[Congressional Record (Bound Edition), Volume 149 (2003), Part 17]
[House]
[Pages 23832-23838]
[From the U.S. Government Publishing Office, www.gpo.gov]




MOTION TO INSTRUCT CONFEREES ON H.R. 1, MEDICARE PRESCRIPTION DRUG AND 
                       MODERNIZATION ACT OF 2003

  Mr. CASE. Mr. Speaker, I offer a motion to instruct conferees on H.R. 
1.
  The Clerk read as follows:

       Mr. Case moves that the managers on the part of the House 
     at the conference on the disagreeing votes of the two Houses 
     on the Senate amendment to the bill H.R. 1 be instructed as 
     follows:
       (1) The House recede to the Senate on the provisions to 
     guarantee access to prescription drug coverage under section 
     1860D-13(e) of the Social Security Act, as added by section 
     101(a) of the Senate amendment.
       (2) To reject the provisions of section 501 of the House 
     bill.
       (3) The House recede to the Senate on the following 
     provisions of the Senate amendment to improve rural health 
     care:
       (A) Section 403 (relating to inpatient hospital adjustment 
     for low volume hospitals).
       (B) Section 404 (relating to medicare disproportionate 
     share adjustment for rural areas), but with the effective 
     date applicable under section 401(b) of the House bill.
       (C) Section 404A (relating to MedPAC report on medicare 
     disproportionate share hospital adjustment payments).
       (D) The following provisions of section 405 (relating to 
     critical access hospital improvements):
       (i) Subsection (a), but with the effective date applicable 
     under section 405(f)(4) of the House bill.
       (ii) Subsection (b), but with the effective date applicable 
     under section 405(c)(2) of the House bill.
       (iii) Subsections (e), (f), and (g).
       (E) Section 414 (relating to rural community hospital 
     demonstration program).
       (F) Section 415 (relating to critical access hospital 
     improvement demonstration program).
       (G) Section 417 (relating to treatment of certain entities 
     for purposes of payment under the medicare program).
       (H) Section 420 (relating to conforming changes relating to 
     Federally qualified health centers).
       (I) Section 420A (relating to increase for hospitals with 
     disproportionate indigent care revenues).

[[Page 23833]]

       (J) Section 421 (relating to establishment of floor on 
     geographic adjustments of payments for physicians' services).
       (K) Section 425 (relating to temporary increase for ground 
     ambulance services), but with the effective date applicable 
     under the amendment made by section 410(2) of the House bill.
       (L) Section 426 (relating to appropriate coverage of air 
     ambulance services under ambulance fee schedule).
       (M) Section 427 (relating to treatment of certain clinical 
     diagnostic laboratory tests furnished by a sole community 
     hospital).
       (N) Section 428 (relating to improvement in rural health 
     clinic reimbursement).
       (O) Section 444 (relating to GAO study of geographic 
     differences in payments for physicians' services).
       (P) Section 450C (relating to authorization of 
     reimbursement for all medicare part B services furnished by 
     Indian hospitals and clinics).
       (Q) Section 452 (relating to limitation on reduction in 
     area wage adjustment factors under the prospective payment 
     system for home health services).
       (R) Section 455 (relating to MedPAC study on medicare 
     payments and efficiencies in the health care system).
       (S) Section 459 (relating to increase in medicare payment 
     for certain home health services).
       (T) Section 601 (Increase in medicaid DSH allotments for 
     fiscal years 2004 and 2005).
       (4) The House insist upon the following provisions of the 
     House bill:
       (A) Section 402 (relating to immediate establishment of 
     uniform standardized amount in rural and small urban areas).
       (B) Section 403 (relating to establishment of essential 
     rural hospital classification).
       (C) Subsections (a), (b), (d), and (e) of section 405 
     (relating to improvements to critical access hospital 
     program).
       (D) Section 416 (relating to revision of labor-related 
     share of hospital inpatient pps wage index).
       (E) Section 417 (relating to medicare incentive payment 
     program improvements).
       (F) Section 504 (relating to wage index classification 
     reform).
       (G) Section 601 (relating to revision of updates for 
     physician services).
       (H) Section 1001 (relating to medicaid disproportionate 
     share hospital (DSH) payments).

