To ensure that current retirees who have prescription drug coverage who will lose their prescription drug coverage as a result of the enactment of this legislation have the option of drug coverage under the Medicare fallback.

PRESCRIPTION DRUG AND MEDICARE IMPROVEMENT ACT OF 2003--Resumed

The PRESIDENT pro tempore. Under the previous order, the hour of 9:15
a.m. having arrived, the Senate will proceed to the consideration of S.
1, which the clerk will report.
The legislative clerk read as follows:

A bill (S. 1) to amend title XVIII of the Social Security
Act to make improvements in the Medicare Program, to provide
prescription drug coverage under the Medicare Program, and
for other purposes.

Pending:

[[Page S8606]]

Kerry amendment No. 958, to increase the availability of
discounted prescription drugs.
Lincoln modified amendment No. 934, to ensure coverage for
syringes for the administration of insulin, and necessary
medical supplies associated with the administration of
insulin.
Lincoln amendment No. 935, to clarify the intent of
Congress regarding an exception to the initial residency
period for geriatric residency or fellowship programs.
Lincoln amendment No. 959, to establish a demonstration
project for direct access to physical therapy services under
the Medicare Program.
Baucus (for Jeffords) amendment No. 964, to include
coverage for tobacco cessation products.
Baucus (for Jeffords) amendment No. 965, to establish a
Council for Technology and Innovation.
Nelson (FL) amendment No. 938, to provide for a study and
report on the propagation of concierge care.
Nelson (FL) amendment No. 936, to provide for an extension
of the demonstration for ESRD managed care.
Baucus (for Harkin) amendment No. 968, to restore
reimbursement for total body orthotic management for
nonambulatory, severely disabled nursing home residents.
Baucus (for Cantwell) amendment No. 942, to prohibit an
eligible entity offering a Medicare prescription drug plan, a
Medicare Advantage organization offering a Medicare Advantage
plan, and other health plans from contracting with a pharmacy
benefit manager (PBM) unless the PBM satisfies certain
requirements.
Rockefeller amendment No. 975, to make all Medicare
beneficiaries eligible for Medicare prescription drug
coverage.
Akaka amendment No. 980, to expand assistance with coverage
for legal immigrants under the Medicaid Program and SCHIP to
include citizens of the Freely Associated States.
Akaka amendment No. 979, to ensure that current
prescription drug benefits to Medicare-eligible enrollees in
the Federal Employees Health Benefits Program will not be
diminished.
Bingaman amendment No. 973, to amend title XVIII of the
Social Security Act to provide for the authorization of
reimbursement for all Medicare Part B services furnished by
certain Indian hospitals and clinics.
Baucus (for Lautenberg) amendment No. 986, to make
prescription drug coverage available beginning on July 1,
2004.
Murray amendment No. 990, to make improvements in the
Medicare Advantage benchmark determinations.
Harkin modified amendment No. 991, to establish a
demonstration project under the Medicaid Program to encourage
the provision of community-based services to individuals with
disabilities.
Dayton amendment No. 960, to require a streamlining of the
Medicare regulations.
Dayton amendment No. 977, to require that benefits be made
available under Part D on January 1, 2004.
Baucus (for Dorgan) amendment No. 993, to amend title XVIII
of the Social Security Act to provide for coverage of
cardiovascular screening tests under the Medicare Program.
Smith/Bingaman amendment No. 962, to provide reimbursement
for federally qualified health centers participating in
Medicare managed care.
Hutchison amendment No. 1004, to amend title XVIII of the
Social Security Act to freeze the indirect medical education
adjustment percentage under the Medicare Program at 6.5
percent.
Sessions amendment No. 1011, 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.
Conrad amendment No. 1019, to provide for coverage of self-
injected biologicals under Part B of the Medicare Program
until Medicare prescription drug plans are available.
Conrad amendment No. 1020, to permanently and fully
equalize the standardized payment rate beginning in fiscal
year 2004.
Conrad amendment No. 1021, to address Medicare payment
inequities.
Clinton amendment No. 999, 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.
Clinton amendment No. 953, to provide training to long-term
care ombudsman.
Clinton amendment No. 954, to require the Secretary of
Health and Human Services to develop literacy standards for
informational materials, particularly drug information.
Reid (for Boxer) amendment No. 1036, to eliminate the
coverage gap for individuals with cancer.
Reid (for Corzine) amendment No. 1037, to permit Medicare
