
for the information of Members.
  The PRESIDING OFFICER. Approximately 6:20 p.m. Is there objection? 
Without objection, it is so ordered.
  Mr. DODD. Mr. President, if I can finish, I can give the chairman a 
chance to respond.
  I ask unanimous consent that a letter signed by 33 of the labor 
unions in this country in support of my amendment be printed in the 
Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:
                                                    June 23, 2003.
       Dear Senator: If the Medicare drug bill before the Senate, 
     S. 1, becomes law, 37 percent of retirees who now have 
     employer-sponsored health benefits will lose that coverage. 
     That's 4.4 million retirees that will be made worse off if S. 
     1, as drafted, is enacted into law. Such an act will 
     represent an enormous and irreversible blow to the employer-
     based system that is the backbone of our nation's health care 
     system.
       As you know, retiree health coverage is already in crisis. 
     Drug costs constitute 40 to 60 percent of employers' retiree 
     health care costs, and steep price increases are prompting 
     employers to eliminate drug benefits, cap their contributions 
     or drop retiree coverage altogether. In fact, just 34 percent 
     of all large firms (200 or more employees) offered retiree 
     benefits in 2002, down from 68 percent of all large firms in 
     1988.
       Both public and private employers need immediate relief for 
     their retiree prescription drug costs, but S. 1, as now 
     drafted, will exacerbate an already dire situation for 
     retiree coverage by discriminating against retirees with 
     employer-sponsored coverage.
       By using a trick definition of out of pocket costs--``true 
     out of pocket''--S. 1 will effectively deny retirees 
     catastrophic coverage by not counting any drug costs covered 
     through an employer plan. This ensures seniors with retiree 
     benefits will get less Medicare coverage than any other 
     beneficiary. As a result, employers that choose to ``wrap 
     around'' the Medicare benefit and provide assistance for 
     costs not covered by Medicare will find the gap in coverage 
     does not end for these retirees.
       Two amendments will be offered to address this critical 
     flaw. The first, offered by Senator Rockefeller, would 
     eliminate the ``true out of pocket'' definition so that 
     retirees receive the same benefit as all other beneficiaries. 
     The second amendment, to be offered by Senator Dodd, would 
     increase the subsidy to employers that retain retiree 
     benefits.
       Although some may claim that the ``true out of pocket'' 
     trick will save money for Medicare, any provision that 
     encourages employers to drop their retiree benefits will only 
     end up costing the federal government more--and hurt millions 
     of seniors in the process. Seniors who have retiree benefits 
     have worked a lifetime and made wage concessions over the 
     years with the expectation that they would have retiree 
     benefits. To change the rules of the game at this point and 
     give them less than other Medicare beneficiaries is patently 
     unfair.
       We urge you to support the amendments aimed at encouraging 
     both public and private employers to continue providing 
     retiree health benefits. Congress must enact a drug benefit 
     that supports, not threatens our fragile employer-based 
     system of health coverage.
       We have many other concerns with the Senate bill, including 
     the enormous gap in coverage and the reliance on uncertain 
     and historically unstable private insurance plans. And we 
     have very grave concerns that the conference report you will 
     be asked to consider will incorporate elements of the House 
     bill that are entirely unacceptable to the millions of 
     American we represent. In particular, the House bill would 
     introduce full competition into Medicare beginning in 2010--a 
     blatant attempt to undermine the traditional Medicare program 
     and start it on a ``death spiral'' of caring for the sickest 
     beneficiaries and unsustainable costs.
       We strongly believe that adding a prescription drug benefit 
     to Medicare is the most urgently needed reform and one that 
     has been promised to our nation's elderly and disabled. 
     However, we cannot accept legislation that does so at the 
     expense of retirees who now have employer-sponsored coverage 
     and the very future of Medicare.
       Thank you for your consideration.
           Sincerely,
         John J. Sweeney, President, AFL-CIO; Ron Gettelfinger, 
           President, United Auto Workers; John J. Flynn, 
           President, International Union of Bricklayers and 
           Allied Craftworkers; Morton Bahr, President, 
           Communications Workers of America; Harold A 
           Schaitberger, President, International Association of 
           Fire Fighters; Douglas H. Dority, International 
           President, United Food and Commercial Workers.
         James A. Grogan, Jr., President, Asbestos Workers, 
           International Association of Heart and Frost 
           Insulators; Frank Hurt, President, Bakery, 
           Confectionary, Tobacco Workers and Grain Millers 
           International Union; Edward C. Sullivan, President, 
           Building and Construction Trades; Edwin D. Hill, 
           President, International Brotherhood of Electrical 
           Workers; Patricia Friend, International President, 
           Association of Flight Attendants; Bobby L. Harnage Sr., 
           President, American Federation of Government Employees.
         David Holway, President, National Association of 
           Government Union Employees/International Brotherhood of 
           Police Officers; S. Richard Elliott, President, 
           International Union of Journeymen, Horseshoers, United 
           Services and Allied Trades; Terence M. O'Sullivan, 
           President, Laborers' International Union; R. Thomas 
           Buffenbarger, President, International Association of 
           Machinists and Aerospace Workers; Thomas F. Lee, 
           President, American Federation of Musicians of the 
           United States and Canada.
         Gregory Junemann, President, International Federation of 
           Professional and Technical Engineers; Andrew L. Stern, 
           President, Service Employees International Union; 
           Gerald W. McEntee, President, American Federation of 
           State, County and Municipal Employees; Sandra Feldman, 
           President, American Federation of Teachers; Sonny Hall, 
           President, Transport Workers Union of America; Donald 
           Wightman, President, Utility Workers Union of America; 
           George Tedeschi, President, Graphic Communications 
           International Union; Joseph J. Hunt, General President, 
           Iron Workers, International Association of Bridge, 
           Structural, Ornamental and Reinforcing.
         John M. Bowers, President, International Longshoremen's 
           Association; Cecil E. Roberts, President, United Mine 
           Workers of America; Boyd D. Young, President, PACE 
           International Union; Joe L. Greene, President, American 
           Federation of School Administrators; Michael J. 
           Sullivan, General President, Sheet Metal Workers 
           International Union; Leo W. Gerard, President, United 
           Steelworkers of America; James P. Hoffa, General 
           President, International Brotherhood of Teamsters; 
           Robert A. Scardelletti, President, Transportation 
           Communications International Union.

  Mr. DODD. Mr. President, I will read a pertinent passage because this 
is really the heart of this issue. I mentioned earlier, one-third of 
all retirees get coverage under the private employer-based plans. If 
CBO is right, almost 40 percent of retirees will lose their coverage 
under this bill, and employers would start dropping them because they 
do not get the subsidies, then I think we have to understand what the 
implications mean for a lot of people. I do not believe my colleagues 
intend this to be the case, but this is what is going to happen if we 
are not careful.
  The letter reads in part:

       If the Medicare drug bill before the Senate, S. 1, becomes 
     law, 37 percent of retirees who now have employer-sponsored 
     health benefits will lose that coverage.

  That is according to CBO.

       That's 4.4 million retirees that will be made worse off if 
     S. 1, as drafted, is enacted into law. Such an act will 
     represent an enormous and irreversible blow to the employer-
     based system that is the backbone of our nation's health care 
     system.

  The letter goes on:

       . . . any provision that encourages employers to drop their 
     retiree benefits will only end up costing the federal 
     government more--and hurt millions of seniors in the process. 
     . . .

[[Page 15921]]

       We urge you to support the [Dodd] amendment aimed at 
     encouraging both public and private employers to continue 
     providing retiree health benefits. Congress must enact a drug 
     benefit that supports, not threatens, our fragile employer-
     based system of health coverage.

  That is what my amendment is designed to do: to provide that subsidy 
if the retiree takes the option of continuing in the employer-based 
plan as the primary provider for health care coverage. If that is the 
case, then I think we ought to provide that encouragement and 
inducement. They make a huge difference in people's lives. If CBO is 
right and we do not adopt this amendment, and 4.5 million people have a 
worse plan as a result of our action, we have taken a step back rather 
than a step forward for that many seniors in our country. I don't know 
of anyone in this Chamber who would like to be a party to that.
  For those reasons, I hope my colleagues could support the man from 
Connecticut on his amendment.
  Mr. GRASSLEY. I am glad to speak about the man from Connecticut and 
his amendment but not to support it.
  First of all, we need to remember, with or without this subject 
before the Senate, these plans could be dropped without any hesitation. 
We can have the prescription drug plan before the Senate, and there 
could be some reason some companies would drop that. But right now, 
remember, our passage of this legislation is very much to fill a gap. 
We are worried about people who do not have any coverage whatever.
  As I have said before, we are all very concerned about the future of 
retirees' benefits and making sure retirees are treated fairly. Under 
the beneficial before the Senate, retirees get the same protection from 
high prescription drugs and the costs as any other beneficiary. That is 
a generous subsidy, far greater than they currently get, which would be 
zero.
  The fact is, typical retiree plans provide much more generous 
coverage, and the beneficiaries spend much less out of pocket for their 
prescriptions.
  There has been a great deal of interest in the assumption by the 
Congressional Budget Office that corporations are going to drop their 
coverage of prescription drugs for about 37 percent of the retirees in 
retiree health plans over the next 10 years. What we cannot forget is 
employers, as I indicated, are already dropping or, maybe more, scaling 
back retiree health benefits not because of our legislation but because 
retiree health benefits are rising because of very high health care 
costs. They have already been dropping plans or cutting them back for 
at least a decade, a point made by my colleague, Senator Dodd.
  We have worked hard to address this problem in the underlying 
legislation. One of the most significant future liabilities faced by 
retiree plans is the cost of prescription drugs. We have given 
employers serious and generous subsidies. The Dodd amendment proposes 
to boost subsidies for employers beyond the 64 percent we have given 
them already. This change would send millions more in taxpayers dollars 
to these corporations during the next decade. We had to put priorities 
first.
  We have $400 billion. We have looked at States and the problems of 
dual eligibles. We looked at corporate retiree plans and what might 
happen and what can we do to keep those that are going out of business 
or dumping theirs on a government plan. We have worked with a lot of 
different problems. We have had to do the best we can to squeeze within 
that $400 billion. We have tried to help the States to some extent on 
dual eligibles. We are trying to help corporations with incentives not 
to dump their retirees on this plan. I can go down a long list we have 
tried to squeeze in and prioritize.
  The overriding goal was to help those who had no drug plans whatever. 
That was very much a high priority. We have maybe 30 percent or a 
little more on private plans. We have people on Medicare with Medigap 
policies. We have people who are duly eligible subject to Medicaid. But 
we have 30 percent or more with zilch. We go beyond just helping those 
who do not have any plan. But that has been our priority. We tried to 
do it in a way that people who have better--and maybe most corporate 
retiree plans do have better incentives than what we can provide--and 
they can continue to have better. But we cannot control entirely what 
corporations are going to do. Particularly, you cannot do that on the 
amount of money we have here.
  As I indicated, this is a very expensive amendment that we cannot 
squeeze into the $400 billion.
  I urge my colleagues to defeat the amendment. I yield the floor.
  The PRESIDING OFFICER. The Senator from Connecticut.
  Mr. DODD. I will take 1 minute on this amendment and move to my 
second amendment.
  This is an optional choice. We are not requiring employers to retain 
an employer-based plan. We are saying we know already, based on CBO's 
analysis, that close to 40 percent of people under the employer-based 
plans will be dropped. We know that.
  Our primary responsibility in this bill is to provide a good 
prescription drug benefit for people. We do not want to be in a 
situation of actually causing people to have a worse plan than they 
have.
  My point is not to increase spending but to say, if you are going to 
provide prescription drug coverage as an employer--and I want you to 
continue doing this; and we are being told 37 percent of the people 
will be dropped--we will increase the subsidy. To encourage employers 
to continue doing it seems to me to be in our interest. That is why I 
offer this amendment and why it is so strongly supported by labor 
unions who believe this will be a major blow to almost 4.5 million 
retirees in the country. I urge adoption of this amendment.


                           Amendment No. 970

  The second amendment I call up is amendment No. 970, and I ask for 
its immediate consideration.
  The PRESIDING OFFICER. That amendment is pending.
  Mr. DODD. Let me briefly explain this amendment. I commend the 
committee.
  This bill does an awful lot for people who are really hurting. I want 
the chairman to know I strongly support his efforts. Those who are 
really hurting get real help with this bill. I commend the committee 
for focusing on that. I commend him for it.
  What this amendment does is a little different. We have all been 
talking about donut holes. People watching this debate may wonder what 
we are talking about, but the donut hole is in the plan when you reach 
a certain level of your costs of prescription drugs. Even though you 
keep paying the premiums of $35 a month, if your costs run somewhere 
around $4,500 to $5,800, during that period you are in the eye of the 
hurricane, and you do not get any help during that period.
  That is not true if you are below 160 percent of poverty. If you are 
below 160 percent of poverty, we will provide help to you even while 
you are in the donut hole.
  My amendment effects those in the donut hole who are between 160 and 
250 percent of poverty. That is an individual who makes $22,000 a year 
or a couple earning $30,000 a year. These are people who are really 
hurting out there as well. They are not as desperately poor as those at 
160 percent of poverty, but they are not much better off. But just in 
the donut hole, could we say that those people might get a 50/50 deal 
in the donut hole, between 160 and 250 percent of poverty? In that one 
set of circumstances where the costs are running from $4,500 to $5,800, 
you get a 50/50 deal if you are making $22,500, or a couple, $30,000, 
that is what the amendment does.
  I know the chairman is going to say these are great ideas and there 
is a cost associated, and there is. But we ought to provide some help 
to people in those earnings groups--$22,000 if you are single or 
$30,000 as a couple. These are probably cancer patients or patients 
with serious medical costs. If you are paying somewhere around $4,500 a 
year, up to $5,800 a year, you have a serious health care problem. If 
you are making $22,000 or $30,000, as an individual or a married 
couple, then to provide 50 percent of the cost of those prescription 
drugs while you are in that donut hole I do not think is asking too 
much of us.