  Mr. CASE (during the reading). Mr. Speaker, I ask unanimous consent 
that the motion to instruct be considered as read and printed in the 
Record.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Hawaii?
  There was no objection.
  The SPEAKER pro tempore. Pursuant to clause 7 of rule XXII, the 
gentleman from Hawaii (Mr. Case) and the gentleman from Florida (Mr. 
Bilirakis) each will control 30 minutes.
  The Chair recognizes the gentleman from Hawaii (Mr. Case).
  Mr. CASE. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, by my calendar, we now have 16 days until the October 
17th deadline announced by the President and the Senate majority leader 
for completing the pending conference on the so-called Medicare reform 
bill. And still before this House, before this Chamber and the Senate 
and the country the unanswered question, in my mind, is: Does the 
current administration and does the congressional majority really care 
about health care for the American people?
  Now, I know a lot of people around here really care about a lot of 
people around here that make a lot of money off of health care. And I 
know that a lot of people around here really care about spending money 
on a lot of things other than health care. I have seen that in my time 
here in Congress. And I have certainly heard a lot of talk, a lot of 
talk about health care. I have certainly heard a lot of talk about 
Medicare. But the question is: Do they really care? What do their 
actions demonstrate? Do they care about the people at the end of this 
food chain?
  It is a long food chain from the halls of this Congress through the 
Federal Government and out through the health care community and down 
into the communities where people live, work and get sick. Do they 
really care about the people at the end? All of us do not just want 
affordable and available health care; we need it, and it has to be 
available and affordable.
  When we look at where the people of our country live, who most want 
and most need health care, and when we look at where the assistance of 
our Federal Government should go, it is in the rural areas of our 
country, our small cities, our small towns, our hamlets, our isolated 
outposts, out where people live away from these urban centers where we 
live and do our work. And the reasons for that need are well 
documented, and I do not think anybody else has to tell us any more.
  We all know why health care is so important to the rural areas of our 
country. First of all, we have less available preventive care 
throughout life, so when people get sick younger, they get sick worse 
in the rural part of our country. In the rural parts of our country 
today and down the road, people are older than in the urban parts of 
our country; they need health care more.

                              {time}  1245

  In the rural parts of our country people have lower incomes, higher 
unemployment, and when we have lower income and higher unemployment, 
health care suffers.
  In the rural parts of our country, it always has been true that there 
has been less access to medical care and specialization, and that is 
getting worse.
  Finally, in the rural parts of our country, there is simply less 
availability and coverage of health care insurance.
  These are not just abstract thoughts. We can read about these in 
Federal reports. We can debate them here in Congress, but let us talk 
about real America, what happens out there in these communities, and 
let me talk about my community, the community that I represent, because 
I represent rural Hawaii. I do not represent downtown Honolulu. I 
represent the rural parts of my State, islands all of them, islands 
that are rural, islands with small cities, small towns, hamlets and 
outposts every bit as rural as the rest of our rural country, every bit 
as prone to all of these problems. They may have different names, but 
the concerns are the same.
  Let me give my colleagues just a couple of examples of areas of my 
District which are just like any part of our country in terms of health 
care. Let us talk about the Hamakua Coast on the island of Hawaii, my 
home. The Hamakua Coast is about as rural as one can get in Hawaii. It 
is an agricultural-based economy. Its largest crop, sugar, failed along 
that coast 10, 15, 20 years ago. And these small towns now have people 
that grew up in the sugar industry and are trying to make a go of small 
business in agriculture in those small towns, small towns like Pepeekeo 
and Papaikou, Laupahoehoe, Paauilo, Honokaa, and their problem is 
health care.
  Let us take West Hawaii, the other side of the same island, a part of 
my Hawaii that has some most of the rural areas of our whole State, 
North Kohala, Ocean View down in South Kona and Kau. They want those 
rural communities to survive. West Hawaii used to have a surgeon that 
qualified for Medicare reimbursements. That surgeon is no longer there. 
There is no surgeon in West Hawaii at the moment for Medicare people.
  So when I walk into the coffee shops, when I walk into the small 
family stores and small post offices of my district, when I go into the 
bon dances that are so much a part of our culture during the summer, 
and I sit down, and I talk to my constituents, and I ask them what is 
on their mind, they say health care, health care and health care.
  This is not an abstract thought. They are scared about the 
availability of health care. They are scared about the availability of 
prescription drugs. They are scared about chronic disease and chronic 
illnesses and their ability to be able to take care of their medical 
needs. They are scared about long-term care, and their children are 
scared for their parents.
  These are the realities of rural America. The availability of 
physicians in this part of my district is significant in the example 
that it shows for what is happening in rural health care. There are 
about two physicians per 1,000 in urban Honolulu, but if one gets out 
there into the rest of the communities in my district, the percentage 
drops well below one, down to 0.1 in communities like Molokai.

[[Page 23834]]