beneficiaries to use federally qualified health centers to
fill their prescriptions.
Reid (for Jeffords) amendment No. 1038, to improve the
critical access hospital program.
Reid (for Inouye) amendment No. 1039, 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.
Thomas/Lincoln amendment No. 988, to provide for the
coverage of marriage and family therapist services and mental
health counselor services under Part B of the Medicare
Program.
Edwards/Harkin amendment No. 1052, to strengthen
protections for consumers against misleading direct-to-
consumer drug advertising.
Enzi/Lincoln amendment No. 1051, to ensure convenient
access to pharmacies and prohibit the tying of contracts.
Enzi amendment No. 1030, to encourage the availability of
Medicare Advantage benefits in medically underserved areas.
Hagel/Ensign amendment No. 1012, to provide Medicare
beneficiaries with an additional choice of Medicare
prescription drug plans under Part D that consists of a
drug discount card and protection against high out-of-
pocket drug costs.
Hagel amendment No. 1026, to provide Medicare beneficiaries
with a discount card that ensures access to privately
negotiated discounts on drugs and protection against high
out-of-pocket drug costs.
Baucus (for Feinstein) amendment No. 1060, to provide for
an income-related increase in the Part B premium for
individuals with income in excess of $75,000 and married
couples with income in excess of $150,000.
Baucus (for Akaka) amendment No. 1061, to provide for
treatment of Hawaii as a low-DSH State for purposes of
determining a Medicaid DSH allotment for the State for fiscal
years 2004 and 2005.
Bingaman/Domenici amendment No. 1065, to update, beginning
in 2009, the asset or resource test used for purposes of
determining the eligibility of low-income beneficiaries for
premium and cost-sharing subsidies.
Bingaman amendment No. 1066, to permit the establishment of
two new Medigap plans for Medicare beneficiaries enrolled for
prescription drug coverage under Part D.
Graham (SC) modified amendment No. 948, to provide for the
establishment of a National Bipartisan Commission on Medicare
Reform.
Stabenow/Levin amendment No. 1075, to permanently extend a
moratorium on the treatment of a certain facility as an
institution for mental diseases.
Stabenow/Levin amendment No. 1076, to provide for the
treatment of payments to certain comprehensive cancer
centers.
Stabenow/Levin amendment No. 1077, to provide for the
redistribution of unused resident positions.
Ensign/Lincoln amendment No. 1024, to amend title XVIII of
the Social Security Act to repeal the Medicare outpatient
rehabilitation therapy caps.
Smith/Feingold amendment No. 1073, to allow the Secretary
to include in the definition of ``specialized Medicare+Choice
plans for special needs beneficiaries'' plans that
disproportionately serve such special needs beneficiaries or
frail, elderly Medicare beneficiaries.
Grassley (for Craig) amendment No. 1087, to permit the
offering of consumer-driven health plans under Medicare
Advantage.
Baucus (for Mikulski) amendment No. 1088, to provide
equitable treatment for children's hospitals.
Baucus (for Mikulski) amendment No. 1089, to provide
equitable treatment for certain children's hospitals.
Baucus (for Mikulski) amendment No. 1090, to permit direct
payment under the Medicare Program for clinical social worker
services provided to residents of skilled nursing facilities.
Baucus (for Mikulski) amendment No. 1091, to extend certain
municipal health service demonstration projects.
Grassley/Baucus amendment No. 1092, to evaluate alternative
payment and delivery systems.
Kyl amendment No. 1093 (to amendment No. 1092) in the
nature of a substitute.

amendment no. 991

The PRESIDENT pro tempore. There will be 2 minutes equally divided on
the amendment.
Who seeks recognition?
The Senator from Iowa.
Mr. HARKIN. The amendment before us is the one where the money
follows the purse. It is $350 million a year for 5 years whereby States
can use this money to get out of institutions, out of nursing homes,
people with disabilities and get them into community, home-based
living.
Thirteen years ago, this Congress and the President signed a bill
called the Americans With Disabilities Act. One of the premises of that
was we no longer wanted to segregate people with disabilities in our
society. We wanted to integrate people with disabilities in education,
work, travel, jobs, everything. However, under the Medicaid system, it
is still segregation.
Seventy percent of our Medicaid money goes to institutional care,
only 30 percent to community-based care. What this amendment says is
that for the first year, the Federal Government will pick up the full
share of the State so the State can take people out of institutions and
put them into community-based living.