[[Page 15922]]

  We should add just a little bit to accommodate these not even middle-
income people. It would be an unfair description to say these are 
middle-income people. There is nothing magic about 250 percent. I just 
tried to reach out a bit to that constituency here that will continue 
paying the $35 a month. They have to do that. They do not get anything. 
If we could just reach a little further to that constituency, beyond 
the 160 percent, between $4,500 and $5,800 in total spending. We try to 
provide an additional bit of help for you, 50 percent of that cost. We 
can't pick up all of it, that would probably be too expensive. I don't 
know what the CBO numbers would be, but we will put you in the 50/50 
bracket up to 250 percent of poverty just while you are in that 
situation. That is what the amendment does. It is no more complicated 
than that.
  Again, I compliment the chairman. They have done a very good job 
taking care of the very desperately poor in the country. But for people 
who are not quite desperately poor--although I suggest some may tell 
you that living on $22,000 a year as a single person or a couple over 
the age of 65 with $30,000 worth of income, they are not out partying. 
These people probably make choices between food and rent and medicines, 
particularly if you are paying $4,500 a year or up to $5,800 a year for 
prescription drugs. That comes off the $22,000 or your $30,000. You do 
not have to do the math to know where you are living, what 
circumstances you are under.
  So this is designed to provide some additional relief for people in 
that category, moving it up just a little bit, up to that 250 percent 
from 160 percent while you are in the donut hole, only there, to get a 
50/50 break. You still pay 50 percent of the cost. You don't get 100 
percent relief, but 50 percent of the cost, and that is what the second 
amendment is designed to do.
  I apologize for racing, but I am trying to get this in in the 5 
minutes. This is obviously complicated stuff. I am trying to 
accommodate my colleagues who I know have other engagements this 
evening to explain what the amendments do. The time does not justify 
the context, as to how important this would be to a lot of people in 
this country. I don't know the numbers of the people in this income 
category, but I have to believe before we get done with this, to 
provide some additional help for people in that category ought not to 
be too much of a stretch when you consider that $22,450 for an 
individual and $30,000 for a couple is going to put a lot of burden, a 
lot of pressure on you if you are already paying somewhere between 
$4,500 and $5,800 in prescription drug costs. This amendment would help 
those people.
  I hope the man from Connecticut might impress the chairman on this 
one with his support. Hope springs eternal. I keep knocking on the 
door, seeing if I can't get some help.
  Mr. KENNEDY. I commend Senator Dodd for offering this important 
amendment today. This amendment will address one of the gaping holes in 
this plan--its failure to treat retirees and retiree health plans 
fairly. Today, we have the opportunity--and the obligation--to correct 
that unfairness.
  Ten million senior citizens depend on retiree health plans to fill 
the gaps in Medicare. Especially given the limitations of the drug 
benefit we are debating, supplemental coverage from retiree health 
plans is crucial. But retiree health plans are being abandoned or cut 
back all over the country--and prescription drug costs are a key part 
of the problem. For retirees who are over 65, prescription drugs make 
up about half of all plan costs--and as much as 80 percent of recent 
cost increases.
  But the prescription drug plan before us treats those plans unfairly, 
by taking the unprecedented step of making senior citizens with retiree 
health plans second class citizens under Medicare. The Congressional 
Budget Office has concluded that even with the new assistance provided 
under this plan, one-third of all retirees--4 million senior citizens--
could lose their supplemental drug coverage. That should be 
unacceptable to every Senator.
  The issue is not one of providing a bail-out or a windfall to retiree 
health plans. It is one of simple fairness. Currently, whenever 
Medicare covers a benefit or service, Medicare is the primary payer for 
that service. If a retiree health plan covers the service, it pays only 
for what Medicare does not cover.
  The reason for that is straightforward. Employers pay taxes to 
support the Medicare Program. So do retirees. So do active workers who 
accept lower wages during their working years in order to have 
supplemental retirement health care in their retirement years.
  But under this legislation, these workers and these employers do not 
get the full benefit of their contribution to the drug benefit. Because 
of the ``true out-of-pocket'' concept included in the bill, Medicare 
does not pay for catastrophic expenses of these workers, even though 
the cost of covering these expenses accounts for more than one-third 
the cost of the current bill.
  And the higher the costs the retiree faces, the more the discrepancy 
between what Medicare pays for the retiree with employer-sponsored 
insurance and what Medicare pays for all other senior citizens grows. 
If the individual's drug costs are $6,000, Medicare pays $2,113 for the 
retiree with insurance but $2,281 for all other senior citizens. If the 
individual's drug costs are $8,000, Medicare still pays $2,113 for the 
retiree with employer-sponsored insurance, but $4,081 for all other 
senior citizens. And if the individual's drug costs are $10,000, 
Medicare still pays just $2,113 for the retiree, but pays $5,881 for 
all other senior citizens.
  This is double taxation at its worst. These retired workers and 
companies are taxed twice. They pay once to support the Mecicare 
program. Then they are forced to pay again by being denied the Medicare 
benefits their contributions have earned. During the debate on the tax 
bill we heard a lot about the injustice of double taxation of dividends 
from the other side of the aisle. Apparently, for them, double taxation 
of the unearned income of millionaires and billionaires is wrong, but 
double taxation of moderate income retired senior citizens is just 
fine.
  The fact is that it is not fine. The American people understand that 
it is wrong. American companies struggling to provide for their retired 
workers in this sour economy understand that is wrong. The Senate 
should understand that it is wrong, too, and right this injustice.
  The PRESIDING OFFICER. The Senator from Iowa.
  Mr. GRASSLEY. Mr. President, how much time do I have?
  The PRESIDING OFFICER. The Senator has 4 minutes.
  Mr. DODD. I had 5.
  Mr. GRASSLEY. First, let me explain to the distinguished Presiding 
Officer why we refer to ``the man from Connecticut.'' When I was going 
to yield him some time, I didn't think of the word ``Senator.'' I said 
I will give 1 minute to the man from Connecticut, and I apologize.
  First of all, I wish I had an exact number for this amendment. It has 
some costs, but I do not have an official score from the Congressional 
Budget Office so I cannot say that this costs X number of billions of 
dollars at this point. But it does have some cost.
  I am going to try to convince the Senator from Connecticut that we 
have done a lot in this legislation for people who are low income. 
Maybe it doesn't go as high up the economic ladder as he would like to 
have us go. But my point is we have done an awful lot.
  We worked very hard to minimize the gap in coverage with resources 
provided in the budget resolution which would be roughly $400 billion. 
The bill also provides generous coverage to lower income beneficiaries, 
those who have income below about $15,000, and couples with incomes 
below about $20,000. They, in fact, have no gap in coverage. That is 44 
percent of Medicare beneficiaries who are completely unaffected by the 
benefit limit.
  In the writing of this bill, a conscious decision was made to devote 
excess dollars to filling in the gap in coverage for all seniors. Under 
the underlying bill, the average senior at this income level will still 
save more than $1,600 annually off the drug spending after paying

[[Page 15923]]

an affordable monthly premium of $35 per month. This is a savings of 
about 53 percent off annual drug costs for the average senior who would 
enroll in the drug benefit.
  Let me remind everybody, this drug benefit is optional. People do not 
have to join it. If anybody is saying I don't want to pay $35 per month 
to get this sort of coverage, then that person does not have to pay $35 
per month for coverage because this is a voluntary program. So the 
people who enroll in this program would save that $1,600, even beyond 
the $35-per-month premium.
  While I appreciate what the Senator from Connecticut is trying to do, 
it cannot possibly fit within the $400 billion that we have. We had to 
draw a limit someplace. We drew the limit at 160 percent of poverty. So 
I cannot support his amendment. I am sorry to say that to the Senator 
from Connecticut.
  The PRESIDING OFFICER. The Senator from Connecticut.
  Mr. DODD. I thank the chairman. He has been very gracious. This is my 
last amendment. I have tried vainly over here in the last couple of 
days with some amendments--I don't know what the implications are; I 
appreciate his candor, in terms of not knowing the cost of this 
amendment--that would fill in the hole, to go from 160 to 250, for 
people in that category. The reason I offered it is it occurred to me 
if you are paying that much in prescription drugs, somewhere around 
$5,000 a year for prescription drugs, and you are making $30,000 as a 
couple or $22,000 as an individual, you probably have a pretty serious 
illness if you are paying about $5,000 in prescription drug costs.
  It occurs to me that during that hole, we might try to do a little 
more. We have done that, as the chairman says, very graciously for the 
desperately poor in this country.
  For those reasons, I urge the adoption of the amendment. I will let 
the chairman proceed. The first amendment, I guess, we will do in that 
order.
  Mr. GRASSLEY. I yield any time I have and I ask for the yeas and 
nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There is a sufficient second.
  The question is on agreeing to amendment No. 970.
  Mr. DODD. There are two amendments. Amendment No. 998?
  The PRESIDING OFFICER. We will vote on one at a time. Amendment No. 
970 is first.
  Mr. GRASSLEY. Mr. President, while I am at it, I would like to ask 
for the yeas and nays on both the Dodd amendments.
  The PRESIDING OFFICER. Is there objection to that request?
  Without objection, it is so ordered. The yeas and nays are in order.
  Is there a sufficient second?
  There is a sufficient second.
  The yeas and nays were ordered.
  The PRESIDING OFFICER. The question is on agreeing to the amendment. 
The yeas and nays have been ordered.
  The clerk will call the roll on amendment No. 970.
  The assistant legislative clerk called the roll.
  Mr. McCONNELL. I announce that the Senator from Colorado (Mr. 
Campbell) and the Senator from South Carolina (Mr. Graham) are 
necessarily absent.
  Mr. REID. I announce that the Senator from Florida (Mr. Graham), the 
Senator from Massachusetts (Mr. Kerry), and the Senator from 
Connecticut (Mr. Lieberman) are necessarily absent.
  I further announce that, if present and voting, the Senator from 
Florida (Mr. Graham) and the Senator from Massachusetts (Mr. Kerry) 
would each vote ``yea.''
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 41, nays 54, as follows:

                      [Rollcall Vote No. 240 Leg.]

                                YEAS--41

     Akaka
     Bayh
     Biden
     Bingaman
     Boxer
     Byrd
     Cantwell
     Carper
     Clinton
     Conrad
     Corzine
     Daschle
     Dayton
     Dodd
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Harkin
     Hollings
     Inouye
     Johnson
     Kennedy
     Kohl
     Lautenberg
     Leahy
     Levin
     Lincoln
     Mikulski
     Murray
     Nelson (FL)
     Nelson (NE)
     Pryor
     Reed
     Reid
     Rockefeller
     Sarbanes
     Schumer
     Stabenow
     Wyden

                                NAYS--54

     Alexander
     Allard
     Allen
     Baucus
     Bennett
     Bond
     Breaux
     Brownback
     Bunning
     Burns
     Chafee
     Chambliss
     Cochran
     Coleman
     Collins
     Cornyn
     Craig
     Crapo
     DeWine
     Dole
     Domenici
     Ensign
     Enzi
     Fitzgerald
     Frist
     Grassley
     Gregg
     Hagel
     Hatch
     Hutchison
     Inhofe
     Jeffords
     Kyl
     Landrieu
     Lott
     Lugar
     McCain
     McConnell
     Miller
     Murkowski
     Nickles
     Roberts
     Santorum
     Sessions
     Shelby
     Smith
     Snowe
     Specter
     Stevens
     Sununu
     Talent
     Thomas
     Voinovich
     Warner

                             NOT VOTING--5

     Campbell
     Graham (FL)
     Graham (SC)
     Kerry
     Lieberman
  The amendment (No. 970) was rejected.
  Mr. GRASSLEY. I move to reconsider the vote.
  Mr. NICKLES. I move to lay that motion on the table.
  The motion to lay on the table was agreed to.


                       Vote on Amendment No. 998

  The PRESIDING OFFICER. The question is on agreeing to amendment No. 
998. The yeas and nays have been ordered. The clerk will call the roll.
  The legislative clerk called the roll.
  Mr. McCONNELL. I announce that the Senator from Colorado (Mr. 
Campbell) is necessarily absent.
  Mr. REID. I announce that the Senator from Florida (Mr. Graham), the 
Senator from Massachusetts (Mr. Kerry) and the Senator from Connecticut 
(Mr. Lieberman) are necessarily absent.
  I further announce that, if present and voting, the Senator from 
Massachusetts (Mr. Kerry) would vote ``yea''.
  The PRESIDING OFFICER (Mr. Talent). Are there any other Senators in 
the Chamber desiring to vote?
  The result was announced--yeas 41, nays 55, as follows:

                      [Rollcall Vote No. 241 Leg.]

                                YEAS--41

     Akaka
     Bayh
     Biden
     Bingaman
     Boxer
     Byrd
     Cantwell
     Carper
     Clinton
     Conrad
     Corzine
     Daschle
     Dayton
     Dodd
     Dorgan
     Durbin
     Edwards
     Feingold
     Feinstein
     Harkin
     Hollings
     Inouye
     Johnson
     Kennedy
     Kohl
     Lautenberg
     Leahy
     Levin
     Lincoln
     Mikulski
     Murray
     Nelson (FL)
     Nelson (NE)
     Pryor
     Reed
     Reid
     Rockefeller
     Sarbanes
     Schumer
     Stabenow
     Wyden

                                NAYS--55

     Alexander
     Allard
     Allen
     Baucus
     Bennett
     Bond
     Breaux
     Brownback
     Bunning
     Burns
     Chafee
     Chambliss
     Cochran
     Coleman
     Collins
     Cornyn
     Craig
     Crapo
     DeWine
     Dole
     Domenici
     Ensign
     Enzi
     Fitzgerald
     Frist
     Graham (SC)
     Grassley
     Gregg
     Hagel
     Hatch
     Hutchison
     Inhofe
     Jeffords
     Kyl
     Landrieu
     Lott
     Lugar
     McCain
     McConnell
     Miller
     Murkowski
     Nickles
     Roberts
     Santorum
     Sessions
     Shelby
     Smith
     Snowe
     Specter
     Stevens
     Sununu
     Talent
     Thomas
     Voinovich
     Warner

                             NOT VOTING--4

     Campbell
     Graham (FL)
     Kerry
     Lieberman
  The amendment (No. 998) was rejected.
  Mr. REID. Mr. President, I move to reconsider the vote and I move to 
lay that motion on the table.
  The motion to lay on the table was agreed to.
  Mr. REID. I ask unanimous consent that the Democratic leader be 
recognized to speak next, and following his statement the Senator from 
Georgia be recognized to speak, both as if in morning business. The 
Senator from Georgia will speak for up to 7\1/2\ minutes; I don't know 
how long Senator Daschle is going to speak, but I don't think it will 
be long.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. REID. While we are waiting for Senator Daschle, if we could 
reverse the order and have the Senator from Georgia proceed.