  Let us talk about Molokai, because that is another good example. The 
island of Molokai, about as rural as one can get in America, an island, 
an island of 7,000 people living on it. They cannot hop a bus or a 
train or a boat to get to some critical access hospital when they have 
medical care. They have to fly, and flying is expensive. Thousands of 
dollars are being spent.
  Hawaii is no different from the rest of rural America. I fly over 
rural America almost every weekend. I look down. I have been across it 
myself, and I look out, and I see places just like my rural Hawaii. 
They are their own islands. They may not be surrounded by water, but 
they are islands of isolation, islands of small towns, small hamlets, 
the prairie towns of the great plains, the mountain hamlets of the 
Sierra, the Rockies or Appalachia. This is our heartland, and they are 
scared about health care.
  In rural America, health care is not an abstract thought either. It 
is a Federal program, Medicare. Health care in rural America is 
Medicare. For seniors in rural America, it is Medicare. For the 
disabled in rural America, it is Medicare, and because in rural America 
it is health care and health care is Medicare, as Medicare goes, so 
goes rural America.
  If we do not have available and affordable medical coverage through 
Medicare, we have no rural America. If we do not have adequate 
reimbursements, no doctors, no hospitals, no clinics in rural America, 
we have no rural America. If we do not have adequate prescription 
coverage for our seniors and disabled that live in rural America 
through Medicare, we have no rural America.
  So one of the things that it is incredibly important to realize is 
that the debate about Medicare is not just about Medicare. The debate 
about Medicare is not just about health care. The debate about America 
is about maintaining rural America. We have to take care of the needs 
of rural America, whether they are economic needs, where the 
manufacturing base is shrinking or whether they are land use needs, 
where the agricultural base is shrinking, and whether they are health 
care needs, where the needs are diminishing. That is the reality of 
Medicare.
  H.R. 1, the Medicare Reform Bill, passed this House by a single vote. 
Like most of my colleagues on this sides of the aisle, I voted no on 
that bill, primarily because that bill did not help rural America. That 
bill did not do the job for rural America that we wanted it to do, and 
in fact, that bill hurt rural America, and I voted no. The motion 
before us today simply says this: Put your money where your mouth is.
  There has been a lot of talk about helping rural America, but talk is 
cheap. Let us prove it. Do not get me wrong, there are some components 
in both the House version of Medicare reform and the Senate version of 
Medicare reform, there are isolated instances of help for rural America 
in both bills. That is not going to be good enough. As these 16 days 
tick by to the deadline set by our President and our Senate majority 
leader, our attention has to turn back to what are the best aspects of 
each bill for rural America, what are the best aspects of the bill that 
help the particular problems in rural America, what are the aspects of 
the bill that provide prescription drug coverage, what are the aspects 
of the bill that provide adequate reimbursements to hospitals and 
doctors.
  On the island of Molokai, for example, we no longer have long-term 
care beds. Why? They cannot provide them under the reimbursement rate 
granted by Medicare. That may seem like an abstract thought, but 
imagine that a person has grown up their whole life on Molokai, and 
their family lives there, too, and it comes time for them to be taken 
care of in their old age, and they have to move islands, they have to 
leave their home because there is not the coverage available to be 
helpful to them if they are needy, and their family has to fly back and 
forth. That is not something we want to sanction.
  We want to take the best of these two bills. We want to take the best 
of these bills on prescription drug coverage. We want to take the best 
of these bills on not cutting our hospital payments, and that is what 
this motion says.
  This motion which has been brought three times now before this House 
by my colleagues, and I now bring it here today, simply says let us not 
talk anymore, let us do it. Let us take the best of these bills that we 
know will do the job, and let us adopt them in conference because we 
have the ingredients, right now, to do a good job for rural America. 
The question is will we do that job for rural America?
  So this bill simply says, on prescription drug coverage, let us have 
a fall-back option. If there is no prescription drug coverage available 
under Medicare in our rural communities, then there is a fall-back 
provision on prescription drug coverage, not by the private sector, but 
by our government.
  This motion says let us take the best of both the House and the 
Senate versions on reimbursing our providers. If we cannot provide 
basic services in our communities to those in need, there is something 
wrong, and we need to provide for the adequate reimbursements, and this 
bill says let us do that, and this bill also says that we need our 
hospitals, our critical access facilities in our rural areas. We need 
access in our rural areas.
  Again, the example of Hawaii, a State that is an island State, where 
one cannot simply get to the urban center of Honolulu easily, where 
people are spending, like I said, thousands of dollars just on 
transportation needs because these are not available in their districts 
whether they be Kauai or Molokai or Maui or the Big Island, that we 
will provide the necessary payments to our hospitals to keep them open 
at a basic level of service for our rural areas. That is what this 
motion says, and I think it is pretty simple. It is a matter of 
priorities.
  If our priorities are to ensure the health of our rural economies, 
our rural lifestyle, which is the heart land not only of our country 
but of our thinking, of our culture, then we need to protect these 
rural communities, and health care is the way to protect them.
  So let us not avoid this anymore. Let us just vote on this motion, 
let us give our conferees direct instructions that we collectively care 
about rural health care and that we intend to follow through and that 
we will put our money where our mouth is.
  Mr. Speaker, I reserve the balance of my time.
  Mr. BILIRAKIS. Mr. Speaker, I yield myself such time as I may 
consume.
  Mr. Speaker, the gentleman makes a very good case for rural health 
care, and I commend him for that and because we have heard the same 
case made time and time again, and this is why we have provided an 
approximately $25 billion increase in payments to rural providers.
  Before I go into that, I would advise the gentleman through the 
Chair, if I may, that I certainly agree with him regarding wellness, 
preventive health care and whatnot, and for something like 60 years or 
30 years after Medicare was devised, we did not have, in Medicare, 
provisions for preventive health care. And it was not until a few years 
ago, in the 1990s, in the late 1990s, when finally a group of us got 
together on a bipartisan basis and finally for the first time put some 
preventive health care coverage reimbursement, if you will, in order to 
cover those areas.
  In the House bill, in the House bill, the gentleman has not referred 
to this, we have a provision to the effect that when a person is about 
to go under Medicare, there is a reimbursement coverage. In other 
words, provided payment by Medicare, for a one-time physical. It is a 
voluntary type of a thing, but a one-time physical to encourage people 
to take that physical before they go into Medicare, and with the idea, 
of course, that many problems, many illnesses, prospective illnesses 
might be picked up at a real early stage and thus save not only an 
awful lot of money, of course, to the taxpayer ultimately, but 
certainly save an awful lot of money and inconvenience and pain for the 
beneficiary.
  This is what is in the House bill, as I understand it. It is not the 
Senate bill.

[[Page 23835]]

It is one of those provisions that we, on the Member level in 
conference, are going to have to address. The American Cancer Society 
supports that provision, and it is my idea, and so, certainly, I 
support it. So I agree with the gentleman about preventive health care, 
and it is something we are trying to do.
  This is, as the gentleman indicated, the fourth time the minority has 
offered this motion to instruct conferees. I do find it perplexing that 
they continue to offer this motion, and for one reason only, and that 
is because by definition, by definition, it would reduce the amount of 
funding available for the new Medicare prescription drug benefit by 10s 
of billions of dollars.
  So, yes, do we want to increase and are we, in fact, increasing the 
reimbursements to rural Medicare providers? Yes, we are doing that. If 
we increase that amount, we are taking it from where? We are taking it, 
of course, from the prescription drug benefits available to seniors.
  The author would have the Medicare conferees accept every rural 
provider increase contained in both bills, as he indicated. I would 
note for my colleagues, and I have already said this, that the House 
has already recognized the need to ensure the rural Medicare providers 
are paid fairly. In fact, the House-passed bill contains a $24.9 
billion increase in payments to rural providers, which will help rural 
hospitals and physicians, among others, continue to provide care to 
rural Americans. So, if the House bill goes down, or if we do not have 
a bill, let us say both bills go down because we want perfection, the 
rural hospitals will lose $25 billion as a result of that decision.
  Since the authors of this motion continue to emphasize that their 
motion will not cause us to exceed the $400 billion laid out in the 
budget resolution, we would have to reallocate funds, I have already 
said it, away from beneficiaries and towards whom? Towards rural 
providers.

                              {time}  1300

  Would we like to do that? Yes. Would we like to take it away from 
prescription drug benefits? The answer is no. I do not support it. I 
think the House bill strikes the right balance between providing a 
meaningful prescription drug benefit and helping ensure that providers, 
especially those in rural areas, continue to serve Medicare 
beneficiaries.
  This motion would also, in some cases, require a type of government-
run fallback. Although the House passed legislation, both bills have a 
fallback. The House passed legislation has a fallback. It already 
guarantees that every Medicare beneficiary will have a choice of the 
least two Medicare prescription drug plans.
  In fact, the Congressional Budget Office tells us, and they are, of 
course, as bipartisan as you can be, that under both acts, CBO 
estimates that all Medicare beneficiaries would have access to 
prescription drug coverage. In spite of that, both bills have a 
fallback. They are good fallbacks. As time goes on, if, God forbid, we 
might have to fall back, if you will, to a fallback, and it looks like 
it is not working, then, of course, that is something that can be 
adjusted. But there really is not that much of a difference in terms of 
what the fallbacks are as I understand it. It is just the case of the 
Senate bill fallback would immediately fall back to the government 
picking up 100 percent of risk whereas the House bill affords 
flexibility, if you will, from the standpoint that one fallback may 
result in government picking up a certain percentage of risk in some 
areas and in some other areas and pick up a larger risk or smaller risk 
or something of that nature.
  We have found that, in order to control costs, it is important that 
Medicare prescription drug sponsors share some of the risk associated 
with providing this new benefit. I am uncomfortable asking the Federal 
taxpayer to completely shoulder the weight of this new entitlement. 
That is why I do not think we need the government running prescription 
drug plans. But the fact of the matter is the fallback is there, and 
there is a guarantee in the House bill that a plan will be available 
for all beneficiaries.
  And, finally, the motion instructs conferees to recede to the Senate 
and remove the hospital market-basket update adjustment contained in 
the House bill. I would note for my colleagues that we are not cutting 
hospital reimbursement. We are not cutting hospital reimbursement. We 
have hospitals all over, whether it be urban areas or rural areas, my 
area is somewhat in between, if you will, but we are not getting 
hospital reimbursements.
  According to the Medicare Payment Advisory Commission, which we call 
MedPAC, it is the nonpartisan panel of experts that advises Congress on 
Medicare policy, hospitals currently make a 10 percent profit for 
Medicare inpatient services and a 5 percent profit, on average, for all 
services provided to Medicare patients.
  So I have already emphasized, if you will, MedPAC unanimously advised 
Congress to increase payments by 3 percent, which is what the House 
bill does. We have gone along with basically the experts in that 
regard, MedPAC.
  The $25 billion approximate increase in provider payments in rural 
areas is based on certain formulas. Iowa hospitals would receive a 
certain percentage, Hawaii hospitals receive a certain percentage, 
increases above and beyond that 3 percent I might add.
  Additionally, and it has not been mentioned in the motion to 
instruct, but under the current law, Medicare providers would have 
reduced their reimbursement by 4.4 percent. The House bill increases 
that by 1.5 percent. You are talking about a swing of 5.9 percent to 
Medicare providers, M.D.-type providers, if you will, which would take 
place if we enact this legislation into law. If we defeat this 
legislation and defeat any version of this type of legislation, those 
providers would be hurting. The rural providers would be hurting 
considerably more than they are now. And obviously, the beneficiaries, 
to whom we have promised prescription drugs of a sort, would be 
hurting.
  Mr. Speaker, given the progress the conferees have made toward 
reaching an agreement, progress is being made, it is slow, there is no 
question about it, but it is moving, I would hope that conferees are 
given the opportunity to work through their differences between both 
bills. After all, that is what the system is all about. There are 
differences between the House version and the Senate version. And 
conferees were appointed on a bipartisan basis in order to try to work 
out those differences.
  Basically what we are saying to the gentleman and to the entire House 
is give the conferees the opportunity to work, and hopefully we will be 
able to successfully address the many competing issues in a 
satisfactory way.
  And more importantly, in addition to helping the rural providers and 
rural hospitals, all providers, et cetera, we will be providing our 
seniors with a prescription drug benefit that they need so very 
desperately.
  Mr. Speaker, I reserve the balance of my time.
  Mr. CASE. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, before yielding to my colleagues, I would simply note 
that as to the last comment made by the gentleman from Florida (Mr. 
Bilirakis) on the bipartisan nature of this conference, I think it is 
well known within this Congress, and I hope that it is well known 
outside of this Chamber, that the minority party is not particularly 
participating in that conference and is not particularly being 
consulted. And as a result, we are certainly willing and able to do 
that in the full glare of publicity before the whole country.
  Mr. Speaker, I yield 4 minutes to the gentleman from Arkansas (Mr. 
Berry), a person who understands rural communities, understands rural 
concerns. He lives them.
  Mr. BERRY. Mr. Speaker, I want to thank the gentleman from Hawaii 
(Mr. Case) for his leadership in this matter. And I can say that I know 
that my distinguished colleague, the gentleman from Florida (Mr. 
Bilirakis), cares about senior citizens and their health. I know that 
there are many Members on both sides of the aisle that have a genuine 
concern about what happens to our health care system and what happens 
to our senior citizens. But I have