[[Page 15924]]

  The PRESIDING OFFICER. The Senator from Georgia.
  (The remarks of Mr. Miller are printed in Today's Record under 
``Morning Business.'')
  (The remarks of Mr. Daschle are printed in Today's Record under 
``Morning Business.'')
  The PRESIDING OFFICER. The Senator from Nevada.
  Mr. REID. I ask unanimous consent the pending amendment be set aside 
and Senator Conrad be recognized to offer a series of amendments, and 
following his offering amendments the Senator from New York, Senator 
Clinton, be recognized to offer her amendments.
  I state for the information of Senators, the manager or I will also 
have some other amendments to offer on behalf of other Senators. 
Following that, there should be no more business of the Senate.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The Senator from North Dakota.


                    Amendments Nos. 1019, 1020, 1021

  Mr. CONRAD. Mr. President, I say to my colleague who is seeking to 
also introduce amendments, I will be very brief.
  I rise to offer three amendments to the Prescription Drug and 
Medicare Improvement Act. I send the three to the desk.
  The PRESIDING OFFICER. The clerk will report the amendments by 
number.
  The legislative clerk read as follows:

       The Senator from North Dakota [Mr. Conrad], for himself, 
     Mrs. Murray, Mr. Smith, Mrs. Lincoln, and Mr. Jeffords, 
     proposes an amendment numbered 1019.

  The Senator from North Dakota [Mr. Conrad] proposes an amendment 
numbered 1020.
  The Senator from North Dakota [Mr. Conrad] proposes an amendment 
numbered 1021.
  Mr. CONRAD. I ask unanimous consent the reading of the amendments be 
dispensed with.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendments are as follows:


                           amendment no. 1019

 (Purpose: To provide for coverage of self-injected biologicals under 
 part B of the medicare program until Medicare Prescription Drug plans 
                             are available)

       At the end of subtitle B of title IV, insert the following:

     SEC. __. MEDICARE COVERAGE OF SELF-INJECTED BIOLOGICALS.

       (a) Coverage.--
       (1) In general.--Section 1861(s)(2) (42 U.S.C. 1395x(s)(2)) 
     is amended--
       (A) in subparagraph (U), by striking ``and'' at the end;
       (B) in subparagraph (V), by inserting ``and'' at the end; 
     and
       (C) by adding at the end the following new subparagraph:
       ``(W)(i) a self-injected biological (which is approved by 
     the Food and Drug Administration) that is prescribed as a 
     complete replacement for a drug or biological (including the 
     same biological for which payment is made under this title 
     when it is furnished incident to a physicians' service) that 
     would otherwise be described in subparagraph (A) or (B) and 
     that is furnished during 2004 or 2005; and
       ``(ii) a self-injected drug that is used to treat multiple 
     sclerosis;''.
       (2) Conforming amendment.--Subparagraphs (A) and (B) of 
     section 1861(s)(2) of the Social Security Act (42 U.S.C. 
     1395x(s)(2)) are each amended by inserting ``, except for any 
     drug or biological described in subparagraph (W),'' after 
     ``which''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to drugs and biologicals furnished on or after 
     January 1, 2004 and before January 1, 2006.

       At the end of title VI, add the following:

     SEC. __. MEDICARE SECONDARY PAYOR (MSP) PROVISIONS.

       (a) Technical Amendment Concerning Secretary's Authority To 
     Make Conditional Payment When Certain Primary Plans Do Not 
     Pay Promptly.--
       (1) In general.--Section 1862(b)(2) (42 U.S.C. 1395y(b)(2)) 
     is amended--
       (A) in subparagraph (A)(ii), by striking ``promptly (as 
     determined in accordance with regulations)''; and
       (B) in subparagraph (B)--
       (i) by redesignating clauses (i) through (iii) as clauses 
     (ii) through (iv), respectively; and
       (ii) by inserting before clause (ii), as so redesignated, 
     the following new clause:
       ``(i) Authority to make conditional payment.--The Secretary 
     may make payment under this title with respect to an item or 
     service if a primary plan described in subparagraph (A)(ii) 
     has not made or cannot reasonably be expected to make payment 
     with respect to such item or service promptly (as determined 
     in accordance with regulations). Any such payment by the 
     Secretary shall be conditioned on reimbursement to the 
     appropriate Trust Fund in accordance with the succeeding 
     provisions of this subsection.''.
       (2) Effective date.--The amendments made by paragraph (1) 
     shall be effective as if included in the enactment of title 
     III of the Medicare and Medicaid Budget Reconciliation 
     Amendments of 1984 (Public Law 98-369).
       (b) Clarifying Amendments to Conditional Payment 
     Provisions.--Section 1862(b)(2) (42 U.S.C. 1395y(b)(2)) is 
     further amended--
       (1) in subparagraph (A), in the matter following clause 
     (ii), by inserting the following sentence at the end: ``An 
     entity that engages in a business, trade, or profession shall 
     be deemed to have a self-insured plan if it carries its own 
     risk (whether by a failure to obtain insurance, or otherwise) 
     in whole or in part.'';
       (2) in subparagraph (B)(ii), as redesignated by subsection 
     (a)(2)(B)--
       (A) by striking the first sentence and inserting the 
     following: ``A primary plan, and an entity that receives 
     payment from a primary plan, shall reimburse the appropriate 
     Trust Fund for any payment made by the Secretary under this 
     title with respect to an item or service if it is 
     demonstrated that such primary plan has or had a 
     responsibility to make payment with respect to such item or 
     service. A primary plan's responsibility for such payment may 
     be demonstrated by a judgment, a payment conditioned upon the 
     recipient's compromise, waiver, or release (whether or not 
     there is a determination or admission of liability) of 
     payment for items or services included in a claim against the 
     primary plan or the primary plan's insured, or by other 
     means.''; and
       (B) in the final sentence, by striking ``on the date such 
     notice or other information is received'' and inserting ``on 
     the date notice of, or information related to, a primary 
     plan's responsibility for such payment or other information 
     is received''; and
       (3) in subparagraph (B)(iii), as redesignated by subsection 
     (a)(2)(B), by striking the first sentence and inserting the 
     following: ``In order to recover payment made under this 
     title for an item or service, the United States may bring an 
     action against any or all entities that are or were required 
     or responsible (directly, as an insurer or self-insurer, as a 
     third-party administrator, as an employer that sponsors or 
     contributes to a group health plan, or large group health 
     plan, or otherwise) to make payment with respect to the same 
     item or service (or any portion thereof) under a primary 
     plan. The United States may, in accordance with paragraph 
     (3)(A) collect double damages against any such entity. In 
     addition, the United States may recover under this clause 
     from any entity that has received payment from a primary plan 
     or from the proceeds of a primary plan's payment to any 
     entity.''.
       (c) Clerical Amendments.--Section 1862(b) (42 U.S.C. 
     1395y(b)) is amended--
       (1) in paragraph (1)(A), by moving the indentation of 
     clauses (ii) through (v) 2 ems to the left; and
       (2) in paragraph (3)(A), by striking ``such'' before 
     ``paragraphs''.


                           amendment no. 1020

 (Purpose: To permanently and fully equalize the standardized payment 
                  rate beginning in fiscal year 2004)

       Strike section 401 and insert the following:

     SEC. 401. EQUALIZING URBAN AND RURAL STANDARDIZED PAYMENT 
                   AMOUNTS UNDER THE MEDICARE INPATIENT HOSPITAL 
                   PROSPECTIVE PAYMENT SYSTEM.

       (a) In General.--Section 1886(d)(3)(A)(iv) (42 U.S.C. 
     1395ww(d)(3)(A)(iv)) is amended--
       (1) by striking ``(iv) For discharges'' and inserting 
     ``(iv)(I) Subject to subclause (II), for discharges''; and
       (2) by adding at the end the following new subclause:
       ``(II) For discharges occurring in a fiscal year beginning 
     with fiscal year 2004, the Secretary shall compute a 
     standardized amount for hospitals located in any area within 
     the United States and within each region equal to the 
     standardized amount computed for the previous fiscal year 
     under this subparagraph for hospitals located in a large 
     urban area (or, beginning with fiscal year 2005, for 
     hospitals located in any area) increased by the applicable 
     percentage increase under subsection (b)(3)(B)(i) for the 
     fiscal year involved.''.
       (b) Conforming Amendments.--
       (1) Computing drg-specific rates.--Section 1886(d)(3)(D) 
     (42 U.S.C. 1395ww(d)(3)(D)) is amended--
       (A) in the heading, by striking ``in different areas'';
       (B) in the matter preceding clause (i), by striking ``, 
     each of'';
       (C) in clause (i)--
       (i) in the matter preceding subclause (I), by inserting 
     ``for fiscal years before fiscal year 2004,'' before ``for 
     hospitals''; and
       (ii) in subclause (II), by striking ``and'' after the 
     semicolon at the end;
       (D) in clause (ii)--

[[Page 15925]]

       (i) in the matter preceding subclause (I), by inserting 
     ``for fiscal years before fiscal year 2004,'' before ``for 
     hospitals''; and
       (ii) in subclause (II), by striking the period at the end 
     and inserting ``; and''; and
       (E) by adding at the end the following new clause:
       ``(iii) for a fiscal year beginning after fiscal year 2003, 
     for hospitals located in all areas, to the product of--
       ``(I) the applicable standardized amount (computed under 
     subparagraph (A)), reduced under subparagraph (B), and 
     adjusted or reduced under subparagraph (C) for the fiscal 
     year; and
       ``(II) the weighting factor (determined under paragraph 
     (4)(B)) for that diagnosis-related group.''.
       (2) Technical conforming sunset.--Section 1886(d)(3) (42 
     U.S.C. 1395ww(d)(3)) is amended--
       (A) in the matter preceding subparagraph (A), by inserting 
     ``, for fiscal years before fiscal year 1997,'' before ``a 
     regional adjusted DRG prospective payment rate''; and
       (B) in subparagraph (D), in the matter preceding clause 
     (i), by inserting ``, for fiscal years before fiscal year 
     1997,'' before ``a regional DRG prospective payment rate for 
     each region,''.

       At the end of title VI, add the following:

     SEC. __. MEDICARE SECONDARY PAYOR (MSP) PROVISIONS.

       (a) Technical Amendment Concerning Secretary's Authority To 
     Make Conditional Payment When Certain Primary Plans Do Not 
     Pay Promptly.--
       (1) In general.--Section 1862(b)(2) (42 U.S.C. 1395y(b)(2)) 
     is amended--
       (A) in subparagraph (A)(ii), by striking ``promptly (as 
     determined in accordance with regulations)''; and
       (B) in subparagraph (B)--
       (i) by redesignating clauses (i) through (iii) as clauses 
     (ii) through (iv), respectively; and
       (ii) by inserting before clause (ii), as so redesignated, 
     the following new clause:
       ``(i) Authority to make conditional payment.--The Secretary 
     may make payment under this title with respect to an item or 
     service if a primary plan described in subparagraph (A)(ii) 
     has not made or cannot reasonably be expected to make payment 
     with respect to such item or service promptly (as determined 
     in accordance with regulations). Any such payment by the 
     Secretary shall be conditioned on reimbursement to the 
     appropriate Trust Fund in accordance with the succeeding 
     provisions of this subsection.''.
       (2) Effective date.--The amendments made by paragraph (1) 
     shall be effective as if included in the enactment of title 
     III of the Medicare and Medicaid Budget Reconciliation 
     Amendments of 1984 (Public Law 98-369).
       (b) Clarifying Amendments to Conditional Payment 
     Provisions.--Section 1862(b)(2) (42 U.S.C. 1395y(b)(2)) is 
     further amended--
       (1) in subparagraph (A), in the matter following clause 
     (ii), by inserting the following sentence at the end: ``An 
     entity that engages in a business, trade, or profession shall 
     be deemed to have a self-insured plan if it carries its own 
     risk (whether by a failure to obtain insurance, or otherwise) 
     in whole or in part.'';
       (2) in subparagraph (B)(ii), as redesignated by subsection 
     (a)(2)(B)--
       (A) by striking the first sentence and inserting the 
     following: ``A primary plan, and an entity that receives 
     payment from a primary plan, shall reimburse the appropriate 
     Trust Fund for any payment made by the Secretary under this 
     title with respect to an item or service if it is 
     demonstrated that such primary plan has or had a 
     responsibility to make payment with respect to such item or 
     service. A primary plan's responsibility for such payment may 
     be demonstrated by a judgment, a payment conditioned upon the 
     recipient's compromise, waiver, or release (whether or not 
     there is a determination or admission of liability) of 
     payment for items or services included in a claim against the 
     primary plan or the primary plan's insured, or by other 
     means.''; and
       (B) in the final sentence, by striking ``on the date such 
     notice or other information is received'' and inserting ``on 
     the date notice of, or information related to, a primary 
     plan's responsibility for such payment or other information 
     is received''; and
       (3) in subparagraph (B)(iii), as redesignated by subsection 
     (a)(2)(B), by striking the first sentence and inserting the 
     following: ``In order to recover payment made under this 
     title for an item or service, the United States may bring an 
     action against any or all entities that are or were required 
     or responsible (directly, as an insurer or self-insurer, as a 
     third-party administrator, as an employer that sponsors or 
     contributes to a group health plan, or large group health 
     plan, or otherwise) to make payment with respect to the same 
     item or service (or any portion thereof) under a primary 
     plan. The United States may, in accordance with paragraph 
     (3)(A) collect double damages against any such entity. In 
     addition, the United States may recover under this clause 
     from any entity that has received payment from a primary plan 
     or from the proceeds of a primary plan's payment to any 
     entity.''.
       (c) Clerical Amendments.--Section 1862(b) (42 U.S.C. 
     1395y(b)) is amended--
       (1) in paragraph (1)(A), by moving the indentation of 
     clauses (ii) through (v) 2 ems to the left; and
       (2) in paragraph (3)(A), by striking ``such'' before 
     ``paragraphs''.


                           amendment no. 1021

           (Purpose: To address medicare payment inequities)

       At the end of subtitle A of title IV, add the following:

     SEC. __. GEOGRAPHIC RECLASSIFICATION OF CERTAIN HOSPITALS FOR 
                   PURPOSES OF REIMBURSEMENT UNDER THE MEDICARE 
                   PROGRAM.