[[Page 23836]]

to tell you, Mr. Speaker, as we consider H.R. 1, and just as my 
distinguished colleague, the gentleman from Hawaii (Mr. Case), just 
mentioned, every meeting of the conference committee does not include 
the Democrats. I do not know why that is, but that is the way it works 
around here.
  I would probably call this H.R. 1 bill that we are working with right 
now, I would be more inclined to call it a fall-back or a fall-off or 
fell-off or jump-off or some characterization like that because this 
bill just simply does not provide any kind of a guarantee for our 
senior citizens as to what it will do or a guarantee to our health care 
industry as to what they need to see in the way of the ability to 
continue to provide services and do business.
  And, certainly, in rural America there are no guarantees. We lose 
hospitals almost on a monthly basis across this country in rural 
America. We have providers now that just simply do not take Medicare 
patients any more. Most of this is as a result of the Balanced Budget 
Act of 1997, which I proudly voted against; and it has put our health 
care system in great jeopardy.
  Now we are talking about another Medicare reform bill that would 
reduce payments in some cases to all hospitals, and certainly it would 
make it more difficult for our rural hospitals and rural providers to 
stay in business, and it does not guarantee any kind of a prescription 
drug benefit to our rural seniors who would need it the most.
  So I would encourage my colleagues to look carefully at this and not 
do something that will hurt rural America and our seniors. It is very 
disappointing to think that the possibility even exists that we would 
not have a fallback provision that would ensure that our seniors in 
rural communities would have access to a Medicare prescription drug 
benefit.
  Over the last 25 years, over 470 rural hospitals have closed. Rural 
hospitals all over the country are in danger of being forced to shut 
their doors. Currently, hospitals receive full inflation market-basket 
payments for inpatient and outpatient services. H.R. 1 would reduce 
hospital payment updates for the next 3 years, costing hospitals an 
estimated $12 billion.
  Our health care system in this country is on the verge of serious, 
serious problems. All we are asking for is a fair deal for rural 
America and a fair deal for the people that provide the services to our 
senior citizens through Medicare so they can stay in business.
  Mr. BILIRAKIS. Mr. Speaker, I yield myself such time as I may consume 
to respond to the gentleman, and I appreciate his comments because he 
is so very much concerned about health care for our seniors; but I 
mentioned the conference is taking place on a bipartisan basis, and the 
truth is it is. We have two United States Senators from the other party 
who are part of that conference, on an everyday basis, I might add.
  Mr. Speaker, I yield such time as he may consume to the gentleman 
from Texas (Mr. Burgess).
  Mr. BURGESS. Mr. Speaker, I thank the chairman for yielding me this 
time and for the opportunity to address this issue.
  Mr. Speaker, as previously pointed out, this is the fourth time the 
minority has offered this motion to instruct Medicare conferees. I 
personally find it perplexing that they continue to offer this motion, 
since by definition it would reduce the amount of funding available for 
the new Medicare prescription drug benefit by tens of billions of 
dollars. The author of this motion would have the Medicare conferees 
accept every rural provider increase contained in both bills, both 
bills.
  I would note for my colleagues that the House has already recognized 
the need to ensure that rural Medicare providers are paid fairly. In 
fact, the House-passed bill contains, as was previously pointed out by 
the chairman, almost $25 billion in increased payments to rural 
providers; and that will help rural hospitals and rural physicians 
continue to provide care to rural Americans.
  Since the authors of this motion continue to emphasize that their 
motion would not cause us to exceed the $400 billion laid out in the 
budget resolution, they would have to radically reallocate funds laid 
out by the House bill in a manner that would disrupt the delicate 
balance laid out by the bill. The House bill strikes the right balance 
between providing a meaningful prescription drug benefit and helping 
provide incentives that providers, especially those in rural areas, 
continue to serve Medicare beneficiaries.
  This motion would force the Department of Health and Human Services 
to offer a Medicare prescription drug plan. This is a Big Government 
fallback that is shortsighted and unneeded. The House-passed 
legislation guarantees that every Medicare beneficiary will have the 
choice of at least two Medicare prescription drug plans. In fact, the 
Congressional Budget Office tells us that under both acts estimates are 
that all Medicare beneficiaries would have access to prescription drug 
coverage.
  We have found that in order to control costs it is important that 
Medicare prescription drug plan sponsors share some of the risk 
associated with providing this new benefit. The taxpayers should not be 
asked to completely shoulder the weight of this new entitlement, and 
that is why we do not think we need the government running prescription 
drug plans.
  Finally, the motion instructs conferees to recede to the Senate and 
remove the hospital market-basket update adjustment contained in the 
House bill. I want to be very clear about how the House bill approaches 
the hospital issue. The House bill does not cut hospital reimbursement. 
According to the Medicare Payment Advisory Commission, hospitals make a 
10 percent profit in Medicare inpatient services, and a 5 percent 
profit on average for services provided to Medicare patients. The 
Medicare Payment Advisory Commission unanimously advised Congress to 
increase payments by 3 percent, which is what the House bill does.
  Mr. Speaker, I think I also need to add that the gentleman from 
Arkansas who just spoke said that rural providers need our help. And I 
would submit that if the other side of the aisle wants to be helpful to 
rural providers, they would instruct Members of their party in the 
other body to take up and pass meaningful medical liability reform. A 
fair justice system would do more to help rural hospitals and rural 
providers than any other action.
  Finally, Mr. Speaker, given the progress the conferees have made 
toward reaching an agreement, I would hope that the conferees are given 
the opportunity to continue to work through the differences in both 
bills. I am confident that we will successfully address many of the 
competing issues in a satisfactory way. Most importantly, we will 
provide our seniors with the prescription drug benefit that they so 
desperately need.

                              {time}  1315

  Mr. CASE. Mr. Speaker, I yield myself such time as I may consume.
  I would simply note, with respect to my colleague's comments, the 
Department of Health and Human Services under the motion would be 
required to do certain things; that is correct. The Department would be 
required to provide the reimbursements that are necessary to preserve 
rural health care through the hospitals.
  I would also note that sometimes the Department does need to be 
required to do things. One of the principal issues on the Medicare 
Reform Bill remains whether the Department of Health and Human Services 
should be required to enter into basic bulk purchasing arrangements to 
lower the cost of prescription drugs. The bill that came out of this 
House would have prohibited them from doing that; and clearly, in this 
instance, the Department needs to be told to do what every American 
knows is the right thing to do.
  Mr. Speaker, I yield 5 minutes to the gentleman from Alabama (Mr. 
Davis) who totally understands rural America.
  Mr. DAVIS of Alabama. Mr. Speaker, let me thank my friend and 
colleague from Hawaii for his passion on this issue and for reminding 
us that in the United States the face of rural America

[[Page 23837]]

is not simply Southern or Western, it can even be Pacific at times.
  Let me begin, first of all, by saying or by reiterating something 
that my friend from Arkansas said, I do not think that any of us on 
this side of the aisle believe that any of our able colleagues on the 
other side want to do violence to the interests of rural America or do 
not care about what goes on in the heartland of America or in the rural 
parts of our country. We are not having a debate about intent today or 
a debate about goals today, but we are having a debate about making a 
system that will work.
  It is a fact, and it is an eventuality under the bill that the 
Republican leadership so narrowly pushed through this body, that over a 
period of time, the prescription drug benefit, that all of us want and 
have endorsed in some sense, will be phased out and delivered through 
the private sector in significant parts of our country. Now, that 
sounds, from a technical standpoint, like a worthy enough aspiration. I 
have heard my colleagues on the other side defend that kind of a world 
in terms of the market choices it will open up. I have heard them 
defend that kind of a world in terms of the choices it will generate 
for the consumers, for senior consumers.
  The reality, as so many of us on this side of the aisle know, is 
this: We can travel to those places in west Alabama, whole places in 
the rural parts of our country where you simply do not have a private 
provider network that is capable or available to carry this burden. So 
when we are talking about expanding market choices, what a wonderful 
thing it would be if those market choices would be available all around 
this country.
  Our seniors are looking to us desperately for leadership on this 
issue. Our seniors are desperately looking to us to give them a 
benefit, but not just any benefit. They want one that is fair, and one 
that is workable, and one that is available all around America.
  I am genuinely amazed that a lot of our colleagues on the other side 
of the aisle are willing to have us move into a system where, at best, 
we can trust the vagaries of the market to provide this benefit for our 
seniors. I talk as I move around my district to far too many seniors 
who are having to spend significant chunks of their limited, disposable 
income on prescription drugs. I run into too many seniors who are 
having to self-medicate, who are told that they have to take medicine 
for a certain number of days, and they chop the pills up to extend the 
timetable. All Members can cite those stories.
  What a tragedy it would be if we had a huge ceremony and a huge 
fanfare, and the President stood up and said we had passed a 
prescription drug benefit bill, and then within 6 or 7 years from now, 
our seniors living in rural America saw what they expected to be a 
Cadillac turned out to be a much smaller, less efficient and less 
effective vehicle.
  Mr. Speaker, I urge my colleagues to support this motion not because 
I think the folks on the other side of the aisle have a different set 
of values, but because I think they misunderstand the market that we 
have and the choices that will be left to our seniors.
  I want to address one other point several of my colleagues make. 
There has been a lot of talk that we are fixing the rural problem 
because we are addressing the disparities in the reimbursement 
formulas; and I compliment the other side of the aisle for recognizing 
that the reimbursement formulas in Medicare have disadvantaged our 