       (a) In General.--Notwithstanding any other provision of 
     law, effective for discharges occurring during fiscal year 
     2004 and each subsequent fiscal year, for purposes of making 
     payments under section 1886(d) of the Social Security Act (42 
     U.S.C. 1395ww(d)), hospitals located in the Bismarck, North 
     Dakota Metropolitan Statistical Area are deemed to be located 
     in the Fargo-Moorhead North Dakota-Minnesota Metropolitan 
     Statistical Area.
       (b) Treatment as Decision of Medicare Geographic 
     Classification Review Board.--
       (1) In general.--Except as provided in paragraph (2), for 
     purposes of section 1886(d) of the Social Security Act (42 
     U.S.C 1395ww(d)), any reclassification under subsection (a) 
     shall be treated as a decision of the Medicare Geographic 
     Classification Review Board under paragraph (10) of that 
     section.
       (2) Nonapplication of 3-year application provision.--
     Section 1886(d)(10)(D)(v) of the Social Security Act (42 
     U.S.C. 1395ww(d)(10)(D)(v)), as it relates to a 
     reclassification being effective for 3 fiscal years, shall 
     not apply with respect to reclassifications made under this 
     section.
       (c) Process for Applications To Ensure that Provisions 
     Apply Beginning October 1, 2003.--The Secretary shall 
     establish a process for the Medicare Geographic 
     Classification Review Board to accept, and make 
     determinations with respect to, applications that are filed 
     by applicable hospitals within 90 days of the date of 
     enactment of this section to reclassify based on the 
     provisions of this section in order to ensure that such 
     provisions shall apply to payments under such section 1886(d) 
     for discharges occurring on or after October 1, 2003.
       (d) Adjustments To Ensure Budget Neutrality.--If 1 or more 
     applicable hospital's applications are approved pursuant to 
     the process under subsection (c), the Secretary shall make a 
     proportional adjustment in the standardized amounts 
     determined under paragraph (3) of such section 1886(d) for 
     payments for discharges occurring in fiscal year 2004 to 
     ensure that approval of such applications does not result in 
     aggregate payments under such section 1886(d) that are 
     greater or less than those that would otherwise be made if 
     this section had not been enacted.

                           Amendment No. 1019

  Mr. CONRAD. Mr. President, the first amendment would provide 
immediate prescription assistance to certain chronically ill 
beneficiaries. We have a very curious circumstance. Under current law, 
Medicare Part B covers injectable drugs if they are routinely 
administered by a physician in the office. However, if a similar drug 
is available that could be self-injected at home, it is not covered.
  That makes no sense at all. This policy causes a significant burden 
for seniors with certain illnesses such as multiple sclerosis, 
rheumatoid arthritis, and other diseases. This amendment would address 
this problem by providing immediate coverage of drugs that could be 
administered at home when they are used to replace drugs that are 
covered when given in a physician's office. This transitional benefit 
would expire when a comprehensive Medicare drug benefit is implemented 
in 2006.
  I am proud to say I am working on this effort with Senator Murray of 
Washington, who has introduced similar legislation in bill form; 
Senator Smith, who is also on the Finance Committee, who has been a 
leading advocate of this approach; Senator Lincoln; and Senator 
Jeffords. It is supported by more than 40 patient organizations.
  This is a common-sense policy which provides real and immediate help 
to thousands of America's seniors. It is entirely paid for by codifying 
that Medicare is the secondary payer when beneficiaries have other 
private insurers that provide them with coverage.
  I hope my colleagues will look with favor on this amendment.


                           Amendment No. 1020

  The second amendment would address payment inequity that has hurt 
America's rural hospitals. As many know, rural health care providers 
are often forced to operate with significantly less resources than 
larger urban

[[Page 15926]]

facilities. In my State of North Dakota, rural hospitals often receive 
only one-half the reimbursement their urban counterparts get for 
treating the exact same illness.
  For example, a rural facility in North Dakota receives approximately 
$4,200 for treating pneumonia, while a hospital in New York receives 
more than $8,500 to treat that same illness. The funding disparity is 
simply unfair and has placed many rural providers on shaky ground.
  To address this situation, MedPAC has recommended various policies, 
including equalizing the standard payment amount, which has been 1.6 
percent higher for urban facilities. There is no policy basis for this 
difference.
  Earlier this year the omnibus appropriations bill took steps to 
equalize the standardized amount but only until the end of fiscal year 
2003. This amendment finishes the job by making this change permanent.
  Again, this amendment is fully paid for by the legislation codifying 
that Medicare is the secondary payer when beneficiaries have 
alternative coverage.


                           Amendment No. 1021

  Finally, I am offering a third amendment that would address a 
disparity related to whether certain hospitals are eligible to be 
reclassified for the purposes of the in-patient hospital wage index.
  Under current law, hospitals have to meet certain mileage or 
proximity requirements in order to reclassify to the wage index value 
applied to another area of the State. In rural States such as North 
Dakota, this restriction has produced unfair, certainly unintended, 
consequences.
  In my State, there are hospitals on the western side of North Dakota 
which are hundreds of miles from the eastern side of the State but 
compete for the same labor pool--compete for the same doctors, the same 
nurses--and have the same costs. However, because of this mileage 
restriction, they are not able to get paid the same. In fact, there is 
an 18-percent difference in the wage index between hospitals in 
Bismarck, ND, and hospitals in Fargo, ND--an 18-percent difference. It 
makes no earthly sense.
  North Dakota hospitals have tried to address this situation by 
appealing to CMS on various occasions, to no avail. And the reason it 
has been to no avail is because the law says you have to be contiguous. 
Well, there is a 200-mile difference between Bismarck and Fargo, but 
they are in contiguous markets. They compete for the same doctors, the 
same nurses, and they need to be treated in the same way.
  This amendment would address this situation by allowing certain 
hospitals in my State to reclassify to another area of the State for 
purposes of the wage index. This change would be budget neutral.
  I urge my colleagues to support these three important amendments.
  Let me just say, if I can, to my colleagues, I am also working on a 
fourth amendment, the dialysis annual update formula. I am working on 
that with Senator Santorum and the chairman and ranking member. We are 
hopeful of being able to work out that amendment at a later point.
  Mr. President, these are the amendments I am seeking to have 
considered.


                           amendment no. 1019

  Mr. SMITH. Mr. President, I rise today with my colleague from North 
Dakota in support of critical drug coverage for beneficiaries who 
contend with the debilitating effects of Multiple Sclerosis. This 
amendment would provide transitional coverage for the four FDA-approved 
therapies in the 2-year interim until 2006, when the prescription drug 
plan will take effect.
  Approximately 400,000 Americans have MS. In my home State of Oregon, 
it is estimated that there are 5,800 people living with MS. Currently, 
Medicare covers only one of the four FDA-approved MS therapies and only 
when administered by a physician.
  This amendment would cover all four MS therapies, including when they 
are administered by the patients themselves, providing better coverage 
and better care for Americans with Multiple Sclerosis. While these 
therapies do not cure MS, they can slow its course, and have provided 
great benefit to MS patients.
  It is critical that MS patients have access to all approved drugs 
because some MS patients do not respond well to, or cannot tolerate, 
the one MS therapy that is currently covered. Currently, many Medicare 
beneficiaries with MS are forced to take the less effective therapy, to 
pay the costs out of pocket, or forgo treatment.
  Equally, this amendment is important to rural Medicare beneficiaries 
with MS. By administering drugs themselves, rural beneficiaries can 
avoid the costs and hassles of traveling long distances to health care 
facilities to receive their MS therapy.
  In the spirit of providing all Medicare beneficiaries with increased 
choice, MS patients need and deserve the full range of treatment 
choices currently available and self-administration helps ensure access 
to needed medications. I urge my colleagues on both sides of the aisle 
to join me in support of this amendment and to provide adequate and 
comprehensive drug coverage for MS patients.
  The PRESIDING OFFICER. The Senator from Nevada.
  Mr. REID. Mr. President, with the graciousness of the Senator from 
New York, I ask unanimous consent that the Senator from Washington be 
recognized for up to 3 minutes to speak on one of the amendments 
offered by the Senator from North Dakota.
  The PRESIDING OFFICER. Is there objection?
  Without objection, it is so ordered.
  Mrs. MURRAY. Mr. President, I thank my colleague from New York.


                           Amendment No. 1019

  Mr. President, I have a statement I will give for the Record, but I 
also want to thank Senator Conrad for his work on the self-injected 
biologics and the offering of this amendment tonight. I am delighted to 
be a cosponsor on this amendment. It is something I have worked on for 
over 2 years. And as Senator Conrad said, we have patients today with 
MS, with rheumatoid arthritis, who are forced to go to a doctor, a 
medical clinic in order to get the drugs they need.
  This will save us money in the long run because people will be able 
to stay home. But, most importantly, it will allow people quality of 
life in the care they need. I thank Senator Conrad and Senator Smith 
and the other cosponsors of this amendment.
  Mr. President, I am pleased to join with Senator Conrad and Senator 
Smith in offering this amendment to give those on Medicare access to a 
new, exciting group of drugs known as self-injected biologics.
  Senator Conrad offered a similar amendment during the Senate Finance 
Committee markup and received a commitment from the chair to work with 
us on this effort.
  As a result of this commitment, Senator Conrad withdrew the 
amendment. We have been working with CBO and Senator Baucus' staff to 
address any concerns.
  Currently, Medicare will only cover biologics if they are 
administered in a physician's office or clinical setting. That means 
patients must travel to the physician's office to receive treatment. 
This is not easy for many patients who have rheumatoid arthritis or 
MS--two diseases that can severely limit a person's mobility.
  Fortunately, there are versions of these drugs that a patient can 
take in their own home. It is a great innovation that will improve a 
patient's access.
  Unfortunately, Medicare won't cover biologics that are administered 
in the home. That just doesn't make sense. I have been working to 
correct this inequity for the past 2 Congresses.
  The Murray-Conrad-Smith amendment would provide 2 years of coverage, 
under Part B, for those self-injected biologics that replace treatments 
currently available only in a physician's office.
  We allow for 2-year coverage to bridge the gap to implementation of a 
Medicare prescription drug benefit.
  We have received a CBO score for the 2 years and believe that we can 
find room in 2004 and 2005 to provide this important coverage for MS 
and RA patients.

[[Page 15927]]

  This legislation is strongly endorsed by the Arthritis Foundation and 
will provide additional coverage to all four MS self-injected or self-
administered treatments.
  For MS, only one treatment is covered under Medicare, provided in a 
physician's office.
  I am hopeful that the managers of this legislation will be able to 
accept our amendment and end this discriminatory practice in Medicare.
  Mr. President, I thank the Senator from New York.
  The PRESIDING OFFICER. The Senator from North Dakota.
  Mr. CONRAD. Mr. President, I appreciate very much the leadership 
Senator Murray has provided on this issue. I really took her 
legislation and, because I am a member of the Finance Committee, I had 
an opportunity to offer it. But I want to make clear, this is a bill 
Senator Murray introduced. I was proud to pick it up in the Finance 
Committee so it could be offered at the appropriate time there.
  I thank her for her leadership. I think we are close to getting this 
accomplished. It will be a great tribute to the Senator from Washington 
and the legislative leadership she has provided.
  The PRESIDING OFFICER. The Senator from New York.
  Mrs. CLINTON. Mr. President, I join with my colleague from North 
Dakota in thanking the Senator from Washington for championing this 
cause for so long because it is clearly long overdue. And I thank both 
Senators for presenting it to us in this context. I look forward to 
supporting it.
  Mr. President, I ask unanimous consent that the pending amendments be 
temporarily set aside so I may offer several amendments.
  The PRESIDING OFFICER. That authority has already been granted.


                      Amendments Nos. 1000 and 999

  Mrs. CLINTON. Mr. President, I rise today to speak of four amendments 
I have filed. And I would like to discuss each in turn, starting with 
amendment No. 1000, offered on behalf of myself, Senator Tim Johnson, 
and Senator----
  The PRESIDING OFFICER. If the Senator will suspend for a moment, we 
are trying to find the amendments here at the desk.
  The clerk will report the amendments that are at the desk.
  The assistant legislative clerk read as follows:

       The Senator from New York [Mrs. Clinton], for herself, Mr. 
     Johnson, and Mr. Bingaman, proposes an amendment numbered 
     1000.
       The Senator from New York [Mrs. Clinton] proposes an 
     amendment numbered 999.

  The amendments are as follows:


                           amendment no. 1000

    (Purpose: To study the comparative effectiveness and safety of 
  important Medicare covered drugs to ensure that consumers can make 
         meaningful comparisons about the quality and efficacy)

       At the end of title VI, add the following:

     SEC. __. STUDY ON EFFECTIVENESS OF CERTAIN PRESCRIPTION 
                   DRUGS.

       (a) In General.--
       (1) Research by nih.--The Director of the National 
     Institutes of Health, in coordination with the Director of 
     the Agency for Healthcare Research and Quality and the 
     Commissioner of Food and Drugs, shall conduct research, which 
     may include clinical research, to develop valid scientific 
     evidence regarding the comparative effectiveness and, where 
     appropriate, comparative safety of covered prescription drugs 
     relative to other drugs and treatments for the same disease 
     or condition.
       (2) Analysis by ahrq.--
       (A) In general.--The Director of the Agency for Healthcare 
     Research and Quality, taking into consideration the research 
     and data from the National Institutes of Health and the Food 
     and Drug Administration, shall use evidence-based practice 
     centers to synthesize available data or conduct other 
     analyses of the comparative effectiveness and, where 
     appropriate, comparative safety of covered prescription drugs 
     relative to other drugs and treatments for the same disease 
     or condition.
       (B) Safety.--In any analysis of comparative effectiveness 
     under this subparagraph, the Director of the Agency for 
     Healthcare Research and Quality shall include a discussion of 
     available information on relative safety.
       (3) Standards.--The Director of the Agency for Healthcare 
     Research and Quality, in consultation with the Commissioner 
     of Food and Drugs, the Director of the National Institutes of 
     Health, and with input from stakeholders, shall develop 
     standards for the design and conduct of studies under this 
     subsection.
       (b) Covered Prescription Drugs.--For purposes of this 
     section, the term ``covered prescription drugs'' means 
     prescription drugs that, as determined by the Director of the 
     Agency for Healthcare Research and Quality in consultation 
     with the Administrator of the Centers for Medicare & Medicaid 
     Services, account for high levels of expenditures, high 
     levels of use, or high levels of risk to individuals in 
     federally funded health programs, including Medicare and 
     Medicaid.
       (c) Dissemination.--
       (1) Annual report.--Each year the Secretary shall prepare a 
     report on the results of the research, studies, and analyses 
     conducted by the National Institutes of Health and the Agency 
     for Healthcare Research and Quality, and the Food and Drug 
     Administration under this section and submit the report to 
     the following:
       (A) Congress.
       (B) The Secretary of Defense.
       (C) The Secretary of Veterans Affairs.
       (D) The Administrator of the Centers for Medicare & 
     Medicaid Services.
       (E) The Director of the Indian Health Service.
       (F) The Director of the National Institutes of Health.
       (G) The Director of the Office of Personnel Management.
       (H) The Commissioner of Food and Drugs.
       (2) Reports for practitioners.--As soon as possible, but 
     not later than a year after the completion of any study 
     pursuant to subsection (a)(2), the Director of the Agency for 
     Healthcare Research and Quality shall--
       (A) prepare a report on the results of such study for the 
     purpose of informing health care practitioners; and
       (B) transmit the report to the Director of the National 
     Institutes of Health.
       (3) FDA drug information.--The Commissioner of Food and 
     Drugs shall--
       (A) review all data and information from studies and 
     analyses conducted or prepared under this section; and
       (B) develop appropriate summaries of such information for 
     inclusion in adequate directions for use under section 
     502(f)(1) of the Federal Food, Drug, and Cosmetic Act and in 
     summaries relating to side effects, contraindications, and 
     effectiveness under section 502(n) of that Act.
       (4) NIH internet site.--The Director of the National 
     Institutes of Health shall publish on the Institutes' 
     Internet site and through other means that will facilitate 
     access by practitioners, each report prepared under this 
     subsection by the Director of the Agency for Healthcare 
     Research and Quality.
       (d) Evidence.--In carrying out this section, the Director 
     of the National Institutes of Health and the Agency for 
     Healthcare Research and Quality shall consider only 
     methodologically sound studies, giving preference to studies 
     for which the Directors have access to sufficient underlying 
     data and analysis to address any significant concerns about 
     methodology or the reliability of data.
       (e) Authorizations of Appropriations.--There are authorized 
     to be appropriated to carry out this section, $75,000,000 for 
     fiscal year 2004, and such sums as may be necessary for each 
     fiscal year thereafter.