rural areas, but I will make a very basic point here. If the Republican 
leadership of this body were serious about fixing the reimbursement 
formula, it could do it tomorrow. Just as we came to the floor in 
record time last week to speak to the court that ruled on the Do-Not-
Call Registry, we could come to this floor in record time to pass a 
stand-alone bill that fixes the unfair reimbursement formulas.
  Right now, the reimbursement formula fix is being held hostage to the 
completion of this bill. It is nothing more than a bargaining chip at 
this point to try to bring conservative Democrats and moderate 
Republicans to the table, and we ought to expose that for what it is. 
If the leadership were serious about fixing this problem, it should be 
done tomorrow as a stand-alone piece of legislation. Let us address the 
hard and serious problem of getting a prescription drug benefit, but 
let us address, in a separate context, the very real problem of 
disparities in this formula that burden so many of our areas.
  Mr. BILIRAKIS. Mr. Speaker, I yield myself such time as I may 
consume.
  Just to respond very briefly to the gentleman from Alabama (Mr. 
Davis), this is my 21st year in the House. Virtually all of that time, 
I have been a member of the Subcommittee on Health, and the question of 
reimbursements to rural providers has always been there. If it were 
simple to correct, it could have been corrected. It could have been 
corrected when the other party was in charge. It could have been 
corrected when this party has been in charge, which is a lot less years 
than when the other party was in charge. It is very difficult, but it 
is being addressed. The conferees are spending a lot of time on that 
particular issue, and, hopefully, they will reach agreement.
  Again, I would say to my colleagues, I have talked to members of the 
AARP who have come into my office back home. Yes, we have all received 
a seven-page letter to the effect of what they want in that bill, but 
they say we want a bill which will help some people now, and, 
hopefully, provide a foundation we can improve upon as we go on.
  If all of us are just going to stand fast and say this is not in the 
bill or that is not in the bill, or this is in the bill and I do not 
like it and we want perfection, we are not going to have a bill. As I 
said before, at least the rural providers are receiving some benefit, 
some help out of this bill. That $25 billion is certainly not chicken 
feed.
  It is significant that we have a piece of legislation that is going 
to be of some help to the rural providers. It may not be enough, it may 
not be as much as the gentleman would like, and I do not blame him. 
This is a representative system of government, and they are 
representing their people, and they are doing a good job of it insofar 
as wanting to help their rural communities. But again, we have to have 
a bill, and it is critical that we all try to work together as much as 
we can.
  All of the conferees are not always meeting together in every 
conference that we have. That is unfortunate, but there are some 
Members who have indicated that they are against anything at all 
involving this type of legislation; and, consequently, I suppose those 
are the reasons. I do not make those decisions, but it is unfortunate. 
But a lot of work is being done every day at 3 p.m., Monday through 
Friday, on a bipartisan basis.
  Mr. Speaker, I reserve the balance of my time.
  Mr. CASE. Mr. Speaker, I yield 3 minutes to the gentleman from 
Florida (Mr. Boyd).
  Mr. BOYD. Mr. Speaker, I thank the gentleman for bringing this 
subject to the floor.
  I think we all, as Americans, understand this prescription drug issue 
very well, and I think we understand the importance of Medicare to this 
Nation. I like to tell my constituents back home that since the advent 
of Medicare 40 years ago, there has been a significant decline in the 
level of folks below the level of poverty. Prior to the advent of 
Medicare, if you reached the age of 65 in this country, there was a 
greater than 50 percent chance that you would be below the poverty 
level. Today that figure is less than 10 percent. There is a dramatic 
drop in poverty in this country, and we think much of that can be 
credited to the successful Medicare and Social Security programs we 
have had in place.
  I think everybody knows that we need a prescription drug component 
because of the changes in health care and technology in the last 30 to 
40 years. We have to reform the Medicare program. We all understand 
that. It is absolutely going to break this country as we move into the 
retirement of the baby boomers if we do not do something. This 
Congress, both sides of the aisle, have laid aside $400 billion to

[[Page 23838]]

deal with this issue. I want to commend the leaders of this House, 
including the gentleman from Florida (Mr. Bilirakis) for his attempts 
to reform Medicare and bring those issues to the floor of the House and 
try to get a bill that we can get the President to sign.
  The thing that I want to encourage, though, is that we have got to 
keep the provisions of the current Medicare system that work. One of 
the key components of the current Medicare system is that it is a 
defined benefit. When you reach eligibility age, everybody qualifies 
for it. I do not care what the situation is, if you live rural America, 
urban America, you qualify because it is a defined benefit, and 
everybody receives that. We have some Medicare+Choice-type programs 
within Medicare now that try to set up HMOs or insurance incentive 
programs to deliver prescription drugs to folks, and they do not work. 
They do not work in rural areas. My constituents do not get them 
because the insurance companies cannot make enough money on them, so 
they go to the larger communities, the urban communities, the big 
cities, where they can make money.
  Mr. Speaker, I just would encourage us to keep those provisions that 
work, and one of them is the defined benefit, the fall-back provision 
which the gentleman from Hawaii (Mr. Case) is stressing here.
  The House bill fails to meet the needs of one-fourth of the Medicare 
beneficiaries of this country that live in rural areas. The Senate bill 
addresses this problem by establishing a guaranteed fall-back 
provision. Again, we need reform, but I would encourage the leadership 
and the conference committee to include the fall-back provision.
  Mr. BILIRAKIS. Mr. Speaker, I have no further requests for time, and 
I yield back the balance of my time.
  Mr. CASE. Mr. Speaker, I yield myself the balance of my time.
  Mr. Speaker, in closing, this has been a good but all-too-short 
discussion which has highlighted some of the principal differences 
between the majority and the minority on the issue of Medicare.
  I would like to respond to some of the points made by the gentleman 
from Florida (Mr. Bilirakis). I agree with my colleagues on the 
minority side that the gentleman from Florida (Mr. Bilirakis) does care 
about Medicare. In fact, he reminds me of a country doctor, nice, calm, 
reassuring presence. And if I was the majority party, I would want a 
nice, calm person to stand up and talk about Medicare, and I have no 
doubt about his sincerity.
  But I will say that in terms of the positions which have been taken 
by his party, the positions that have been advocated by this 
administration and the positions that are now pending in Congress, 
actions speak louder than words. Perception is not reality. We would 
not be standing here bringing this fourth motion, and we bring this 
fourth motion because we care about rural America. We care about health 
care in rural America, and we believe that it is at risk, serious risk 
right now.

                              {time}  1330

  We want people to know that so that in the 16 days remaining before 
the largest health care reform initiative in decades, if you want to 
call it reform, comes up to us for a final yes or no vote, the people 
of this country can weigh in. That is why we keep on bringing this 
motion and we will keep on bringing this motion.
  I want to highlight some of the things that were said here today. 
First of all, much has been said about affordability. Affordability is 
a matter of priorities. Affordability is a matter of where you put your 
money. You ask any rural hospital, rural clinic, any senior living in 
rural America where they think that the resources of this country 
should be devoted and they will tell you health care, and they will be 
right.
  So this is a box that the majority has put itself in. It has decided 
that there are these limits and that is all that we are going to give 
to this problem and then we are going to live within these limits.
  When we on this side say, those limits are not accurate, those limits 
are not good, they say, well, you are trying to get out of the box. You 
bet we are trying to get out of that box. That box does not work for 
America.
  Reforming Medicare is one thing. We all agree that Medicare needs 
reforming. We all agree that Medicare needs fixing, but reforming it 
should not be destroying it, and that is what is at risk here.
  There are good ingredients in both the House and the Senate versions. 
All we are asking in this motion is to take the best of both the House 
and the Senate provisions, homogenize them, do not duplicate them. We 
are not asking for things to be duplicated and run up; we are saying 
take the best. Guarantee a prescription drug coverage where the private 
sector is not going to provide it if, in fact, the effort to privatize 
Medicare is successful. Make sure that our rural areas have basic 
hospitals.
  We do not want a country where everybody has to take a train, plane, 
boat or other means of transportation to get to some big city that has 
some big hospital. That is not the answer to health care in this 
country. That is what we care about.
  I would close by saying again that this motion, this issue, is not 
just about Medicare. It is not just about health care. It is not just 
about seniors. It is about rural America. And when it is about rural 
America, it is about the America that we live in and that we want to 
preserve.
  I urge my colleagues to support this motion. It is a simple motion. 
Just take the best. Do what is necessary for rural America. Put rural 
America first.
  Mr. Speaker, I yield back the balance of my time.
  The SPEAKER pro tempore (Mr. Bass). All time has expired.
  Without objection, the previous question is ordered on the motion to 
instruct.
  There was no objection.
  The SPEAKER pro tempore. The question is on the motion to instruct 
offered by the gentleman from Hawaii (Mr. Case).
  The question was taken; and the Speaker pro tempore announced that 
the ayes appeared to have it.
  Mr. CASE. Mr. Speaker, on that I demand the yeas and nays.
  The yeas and nays were ordered.
  The SPEAKER pro tempore. Pursuant to clause 8 of rule XX and the 
Chair's prior announcement, further proceedings on this motion will be 
postponed.

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