                           amendment no. 999

(Purpose: To provide for the development of quality indicators for the 
priority areas of the Institute of Medicine, for the standardization of 
quality indicators for Federal agencies, and for the establishment of a 
demonstration program for the reporting of health care quality data at 
                          the community level)

       On page 389, between lines 6 and 7, insert the following:

     SEC. __. PRIORITY AREA QUALITY INDICATORS.

       (a) In General.--The Director of the Agency for Healthcare 
     Research and Quality, in consultation with the Quality 
     Interagency Coordination Task Force, the Institute of 
     Medicine, the Joint Commission on Accreditation of Healthcare 
     Organizations, the National Committee for Quality Assurance, 
     the American Health Quality Association, the National Quality 
     Forum, and other individuals and organizations determined 
     appropriate by the Secretary of Health and Human Services, 
     shall assemble, evaluate, and, where necessary, develop or 
     update quality indicators for each of the 20 priority areas 
     for improvement in health care quality as identified by the 
     Institute of Medicine in their report entitled ``Priority 
     Areas for National Action'' in 2003, in order to assist 
     medicare beneficiaries in making informed choices about 
     health plans. The selection of appropriate quality indicators 
     under this subsection shall include the evaluation criteria 
     formulated by clinical professionals, consumers, data 
     collection experts.
       (b) Risk Adjustment.--In developing the quality indicators 
     under subsection (a), the Director of the Agency for 
     Healthcare Research and Quality shall ensure that adequate 
     risk adjustment is provided for.
       (c) Best Practices.--In carrying out this section, the 
     Director of the Agency for Healthcare Research and Quality 
     shall--
       (1) assess data concerning appropriate clinical treatments 
     based on the best scientific evidence available;
       (2) determine areas in which there is insufficient evidence 
     to determine best practices; and

[[Page 15928]]

       (3) compare existing quality indicators to best clinical 
     practices, validate appropriate indicators, and report on 
     areas where additional research is needed before indicators 
     can be developed.
       (d) Report.--Not later than 1 year after the date of 
     enactment of this Act, and annually thereafter, the Director 
     of the Agency for Healthcare Research and Quality shall--
       (1) submit to the Director of the National Institutes of 
     Health a report concerning areas of clinical care requiring 
     farther research necessary to establish effective clinical 
     treatments that will serve as a basis for quality indicators; 
     and
       (2) submit to Congress a report on the state of quality 
     measurement for priority areas that links data to the report 
     submitted under paragraph (1) for the year involved.
       (e) Authorization of Appropriations.--There are authorized 
     to be appropriated to carry out this section $12,000,000 for 
     fiscal year 2004, and $8,000,000 for each of fiscal years 
     2005 through 2009.

     SEC. __. STANDARDIZED QUALITY INDICATORS FOR FEDERAL 
                   AGENCIES.

       (a) In General.--In addition to other activities to be 
     carried out by the Quality Interagency Coordination Taskforce 
     (as established by executive order on March 13, 1998), such 
     Taskforce shall standardize indicators of health care quality 
     that are used in all Federal agencies, as appropriate.
       (b) Consultation.--In carrying out subsection (a), the 
     Quality Interagency Coordination Taskforce shall consult with 
     a public-private consensus organization (such as the National 
     Quality Forum) to enhance the likelihood of the simultaneous 
     application of the standardized indicators under subsection 
     (a) in the private sector.
       (c) Report.--Not later than 1 year after the date of 
     enactment of this Act, and annually thereafter, the Secretary 
     of Health and Human Services shall submit to Congress a 
     report on the progress made by the Quality Interagency 
     Coordination Taskforce to standardizing quality indicators 
     throughout the Federal Government.

     SEC. __. DEMONSTRATION PROGRAM FOR COMMUNITY HEALTH CARE 
                   QUALITY DATA REPORTING.

       (a) In General.--The Secretary of Health and Human 
     Services, acting through the Director of the Centers for 
     Disease Control and Prevention and the Director of the Agency 
     for Healthcare Quality and Research, shall award not to 
     exceed 20 grants to eligible communities for the 
     establishment of demonstration programs for the reporting of 
     health care quality information at the community level.
       (b) Quality Indicators.--
       (1) In general.--For purposes of reporting information 
     under the demonstration programs under this section, 
     indicators of health care quality may include the indicators 
     developed for the 20 priority areas as identified by the 
     Institute of Medicine in the report entitled ``Priority Areas 
     for National Action'', 2003, or other indicators determined 
     appropriate by the Secretary of Health and Human Services.
       (2) Type of data.--All quality indicators with respect to 
     which reporting will be carried out under the demonstration 
     program shall be reported by race, ethnicity, gender, and 
     age.
       (c) Eligibility.--The Secretary of Health and Human 
     Services shall award grants to communities under this section 
     based on competitive proposals and criteria to be determined 
     jointly by the Director of the Centers for Disease Control 
     and Prevention and the Director of the Agency for Healthcare 
     Research and Quality. Such criteria may include a 
     demonstrated ability of the community to collect data on 
     quality indicators and a demonstrated ability to effectively 
     transmit community-level health status results to relevant 
     stakeholders.
       (d) Technical Advisory Committee.--The Secretary of Health 
     and Human Services shall establish a technical advisory 
     committee to assist grantees in data collection, data 
     analysis, and report dissemination.
       (e) Report.--Not later than 1 year after the date of 
     enactment of this Act, and annually thereafter, the Director 
     of the Centers for Disease Control and Prevention and the 
     Director of the Agency for Healthcare Research and Quality 
     shall--
       (1) submit to the Congress a report on the results of the 
     demonstration programs under this section; and
       (2) make such reports publicly available, including by 
     posting the reports on the Internet.
       (f) Evaluation.--The Secretary of Health and Human Services 
     shall, upon awarding grants under subsection (a), enter into 
     a contract for the evaluation of demonstration programs under 
     this section. Such evaluation shall compare the effectiveness 
     of such demonstration programs in collecting and reporting 
     required data, and on the effectiveness of distributing 
     information to key stakeholders in a timely fashion. Such 
     evaluations shall provide for a report on best practices.
       (g) Authorization of Appropriations.--There are authorized 
     to be appropriated to carry out this section $25,000,000 for 
     fiscal year 2004, and such sums as may be necessary for each 
     fiscal year thereafter.
  The PRESIDING OFFICER. The Senator from New York.
  Mrs. CLINTON. Thank you, Mr. President.


                           Amendment No. 1000

  Mr. President, amendment 1000, offered on behalf of myself and 
Senators Tim Johnson and Jeff Bingaman, is being offered to ensure our 
seniors have information they need to make informed consumer choices 
about their drugs, and also to ensure practitioners have the 
information needed to choose the right drug for a patient, and, 
further, that the private plans this bill would create have the 
information they need to make formulary and benefit design choices 
based on sound science.
  This amendment ensures that various Government agencies--NIH, FDA, 
CMS, and the others involved in this effort--conduct research comparing 
the efficacy and, if applicable, the comparative safety of the top 
drugs used by Medicare and Medicaid beneficiaries who are Medicare 
eligible.
  Now often there are a number of competing drugs to treat the same 
condition. But which is more effective? Oftentimes we just do not know.
  While the FDA is responsible for determining safety and effectiveness 
of prescription drugs compared to a placebo, there is no Government 
entity responsible for examining whether drug A is more effective at 
treating a particular condition than drug B. Meanwhile, drug companies 
do not always have an incentive to do head-to-head trials of the drugs 
they put out versus those of their competitors. But this information is 
critical to all decisionmakers, to patients and consumers, to 
practitioners, and to the private plans that are being created.
  Now clinicians have told me they are frequently trying to decide 
whether to switch a patient from an old drug to a new drug. They are 
not deciding between the old drug and a placebo; they are deciding 
between a drug they have used for a particular patient and then one 
which has come to their attention because it is now on the market, and 
they are trying to decide: Which is best for my patient? They wish they 
had more information that would enable them, besides trial and error 
and possible adverse consequences, to make that determination.
  Clearly, consumers will also benefit from more sources of 
information. Right now advertising is a source available to consumers, 
but this amendment will help us provide an unbiased, scientific source 
of information that consumers can compare side by side rather than just 
a beautiful advertisement of people running through a field or twirling 
their grandchildren and then being told: This is the drug for the 
condition you have. They will be able to say: Well, wait a minute. Here 
is the drug I have been prescribed, here is a drug I have heard about. 
Let me look on the Internet to see what the differences might be.
  Now we have all heard of ``me too'' drugs, and there is nothing wrong 
with ``me too'' drugs. Sometimes a ``me too'' drug will work 
incrementally better than a previous drug or it may be better 
tolerated. Even if a ``me too'' drug does not have those 
characteristics, it might be superior for a certain portion of the 
population but not for others. The problem is, we do not have that kind 
of comparative data.
  My amendment directs NIH to do comparative efficacy trials for the 
top Medicare drugs--the ones that are primarily prescribed for the 
Medicare population--for the kinds of conditions the Medicare 
population primarily suffers from.
  No single study will settle that question once and for all, so my 
amendment then directs the Agency for Health Research and Quality, 
AHRQ, to do what it does best, which is to synthesize the literature 
that is out there as well as the NIH data to report information on the 
comparative efficacy of these medical interventions that we are 
subsidizing now in this bill for our seniors.
  HHS will then make this comparative information available to 
clinicians, to Congress, to relevant Federal agencies. And it will, 
most particularly and importantly, make that available to seniors so 
they can make informed choices for themselves.

[[Page 15929]]

  Under this amendment, we would put this information on the Internet. 
FDA would look at whether this information needs to be included in drug 
labels, and drug ads would also contain this information so that they 
do not mislead seniors.
  One indicator of the rarity of these studies is that completion of a 
comparative efficacy study can make national news. For example, many of 
us read last December when the National Heart, Lung, and Blood 
Institute published a study and discovered that it corrected the 
assumption that newer drugs, such as calcium channel blockers and ACE 
inhibitors, which cost 30 to 40 times more than diuretics, were not 
more effective than those long-time treatments for high blood pressure. 
This is information we have needed for years. We have one of the most 
advanced health care systems, if not the most advanced, in the world. 
If the information stream our doctors count is such a tiny trickle that 
the daily news can keep track of all major developments, then this 
amendment must be passed in order to give us a sound scientific basis 
for the decisions that are going to be made with the $400 billion that 
we are allocating.
  When the research is done, as we learned about in the calcium channel 
blockers and ACE inhibitors versus old-fashioned diuretics, it is 
important and its benefits are immediately obvious.
  In January 2003, the American Journal of Ophthalmology published an 
article comparing the efficacy of two glaucoma drugs. One is 
latanoprost and the other bimatoprost. These were compared in an NIH-
sponsored randomized clinical trial. Despite the fact that the 
Latanoprost is currently the most popular medication, the study found 
that Bimatoprost was more effective.
  This is critically important because if we are going to be putting 
money into drugs and we are going to be holding out the promise to our 
seniors that finally help is on the way, then let's make sure these tax 
dollars are used to fund the drugs that are most effective.
  In 1999, an NIH-sponsored study showed that a well-known, safe, cheap 
generic drug, Metoprolol, was just as effective for treating patients 
with heart failure as a more expensive drug which had come on to the 
market just a few years earlier. Some may say these studies could 
promote a one-size-fits-all approach to prescribing, but to the 
contrary, these studies can actually help make prescribing more nuanced 
and appropriate to each subpopulation.
  For instance, in March 2003, the American Journal of Cardiology 
reviewed numerous clinical trials of medications used to treat what is 
called atrial fibrillation, a type of heart arrhythmia, and came up 
with recommendations about what are the most effective drugs for use 
for this condition based on what the underlying cause of the condition 
was in each case.
  As someone who is fast approaching the age of Medicare eligibility, I 
want, both for my pocketbook and my health, to know that my doctor and 
I have the best information available about which drug is appropriate 
for me. And I certainly think that we can, through this amendment, 
begin to provide that information to ensure that seniors and their 
physicians have good, solid data on which to make their decisions.
  This amendment is supported by a number of groups that are aware of 
the significance of trying to put into this bill some scientifically 
based data on which to make these decisions. The RxHealth Value 
Coalition is supporting the amendment. I have a letter from them. They 
consist of not only large employers--Verizon, General Motors, Ford, et 
cetera--but Blue Cross, Blue Shield, Kaiser, AARP, and many others.
  I ask unanimous consent to print the RxHealth Value letter of June 
24, 2003, supporting this amendment, in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:


                                                RxHealthValue,

                                    Washington, DC, June 24, 2003.
     Hon. Hillary Rodham Clinton,
     U.S. Senate,
     Russell Senate Office Building,
     Washington, DC.
       Dear Senator Clinton: As the 108th Congress considers 
     reforming the Medicare program and addressing one of the 
     programs major shortcomings--lack of an outpatient 
     prescription drug benefit, we want to express support for 
     your amendment to the Medicare legislation being considered 
     by the Senate that would provide limited support for the 
     Centers of Medicare and Medicaid Services, the Center for 
     Medicare Choices, which would be created by S. 1, the 
     National Institutes of Health and the Agency for Healthcare 
     Research and Quality to collaborate on studies to compare the 
     relative efficacy and safety of prescription medicines 
     designed to treat the same condition. It is this very 
     information that is vital to patients, practitioners, and 
     purchasers. With comparative information on prescription 
     medicines patients, practitioners and purchasers can make 
     better decisions with respect to choosing the prescription 
     medicines to take, prescribe, cover, and pay for.
       RxHealthValue is a national coalition of large employers, 
     consumer groups, labor unions, health plans, health care 
     providers and pharmacy benefit managers that, through its 
     members, represents almost 100 million Americans. 
     RxHealthValue is committed to research, education and both 
     public- and private-sector solutions to ensure that Americans 
     receive the full health and economic value from their 
     prescription drugs. The Coalition's definition of ``value'' 
     includes effectiveness, cost, appropriate use and safety.
       Your amendment is a very important component of any 
     Medicare prescription drug benefit proposal, since it is 
     imperative that the federal Centers for Medicare & Medicaid 
     Services (CMS) and the proposed Center for Medicare Choices 
     (CMC) have the needed information to be a prudent purchaser 
     of prescription drugs. We are pleased that you ask the 
     National Institutes of Health (NIH) to add to the very 
     limited research results from which evidence-based reviews 
     get their information, and that you recognized the importance 
     of dissemination so that information gets to providers and 
     consumers when they need it. We agree that AHRQ's Evidence-
     based Practice Centers (EPCs), which have been involved in 
     the innovative Oregon prescription drug program, would be an 
     outstanding vehicle for such reviews.
       This legislation is especially important as Congress works 
     to provide Medicare beneficiaries with high quality 
     outpatient drug coverage. We applaud your efforts on this 
     important amendment and look forward to working with you and 
     others to ensure that improved information on prescription 
     drugs is available to all.
       For more information on RxHealth's position on this and 
     other drug value initiatives, please contact Steve Cole, 
     RxHealthValue Policy Committee Chair, at 202-296-1314.
       Again, thank you from the member organizations of 
     RxHealthValue:
       Blue Cross/Blue Shield.
       Kaiser.
       AARP.
       National Consumers League.
       Verizon.
       Association of Community Health Plans.
       General Motors.
       Ford.
       Daimler Chrysler.
       Families USA.
       National Organization of Rare Disorders.
       American Academy of Family Physicians.
       Academy of Managed Care Pharmacy.
       UAW.
       AFSCME.
       Pacific Business Group on Health.
       Midwest Business Group on Health.
       Washington Business Group on Health.
       Advance-PCS.
       Caremark Rx.
       AFL-CIO.

  Mrs. CLINTON. Similarly, I have a letter from Consumers Union, dated 
June 24, 2003, which also supports amendment No. 1000, and I ask 
unanimous consent that letter, too, be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:


                                              Consumers Union,

                                                    June 24, 2003.
     Hon. Tim Johnson,
     U.S. Senate,
     Washington, DC.
       Dear Senator Johnson: Consumers Union strongly supports 
     your amendment that would provide for study by the National 
     Institute of Health and the Agency for Healthcare Research 
     and Quality of the comparative effectiveness of prescription 
     drugs. The development of scientific evidence-based 
     information about the relative effectiveness of drugs has the 
     potential to dramatically increase consumers' (and 
     taxpayers') bang-for-the-buck paid for prescription drugs.
       Millions of Medicare beneficiaries (in addition to the tens 
     of millions of uninsured and underinsured consumers 
     nationwide) are paying increasing out-of-pocket costs for 
     their prescription drugs. Despite these escalating costs, it 
     is often difficult for consumers and health care 
     professionals to ensure that consumers receive value for each 
     healthcare dollar spent.

[[Page 15930]]

       The proposed amendment would create a resource for 
     independent information about the comparative medical 
     effectiveness of important medicines. We believe that this 
     information will substantially reduce the nation's 
     prescription drug expenditures, because consumers and doctors 
     will be able to make decisions using reliable evidence-based 
     information about comparative effectiveness. The amendment 
     would require this information to be made available through 
     the Internet to the public. As a result, consumers, 
     employers, state governments and the federal government will 
     have access to information that will enable them to choose 
     more cost-effective medicines without sacrificing medical 
     effectiveness or quality of care.
           Sincerely,

                                              Gail E. Shearer,

                                 Director, Health Policy Analysis,
                                                Washington Office.

  Mrs. CLINTON. Finally, I have a letter from Families USA, dated June 
24, 2003, that similarly supports the amendment. I will read the 
following paragraph from it:

       It would be unfortunate if Congress decides to spend $400 
     billion on pharmaceuticals over the next decade, without 
     providing a few dollars to ensure that what we are buying is 
     indeed worth buying.

  I ask unanimous consent that letter be printed in the Record as well.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:


                                                 Families USA,

                                                    June 24, 2003.
     Hon. Hillary Rodham Clinton,
     U.S. Senate,
     Washington, DC.
       Dear Senator Clinton: Congratulations on your amendment to 
     help Americans understand which prescription drugs are truly 
     effective and safe. Families USA, the national health 
     consumer advocacy organization, strongly endorses the effort 
     of you and Senator Johnson to provide reliable, unbiased 
     information on pharmaceuticals.
       Too often today, prescription drug information is 
     influenced by the manufacturer, by advertisements, and by 
     clinical studies financed by those who will gain from 
     favorable reports. Americans need an objective, reliable 
     source of information on which prescription drugs are most 
     effective.
       It would be unfortunate if Congress decides to spend $400 
     billion on pharmaceuticals over the next decade, without 
     providing a few dollars to ensure that what we are buying is 
     indeed worth buying.
       Thank you again for you leadership on this important health 
     consumer initiative.
           Sincerely,
                                                Ronald F. Pollack,
                                               Executive Director.

  Mrs. CLINTON. Mr. President, if we are serious about making changes 
that will improve the health of our seniors on Medicare, I hope that we 
look to establish in this bill the proposition that good information, 
solid science that can be made available to seniors, to clinicians, to 
plans, be part of what we are establishing with the proposition that 
this money needs to be well spent, well spent not only to safeguard the 
taxpayers' dollars but well spent to ensure that our doctors and 
patients get the best possible treatment.
  I also am offering amendment No. 999 that is intended to ensure that 
Medicare plans compete to improve rather than cut corners on quality. 
This bill already includes a measure that I have supported, along with 
Senator Hatch and others, to commission the Institute of Medicine to 
ensure the Medicare Program pays plans for providing higher quality 
care.
  Unfortunately, even for the many common diagnoses and treatments that 
are part of a senior's medical history, we lack the quality standards 
that the Medicaid Program would use to help consumers make informed 
comparisons and choices among health plans.
  For some diseases, the National Commission for Quality Assurance does 
collect information about health plans by providing data, for example, 
on how well HMOs screen for breast cancer or provide flu shots for 
older adults.
  For many other diseases, however, we do not know which plans make 
sure that their diabetic patients get their eyes examined for retinal 
damage, what percent of asthmatics receive adequate therapy to control 
their asthma, or many other issues that go to the heart of the quality 
of health care that is being provided to our seniors.
  The data tells us that Medicare beneficiaries are often not receiving 
the care they need to maintain their health. In 2001, for example, 23 
percent of Medicare beneficiaries in private health plans did not have 
their cholesterol managed after a heart attack.
  Now, my amendment is based on recommendations made by the Institute 
of Medicine. It authorizes a collaborative effort among the relevant 
Government agencies to develop quality indicators in the 20 most 
important areas identified in this Institute of Medicine report 
entitled ``Priority Areas for National Action.'' It authorizes the 
Quality Interagency Coordination Task Force--that is a task force that 
brings together all the Federal agencies that are needed to collect 
health quality data--to implement these indicators so that they are all 
collecting quality information in the same way. The Secretary of Health 
and Human Services would then develop demonstration programs for 
communities to engage in community-wide reporting, according to these 
quality indicators.
  This amendment also has the potential to lower the cost of the 
Medicare Program. Because plans will provide quality measures that 
consumers will use, health plans will want to implement those quality 
improvement measures that have also been proven to lower health care 
costs. One such program, as an example, is a diabetes intervention 
program implemented by Group Health Cooperative, a group model health 
plan in Washington State. This intervention program improved diabetic 
blood sugar control and saved between $685 and $950 annually from 
reduced hospital admissions, emergency department visits, and physician 
consultations.
  This is the kind of emphasis on quality that I think we need to put 
into this bill. Otherwise, as we try to make sense of the variety of 
options and choices that are available, we are not going to know what 
improved quality or what decreases costs. That should be one of our 
goals, and this amendment holds out the promise that the Medicare 
Program, with proper implementation of quality indicators, can do 
both--improve health and quality control and decrease costs.


                           Amendment No. 953

  Mrs. CLINTON. Mr. President, I will also be talking about amendment 
No. 953, which is at the desk.
  The PRESIDING OFFICER. The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from New York [Mrs. CLINTON] proposes an 
     amendment numbered 953.

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

       (Purpose: To provide training to long-term care ombudsman)

       On page 608, between lines 10 and 11, insert the following:

     SEC. __. TRAINING FOR LONG-TERM CARE OMBUDSMAN.

       (a) In General.--The Secretary of Health and Human 
     Services, acting through the Director of the Administration 
     on Aging and in consultation with the Director of the Agency 
     for Healthcare Research and Quality and the Administrator of 
     the Centers for Medicare & Medicaid Services, shall authorize 
     a program, to be developed and implemented by the National 
     Long-Term Care Ombudsman Resource Center, for the training of 
     long-term care ombudsmen in the use of quality of care 
     information.
       (b) Training.--Under the program developed under subsection 
     (a), training shall be provided to long-term care ombudsman 
     to enable such ombudsman to educate consumers concerning--
       (1) nursing home quality of care issues;
       (2) available nursing home quality of care reports, 
     including existing quality data that the Administrator of the 
     Centers for Medicare & Medicaid Services has released for use 
     by the public in choosing long-term care facilities; and
       (3) the manner in which an individual can successfully 
     integrate quality information into health care decision 
     making regarding nursing home decisions.
       (c) Duties of Resource Center.--The National Long-Term Care 
     Ombudsman Resource Center shall--
       (1) develop and maintain a curriculum for ombudsmen;
       (2) develop, produce, and maintain training materials;
       (3) conduct train-the-trainer programs at regional and 
     national levels; and
       (4) act as a clearinghouse for best practices in 
     communicating the significance of nursing home quality 
     indicators to residents and their caregivers.

[[Page 15931]]

       (d) Pilot Programs.--The Secretary of Health and Human 
     Services shall award grants for the establishment of 1-year 
     pilot demonstration programs in 10 States using long-term 
     care ombudsmen to educate consumers regarding home health 
     care quality. Such pilot demonstration programs shall test 
     the effectiveness of having a committed position within the 
     State dedicated to helping consumers use home health care 
     quality indicators.
       (e) Report.--Not later than 18 months after the date of 
     enactment of this Act, and annually thereafter, the Secretary 
     of Health and Human Services shall submit to Congress a 
     report concerning the effectiveness of the program 
     established under this section, including the benefits of 
     providing for dedicated staff who are responsible for 
     educating consumers to use home health quality indicators in 
     their health care decision-making.
       (f) Authorization.--In addition to any other amounts 
     authorized to be appropriate for long-term care ombudsman 
     programs, there are authorized to be appropriated to carry 
     out this section $4,000,000 for fiscal year 2004 (of which 
     $1,000,000 shall be used to carry out subsection (d)), and 
     $2,000,000 for each fiscal year thereafter.

  Mrs. CLINTON. Mr. President, amendment No. 953 would empower Medicare 
beneficiaries and their families in making decisions about nursing 
homes and home health services. Data on nursing home quality is 
publicly available through a project strongly supported by 
Administrator Scully, and I am very appreciative of that because that 
information is imperative.
  However, I know from talking with people throughout New York that 
there are still many problems in nursing homes with respect to errors 
and mishaps that undermine the quality of care, the quality of life 
and, in some respects, even the health of the nursing home residents. 
Many people still don't know about this existing quality data and about 
the existing ombudsman program within the administration on aging that 
is intended to help families navigate nursing home decisions.
  This amendment would establish a national long-term care ombudsman 
resource center, which will help to develop and train ombudsmen. The 
amendment would establish pilot programs, including grants to create 
ombudsman offices in 10 States. These are the people--it should really 
be ``ombudspeople,'' I guess--who are uniquely positioned to know about 
the facilities they serve. They visit the facilities regularly. They 
are often located at agencies in the local communities. They have 
firsthand knowledge. They are very valuable resources. However, their 
knowledge, if it doesn't actually get to the users, the nursing home 
residents and, more importantly, their family members or advocates, 
doesn't help anyone.
  This pilot project would fund specific ombudsman programs to provide 
comprehensive outreach, public education, and individual consultation 
that integrate quality information into health care decisionmaking. 
Through this pilot project, the ombudsman center would be able to 
identify the resources needed to actually provide consumer education on 
long-term care and home health, as well as best practices and 
collaborative models that could then be replicated around the country.
  I ask my colleagues also to support this amendment because, again, I 
think information is critical. We talk about trying to create more of a 
market for these health care resources. Markets exist on information. A 
market without good information is not really a market at all. So if we 
are going to move toward the private market and provide these private 
health plans as competition to the existing Medicare delivery system, 
then I think we have to do more than just talk about the market. We 
need to empower the consumers within the marketplace. Information is 
that basis for empowerment.


                           Amendment No. 954

  Mrs. CLINTON. Mr. President, I ask the clerk to report amendment No. 
954, which is at the desk.
  The PRESIDING OFFICER. The clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from New York [Mrs. Clinton] proposes an 
     amendment numbered 954.

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

  (Purpose: To require the Secretary of Health and Human Services to 
 develop literacy standards for informational materials, particularly 
                           drug information)

       On page 46, between lines 13 and 14, insert the following:
       ``(i) Health Literacy Standards.--
       ``(1) In general.--For purposes of assisting eligible 
     entities in providing quality assurance measures as described 
     in subsection (c)(1)(B), the Secretary, acting through the 
     Director of the Agency for Healthcare Research and Quality, 
     the Administrator of Health Resources and Services 
     Administration, the Director of the National Library of 
     Medicine, and the Commissioner of Food and Drugs, shall 
     develop standardized materials that pharmacists may use to 
     assist non-English speaking or functionally illiterate 
     patients in the safe and appropriate use of prescription 
     drugs. Such materials may include the use of pictures and the 
     development of standardized translations in multiple 
     languages of prescription labels and bottle labels and other 
     patient safety initiative information. Such materials shall 
     be available electronically for direct access by pharmacists.
       ``(2) Authorization of appropriations.--There are 
     authorized to be appropriated to carry out this subsection, 
     such sums as may be necessary for each of fiscal years 2004 
     and 2005.

  Mrs. CLINTON. Mr. President, this amendment is intended to improve 
the safety of the prescription drug program. As our seniors are using a 
growing number of medications to stay out of the hospital, to live 
healthier and longer lives, we are inadvertently, but inevitably, 
creating a burden on our seniors to understand and know how to use all 
of these prescription drugs. There are interactions, there are other 
issues, there are many problems with trying to sort out for our seniors 
how drugs work, how they interact with one another. This is a very 
important issue that I think, again, we need to address at the 
beginning of this process, not after some additional problems have been 
discovered.
  In a recent study of adverse drug events published in the Journal of 
the American Medical Association, 21 percent of preventable adverse 
drug events were caused by patients not following drug prescription 
instructions. That is just human nature. People make mistakes and, as 
you get older, it is harder to read all that little writing on the 
prescription bottles. That is something that just kind of comes with 
the process. Of course, we have many people for whom English is not 
their first language. We have others who have challenges with eyesight 
and literacy. So, clearly, our seniors, like the rest of us, could make 
mistakes.
  Studies have found that one-third of patients often don't take the 
prescription the way they are supposed to because they don't understand 
it. Now, if you have a dose of a three-times-a-day antibiotic, and you 
also have other prescription drugs to be taken five, six, seven times a 
day, or whatever the combination is, there are all kinds of 
opportunities for confusion because many seniors take complex drugs 
with multiple dangerous side effects, often much more serious than 
those from antibiotics. They are more likely to suffer injuries and 
hospitalizations as a result. As many as 60 percent of the elderly have 
these problems about understanding and following the directions. This 
is a very critical statistic. Twenty-three percent of nursing home 
admissions in our country result from the inability of older Americans 
to manage their medication at home.
  That is why I am offering this amendment to ensure that the Secretary 
of HHS works to ensure the use of health literacy standards and 
information that will minimize adverse drug events, to ensure that we 
develop drug informational materials for non-English-speaking people 
and the functionally illiterate patients that can be made available to 
pharmacists who can access them electronically for easy use.
  So, Mr. President, these amendments can be summed up in a very few 
words: enhanced quality, lower cost.
  If we enhance quality, we avoid a lot of the problems that exist in 
our system today. We learn more about quality. We empower patients, as 
well as clinicians, with information that can better determine quality 
outcomes,

[[Page 15932]]

and we save money. We do not have people being admitted to the hospital 
because they mix up their drugs. We do not have people trying to figure 
out how they can get good information about quality standards in 
nursing homes. We have all kinds of issues that cost money, as well as 
put the health and well-being of our seniors at risk.
  I ask that my colleagues favorably consider these amendments. There 
is no cost attached to these amendments, but they will do what we hope 
to achieve by this significant legislation: improve quality for our 
seniors and lower costs in the long run by making prescription drugs 
readily available and understanding appropriately their use.
  Mr. President, I thank you for your kind attention, and I yield the 
floor.


                           Amendment No. 1000

  Mr. JOHNSON. Mr. President, I join my colleagues Senators Clinton and 
Bingaman today to offer an amendment to S. 1 that will provide 
consumers and practitioners with real, objective information regarding 
the comparative effectiveness of prescription drugs.
  Too often, prescription drug information is influenced by drug 
manufacturers, through advertisements, and by clinical studies financed 
by those who will gain from favorable reports. Consumers are just 
inundated with information--from direct-to-consumer advertising on 
drugs which can paint a misleading picture, to a sea of free drug 
samples from their physicians--with all this information it can be 
extremely difficult to make a sound decision which can be just 
overwhelming for average Americans.
  But what does the data really say about differing prescription drug 
options? Does a newer drug that costs more than an earlier version 
necessarily do a better job for most patients? Is it possible that a 
Medicare beneficiary may get the same, or even better outcome from the 
drug that has been on the market for a longer time? We just really 
don't have the answers to these--questions at least from independent, 
objective sources.
  We are about to create a massive new program that will effect 40 
million Americans and with this comes responsibility to deliver a 
program that ensures the availability of appropriate prescription drugs 
for all beneficiaries. This amendment will create a reliable source for 
valid, evidence-based information about the comparative medical 
effectiveness of medicines used by Medicare beneficiaries. It will 
provide unbiased information on how drugs that treat particular 
diseases and conditions compare to one another.
  By authorizing the National Institutes of Health, in coordination 
with the Agency for Healthcare Research and Quality to conduct research 
on comparative effectiveness of drugs, consumers, employers, State 
governments and the Federal Government will finally have access to 
information that will enable them to choose medicines based on clinical 
research. This information will be made available to help them make 
better decisions with respect to choosing the prescription medicines to 
take, prescribe, cover and pay for. By using the objective, scientific 
expertise available at NIH and AHRQ, this amendment assures that the 
information received comes from independent and impartial sources.
  This amendment is supported by RxHealthValue, a national coalition of 
large employers, consumer groups, labor unions, health plans, health 
providers and pharmacy benefit managers that through its members 
represent almost one-hundred million Americans. It is also supported by 
Families USA and Consumers Union.
  This amendment preserves individuals' freedom to get any medicine 
that they want, but would encourage the use of medicines that are 
scientifically proven more effective for patients. It will not create 
``one-size-fits-all'' medicine as Republicans will try and tell you. It 
does nothing to prevent independent decisionmaking by practitioners and 
their patients, just better educated decisionmaking.
  Our Republican colleagues believe in the strength of the free market. 
Well, a well functioning marketplace depends on the free flow of 
information. Denying consumers and providers, as well as other 
purchasers of prescription drugs access to comparative information 
about effectiveness means that decisions in the marketplace are made 
without perfect information--which should not be the case in an open 
market. You are not going to buy a car without taking a look at 
Consumer Reports are you? Are you only going to base your purchase on 
the glitzy adds in ``Car and Driver'' magazine? I think we all know the 
answer to this is ``no'', and most certainly Medicare beneficiaries 
should have access to similar information for drugs they put in their 
bodies as they do for the car they drive.


                     Amendment No. 985, As Modified

  Mr. REID. Mr. President, on behalf of Senator Edwards of North 
Carolina, I send a modification to the desk, and I ask unanimous 
consent the amendment be so modified.
  The PRESIDING OFFICER. Without objection, it is so ordered. The 
amendment will be so modified.
  The amendment (No. 985), as modified, is as follows:

       At the end, add the following:

       TITLE __--DIRECT-TO-CONSUMER PRESCRIPTION DRUG ADVERTISING

     SEC. __01. HEAD-TO-HEAD TESTING AND DIRECT-TO-CONSUMER 
                   ADVERTISING.

       (a) New Drug Application.--Section 505 of the Federal Food, 
     Drug, and Cosmetic Act (21 U.S.C. 355) is amended--
       (1) in subparagraph (A) of the second sentence of 
     subsection (b)(1), by inserting before the semicolon at the 
     end the following ``(including, if the Secretary so requires, 
     whether the drug is safe and effective for use in comparison 
     with other drugs available for substantially the same 
     indications for use prescribed, recommended, or suggested in 
     the labeling proposed for the drug)''; and
       (2) in subsection (d)(5)--
       (A) by inserting ``(A)'' after ``will''; and
       (B) by inserting after ``thereof'' the following: ``or (B), 
     if the Secretary has required information related to 
     comparative safety and effectiveness, offer a benefit with 
     respect to safety or effectiveness (including effectiveness 
     with respect to a subpopulation or condition) that is greater 
     than the benefit offered by other drugs available for 
     substantially the same indications for use prescribed, 
     recommended, or suggested in the labeling proposed for the 
     drug''.
       (b) Misbranding.--Section 502(n)(3) of the Federal Food, 
     Drug, and Cosmetic Act (21 U.S.C. 352(n)(3)) is amended by 
     inserting after ``effectiveness'' the following: ``(including 
     effectiveness in comparison to other drugs for substantially 
     the same condition or conditions if such comparative 
     information is available)''.
       (c) Regulations.--
       (1) In general.--Not later than 180 days after the date of 
     enactment of this Act, the Secretary of Health and Human 
     Services shall promulgate amended regulations governing 
     prescription drug advertisements.
       (2) Contents.--In addition to any other requirements, the 
     regulations under paragraph (1) shall require that--
       (A) any advertisement present a fair balance, comparable in 
     depth and detail, between--
       (i) information relating to effectiveness of the drug 
     (including effectiveness in comparison to similar drugs for 
     substantially the same condition or conditions if such 
     comparative information is available);
       (ii) information relating to side effects and 
     contraindications; and
       (B) any advertisement present a fair balance comparable in 
     depth, between--
       (i) aural and visual presentations relating to 
     effectiveness of the drug; and
       (ii) aural and visual representations relating to side 
     effects and contraindications, provided that, nothing in this 
     section shall require explicit images or sounds depicting 
     side effects and contraindications;
       (C) prohibit false or misleading advertising that would 
     encourage a consumer to take the prescription drug for a use 
     other than a use for which the prescription drug is approved 
     under section 505 of the Federal Food, Drug, and Cosmetic Act 
     (21 U.S.C. 355); and
       (D) require that any prescription drug that is the subject 
     of a direct-to-consumer advertisement include in the package 
     in which the prescription drug is sold to consumers a 
     medication guide explaining the benefits and risks of use of 
     the prescription drug in terms designed to be understandable 
     to the general public.

     SEC. __02. CIVIL PENALTY.

       Section 303 of the Federal Food, Drug, and Cosmetic Act (21 
     U.S.C. 333) is amended by adding at the end the following:
       ``(h) Direct-to-Consumer Prescription Drug Advertising.--
       ``(1) In general.--A person that commits a violation of 
     section 301 involving the misbranding of a prescription drug 
     (within the meaning of section 502(n)) in a direct-to-
     consumer advertisement shall be assessed a civil penalty if--

[[Page 15933]]

       ``(A) the Secretary provides the person written notice of 
     the violation; and
       ``(B) the person fails to correct or cease the 
     advertisement so as to eliminate the violation not later than 
     180 days after the date of the notice.
       ``(2) Amount.--The amount of a civil penalty under 
     paragraph (1)--
       ``(A) shall not exceed $500,000 in the case of an 
     individual and $5,000,000 in the case of any other person; 
     and
       ``(B) shall not exceed $10,000,000 for all such violations 
     adjudicated in a single proceeding.
       ``(3) Procedure.--Paragraphs (3) through (5) of subsection 
     (g) apply with respect to a civil penalty under paragraph (1) 
     of this subsection to the same extent and in the same manner 
     as those paragraphs apply with respect to a civil penalty 
     under paragraph (1) or (2) of subsection (g).''.

     SEC. __03. REPORTS.

       The Secretary of Health and Human Services shall annually 
     submit to the Committee on Health, Education, Labor, and 
     Pensions of the Senate and the Committee on Energy and 
     Commerce of the House of Representatives a report that, for 
     the most recent 1-year period for which data are available--
       (1) provides the total number of direct-to-consumer 
     prescription drug advertisements made by television, radio, 
     the Internet, written publication, or other media;
       (2) identifies, for each such advertisement--
       (A) the dates on which, the times at which, and the markets 
     in which the advertisement was made; and
       (B) the type of advertisement (reminder, help-seeking, or 
     product-claim); and
       (3)(A) identifies the advertisements that violated or 
     appeared to violate section 502(n) of the Federal Food, Drug, 
     and Cosmetic Act (21 U.S.C. 352(n)); and
       (B) describes the actions taken by the Secretary in 
     response to the violations.

     SEC. __04. REVIEW OF DIRECT-TO-CONSUMER DRUG ADVERTISEMENTS.

       (a) In General.--The Secretary of Health and Human Services 
     shall expedite, to the maximum extent practicable, reviews of 
     the legality of direct-to-consumer drug advertisements.
       (b) Policy.--The Secretary of Health and Human Services 
     shall not adopt or follow any policy that would have the 
     purpose or effect of delaying reviews of the legality of 
     direct-to-consumer drug advertisements except--
       (1) as a result of notice-and-comment rulemaking; or
       (2) as the Secretary determines to be necessary to protect 
     public health and safety.


                           Amendment No. 1036

  Mr. REID. Mr. President, I ask unanimous consent that the pending 
amendments be set aside, and I send an amendment to the desk on behalf 
of Senator Boxer. This is an amendment to eliminate the coverage gap 
for individuals with cancer.
  The PRESIDING OFFICER. Without objection, the clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from Nevada [Mr. Reid], for Mrs. Boxer, 
     proposes an amendment numbered 1036.

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

  (Purpose: To eliminate the coverage gap for individuals with cancer)

       On page 53, between line 8 and 9, insert the following:
       ``(6) No coverage gap for eligible beneficiaries with 
     cancer.--
       ``(A) In general.--In the case of an eligible beneficiary 
     with cancer, the following rules shall apply:
       ``(i) Paragraph (2) shall be applied by substituting `up to 
     the annual out-of-pocket limit under paragraph (4)' for `up 
     to the initial coverage limit under paragraph (3)'.
       ``(ii) The Administrator shall not apply paragraph (3), 
     subsection (d)(1)(C), or paragraph (1)(D), (2)(D), or 
     (3)(A)(iv) of section 1860D-19(a).
       ``(B) Procedures.--The Administrator shall establish 
     procedures to carry out this paragraph. Such procedures shall 
     provide for the adjustment of payments to eligible entities 
     under section 1860D-16 that are necessary because of the 
     rules under subparagraph (A).''


                           Amendment No. 1037

  Mr. REID. Mr. President, I ask unanimous consent that the pending 
amendments be set aside, and I send an amendment to the desk on behalf 
of Mr. Corzine. This is a technical amendment regarding federally 
qualified health centers.
  The PRESIDING OFFICER. Without objection, the clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from Nevada [Mr. Reid], for Mr. Corzine, 
     proposes an amendment numbered 1037.

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

 (Purpose: To permit medicare beneficiaries to use Federally qualified 
              health centers to fill their prescriptions)

       At the end of subtitle A of title I, add the following:

     SEC. __. CONFORMING CHANGES REGARDING FEDERALLY QUALIFIED 
                   HEALTH CENTERS.

       (a) Permitting FQHCs To Fill Prescriptions.--Section 
     1861(aa)(3) (42 U.S.C. 1395x(aa)(3)) is amended--
       (1) in subparagraph (A), by striking ``and'' after the 
     comma at the end;
       (2) in subparagraph (B), by inserting ``and'' after the 
     comma at the end; and
       (3) by adding at the end the following new subparagraph:
       ``(C) drugs and biologicals for which payment may otherwise 
     be made under this title,''.
       (b) Elimination of Per Visit Limit.--Section 1833(a)(3) (42 
     U.S.C. 1395l(a)(3)) is amended by inserting ``, except that 
     such regulations may not limit the per visit payment amount 
     with regard to drugs and biologicals described in section 
     1861(aa)(3)(C)'' after ``the Secretary may prescribe in 
     regulations''.


                           Amendment No. 1038

  Mr. REID. Mr. President, I ask unanimous consent that the pending 
amendments be set aside, and I send an amendment to the desk on behalf 
of Senator Jeffords dealing with critical access to hospitals.
  The PRESIDING OFFICER. Without objection, the clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from Nevada [Mr. Reid], for Mr. Jeffords, 
     proposes an amendment numbered 1038.

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

       (Purpose: To improve the critical access hospital program)

       At the end of section 405 add the following:
       (g) Exclusion of Certain Beds from Bed Count and Removal of 
     Barriers to Establishment of Distinct Part Units.--
       (1) Exclusion of certain beds from bed count.--Section 
     1820(c)(2) (42 U.S.C. 1395i-4(c)(2)) is amended by adding at 
     the end the following:
       ``(E) Exclusion of certain beds from bed count.--In 
     determining the number of beds of a facility for purposes of 
     applying the bed limitations referred to in subparagraph 
     (B)(iii) and subsection (f), the Secretary shall not take 
     into account any bed of a distinct part psychiatric or 
     rehabilitation unit (described in the matter following clause 
     (v) of section 1886(d)(1)(B)) of the facility, except that 
     the total number of beds that are not taken into account 
     pursuant to this subparagraph with respect to a facility 
     shall not exceed 25.''.
       (2) Removing barriers to establishment of distinct part 
     units by critical access hospitals.--Section 1886(d)(1)(B) 
     (42 U.S.C. 195ww(d)(1)(B)) is amended by striking ``a 
     distinct part of the hospital (as defined by the Secretary)'' 
     in the matter following cause (v) and inserting ``a distinct 
     part (as defined by the Secretary) of the hospital or of a 
     critical access hospital''.
       (3) Effective date.--The amendments made by this subsection 
     shall apply to determinations with respect to distinct part 
     unit status, and with respect to designations, that are made 
     on or after October 1, 2003.


                           Amendment No. 1039

  Mr. REID. Mr. President, I ask unanimous consent that the pending 
amendments be set aside, and I send an amendment to the desk on behalf 
of Senator Inouye dealing with Native Hawaiians.
  The PRESIDING OFFICER. Without objection, the clerk will report.
  The assistant legislative clerk read as follows:

       The Senator from Nevada [Mr. Reid], for Mr. Inouye, 
     proposes an amendment numbered 1039.

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

(Purpose: To amend title XIX of the Social Security Act to provide 100 
   percent reimbursement for medical assistance provided to a Native 
   Hawaiian through a Federally-qualified health center or a Native 
                      Hawaiian health care system)

       At the appropriate place, insert the following:

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Native Hawaiian Medicaid 
     Coverage Act of 2003''.

[[Page 15934]]



     SEC. 2. 100 PERCENT FMAP FOR MEDICAL ASSISTANCE PROVIDED TO A 
                   NATIVE HAWAIIAN THROUGH A FEDERALLY-QUALIFIED 
                   HEALTH CENTER OR A NATIVE HAWAIIAN HEALTH CARE 
                   SYSTEM UNDER THE MEDICAID PROGRAM.

       (a) Medicaid.--Section 1905(b) of the Social Security Act 
     (42 U.S.C. 1396d(b)) is amended, in the third sentence, by 
     inserting ``, and with respect to medical assistance provided 
     to a Native Hawaiian (as defined in section 12 of the Native 
     Hawaiian Health Care Improvement Act) through a Federally-
     qualified health center or a Native Hawaiian health care 
     system (as so defined) whether directly, by referral, or 
     under contract or other arrangement between a Federally-
     qualified health center or a Native Hawaiian health care 
     system and another health care provider'' before the period.
       (b) Effective Date.--The amendment made by this section 
     applies to medical assistance provided on or after the date 
     of enactment of this Act.

  Mr. REID. I suggest the absence of a quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. SESSIONS. Mr. President, I ask unanimous consent that the order 
for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. SESSIONS. Mr. President, I ask unanimous consent that the pending 
amendments be set aside so that I may speak on my amendment No. 1011.
  The PRESIDING OFFICER. Without objection, it is so ordered.


                           Amendment No. 1011

  Mr. SESSIONS. Mr. President, the bill we are moving forward today is 
a prescription drug bill, a Medicare reform bill. It is not a welfare 
reform bill. Unfortunately, through the process, as it often happens 
when legislation moves through this body, the Finance Committee, 
without having hearings, faced an amendment that came up and it became 
a part of the bill that is on the Senate floor today. It would provide 
benefits not to American citizens but to non-citizens. It would amend 
the law that was passed some time ago prohibiting such actions.
  So I have sent to the desk an amendment which would strike section 
605 of the bill, the section that allows Medicaid and State health 
insurance program coverage to be given to noncitizens, and insert a 
sense of the Senate that this section should be referred back to the 
Finance Committee.
  In 1996, with a vote of 74 to 24, this body made a principled, 
purposeful decision during reform of welfare in this country, that non-
citizens should not access Federal programs such as TANF and Medicaid 
for the first 5 years they are in the United States. That is because 
these costs are supposed to be incurred by the sponsors of those people 
who come into the United States. That is why we make the sponsor of an 
immigrant who comes into the United States lawfully sign an affidavit 
that they will be responsible for that person's health care benefit. Of 
those Senators who are still in service in this body, 45 voted for it. 
That is quite a significant number.
  Section 605 would lift the 5-year ban for pregnant women, and 
children, from fiscal year 2005 through fiscal year 2007. In other 
words, we would allow pregnant women and children who have sponsors in 
the United States to access the welfare system of America to pay for 
their health care, contrary to the fully debated and wisely established 
rule in 1996 not to do that.
  The President is concerned about that. The administration is opposed 
to this change. They note that the administration has proposed 
substantial new flexibility on the part of Medicaid and SCHIP reform, 
and coverage for legal immigrants should be examined as part of this 
context.
  So we will be examining Medicaid, the SCHIP program, and Medicare 
reform later this year. That is the time we should be discussing 
changing our current policy as to what benefits are available to 
noncitizens, not slipping it through as part of this important bill.
  This is not a decision that we should change, not a policy that ought 
to be altered, without some significant study and debate. We are 
amending the welfare reform bill as part of a prescription drug bill. 
This is a major policy shift. It ought not to be added in this fashion. 
This bill is for America's senior citizens, not for non-citizens. If we 
want to make such important changes in funding eligibility and criteria 
for these programs, we ought to be ready to have a full and open debate 
on welfare policy. That is the kind of debate we had in 1996. I think 
some good decisions were made then that helped this country 
tremendously. It helped poor families move from welfare to work and did 
a lot of things for children in this country.
  The Finance Committee, which added section 605, should have hearings 
and go about it as part of the welfare reform bill. I feel strongly 
about that.
  Before 1996, the cost of welfare for immigrants had skyrocketed in 
America to $8 billion a year. That was in 1996. Harvard economist 
George Borjas found that immigrant households were 50 percent more 
likely to use Federal welfare programs than were citizen households. So 
this was the untenable position and situation in 1996, and that is what 
was ended by the legislation then.
  In 1996, Congress dealt specifically with the issue of welfare and 
immigration. In an overwhelming manner they passed the Personal 
Responsibility and Work Opportunity Reconciliation Act of 1996 which 
was signed by President Clinton and became law.
  The 1996 welfare and immigration reforms significantly restricted 
participation of new immigrants in Federal means-tested poverty 
programs and dramatically curtailed the access of permanent resident 
aliens to Federal welfare programs. That was exactly our goal. The 1996 
reform strengthened the welfare system and made more funds available 
for citizens in need. In passing this law in 1996, this Senate 
specifically stated certain national policy concerns related to welfare 
and immigration that should not be changed haphazardly.
  They said self-sufficiency has been a basic principle of United 
States immigration law since this country's earliest immigration 
status. Self-sufficiency is a key part of our whole concept of 
immigration.

       It continues to be the immigration policy of the United 
     States that:
     (A) Aliens within the Nation's borders not depend on public 
     resources to meet their needs, but rather rely on their own 
     capabilities and the resources of their families, their 
     sponsors, and private organizations, and the availability of 
     public benefits not constitute an incentive for immigration 
     to the United States.
       Despite the principle of self-sufficiency, aliens have been 
     applying for and receiving public benefits from Federal, 
     State, and local governments at increasing rates.
       It is a compelling government interest to enact new rules 
     for eligibility and sponsorship agreements in order to assure 
     that aliens be self-reliant in accordance with national 
     immigration policy.
       It is a compelling government interest to remove the 
     incentive for illegal immigration provided by the 
     availability of public benefits.

  That is what we are talking about. That sums it up. That was a 
thoughtful policy and change made in 1996. We ought not to have it slip 
through here on this important bill today without full hearings and 
discussion.
  Section 605, which now in this bill, would repeal the general 
prohibition of nonqualified aliens being eligible for any Federal 
public benefits, as it applies to protect women and children, even 
though ample exceptions for certain public benefits are already 
provided, such as emergency medical assistance. That is available now. 
Short-term disaster relief. Immunization, housing, and communities 
development assistance, and any assistance specified by the Attorney 
General.
  Section 605 waives the 5-year waiting period before immigrants are 
allowed to receive Federal benefits, thus creating a huge incentive for 
the benefited class of citizens to rush the borders for instant care. A 
person who has the possibility of coming to this country, has 
considered it and decided not to, if their child has a health problem, 
would not they, therefore, be incentivized to try to come across this 
border, knowing they could apply for and have public benefit of the 
United States?
  And we would like to do that. Do we do that for the entire world? It 
is just not possible. It is not good public policy. A nation has to 
have policy that is rational and defensible.

[[Page 15935]]

  A wide range of Federal programs are exempted from this requirement, 
including emergency Medicaid, certain immunizations, short-term 
disaster relief, school lunch programs, the WIC program, foster care, 
adoptive assistance, and Head Start. Those are available now.
  Section 605 will dissolve the financial accountability requirement of 
the sponsor. If section 605 passes, sponsors will no longer be held 
responsible to the Government for the cost of the Federal means-tested 
benefits to the aliens they sponsor.
  The Illegal Immigration Reform and Immigrant Responsibility Act of 
1996, coupled with the 1996 welfare reform law, purposefully altered 
the obligations of persons whose sponsored immigrants arrived or are 
adjusting status in the United States.
  In 1996, as part of the immigration reform, we required that 
affidavit of support be rewritten as a legally binding contract, 
enforceable against the sponsor through the time the sponsor immigrant 
becomes a citizen or has contributed to Social Security for 10 years. 
Affidavits of support are intended to implement the provisions of the 
INA that excludes aliens who appear ``likely at any time to become a 
public charge.'' No nation accepts people into their country who are 
likely to be a public charge of the country. A nation accepts people 
who are going to be contributors and will benefit that society.
  This is consistent with the recommendation of the Commission on 
Immigration Reform. In a report to Congress the commission stated 
sponsors of immigrants should be held financially responsible for the 
immigrants they bring into this country.
  Under the INA code a sponsor is defined as a person who is a citizen, 
national or lawfully admitted, of the United States, 18 years of age, 
lives in the United States and demonstrates the means to financially 
maintain a sponsorship. They can petition the Federal Government 
through an affidavit of support for the admittance of an individual 
residing outside the United States.
  In other words, a sponsor has to be a person who has the means to 
financially maintain a sponsorship. If they cannot sign that affidavit 
honestly, then the person should not be admitted into the country. The 
sponsor requirement allows for the admission of any person into the 
United States who is unable to take care of himself or herself without 
becoming a charge to the taxpayers by assuring, via affidavit, that the 
sponsor will financially support the person.
  An affidavit for support may not be accepted unless the sponsor 
agrees to, one, provide financial support to maintain the sponsored 
alien; two, be legally bound to the Federal Government of any entity 
that provides any means-tested public benefit which includes Medicaid; 
and three, submit to the jurisdiction of any Federal court.
  If a sponsored alien received any means-tested public benefits, the 
entity which provided such benefits can request to be reimbursed by the 
sponsor, and if reimbursement is not satisfied, then the sponsor will 
face civil penalty.
  Under this proposed legislation, the sponsors of these new immigrants 
would be absolved from their liability under the program. Aliens will 
no longer be supported and maintained by their sponsors and would 
become a charge on the public once again, a problem we sought to and 
did remedy in 1996.
  As we finish here tonight, we have a lot of important matters 
involved in this legislation, involving a lot of money. CBO estimates 
that this provision would cost half a billion over three years. It 
spends that money by changing what I think to be a good policy by 
creating a bad policy, a policy that will incentivize people to come to 
the United States for free health care when they may not otherwise wish 
to come or may not otherwise benefit from coming here. We really have 
not had the kind of debate, as a comprehensive review of welfare, that 
should be made a part of that.
  The Finance Committee will be considering welfare reform. It will be 
considering these issues in the months to come. They have a lot on 
their plate.
  This amendment simply says let's not rush this through now. Let's not 
move it through on this important bill that is going to move through 
Congress. Let's send it back to the Finance Committee. Let's encourage 
them to give thoughtful and serious concern to it. Let's have them come 
forward with a program that would justify us changing this important 
rule, established in 1996.
  I yield the floor.
  The PRESIDING OFFICER. The Senator from Iowa.

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