[[Page S8607]]

This was proposed by President Bush in his budget proposal for next
year. It is exactly what the President proposed.
The PRESIDENT pro tempore. The Senator's time has expired.
Mr. HARKIN. I ask unanimous consent for an additional 30 seconds.
The PRESIDENT pro tempore. Without objection, it is so ordered.
Mr. HARKIN. The offset we use is also an offset supported by the
administration. I have a letter Senators can look at--I put it in the
Record last night--from the Department of Justice, supporting the
offset we use to pay for this to ensure that we can get people in
community-based settings and out of institutions.
I yield the floor.
Mr. SMITH. Mr. President. I would like to urge my colleagues to
support the Harkin/Smith Money Follows the Person Amendment pending
before the Senate.
This amendment would authorize the 2004 Money Follows the Person
initiative in Medicaid, a part of the President's New Freedom
Initiative to integrate people with disabilities into the communities
where they live.
This amendment would create a 5-year program to help States move
people with disabilities out of institutional settings and into their
communities. For example, under this legislation, Oregon's effort to
help an individual move out of an institutional care facility and into
a community home would be 100-percent federally funded for 1 year.
After that first year, the Federal Government would pay its usual
rate. Under the provisions of this amendment, states like Oregon can
take advantage of $350 million dollars of Federal assistance for 5
years for a total of $1.75 billion.
This amendment is important to the disabled community for many
reasons. First, by supporting States' efforts to help Americans who
have been needlessly placed in institutional settings move into
community settings, this amendment will help States increase access to
home and community-based support for people with disabilities.
Second, by assisting the movement of people who are not best served
by an institution into a community care facility, this amendment gives
them the freedom to make choices. Too often, Americans with
disabilities are unable to take advantage of opportunities others take
for granted--to choose where they want to live, when to visit family
and friends, and to be active members of their communities.
Third, this amendment helps honor those veterans whose disabilities
resulted from noble and selfless service to this Nation. This morning,
I heard from the head of the Oregon Chapter of the Paralyzed Veterans
of America. He confirmed that this amendment would benefit countless
disabled veterans in Oregon alone. I would ask unanimous consent that
the letter that I received from the Paralyzed Veterans of America in
support of this amendment be printed in the Record.
I likewise ask unanimous consent that a letter I received from United
Cerebral Palsy and The Arc of the United States in support of this
amendment be printed in the Record.
Finally, this amendment would help States comply with the Americans
with Disabilities Act. As my colleagues in the Senate are well aware,
we are nearing the 13th anniversary of the Americans with Disabilities
Act and of the Olmstead Supreme Court decision.
That decision ruled that needless institutionalization of Americans
with disabilities constitutes discrimination under the Americans with
Disabilities Act. I urge my colleagues on both sides of the aisle to
support this important amendment and to support the freedom of choice
for Americans with disabilities.
There being no objection, the material was ordered to be printed in
the Record, as follows:

The Arc and UCP

Public Policy Collaboration,

Washington, DC, June 25, 2003.
Hon. Gordon Smith,
U.S. Senate, Russell Senate Office Building, Washington, DC.
Dear Senator Smith: On behalf of United Cerebral Palsy and
The Arc of the United States, we applaud your co-sponsorship
of S. AMDT. 991 to the Prescription Drug and Medicare
Improvement Act that would authorize the Money Follows the
Person initiative in Medicaid proposed by President Bush in
his FY 2004 budget as part of his New Freedom Initiative.
Senate Amendment 991 and the President's proposal would
create a five-year program to provide 100 percent federal
funding for one year on behalf of individuals who move from
an institutional setting to the community with home and
community services and supports. Money Follows the Person
would assist states in meeting their obligations under the
Olmstead Supreme Court decision to serve people with long
term support needs in the least restrictive setting. The Arc
and UCP believe that the Money Follows the Person initiative
will help states increase access to home and community-based
supports for people with disabilities and help states take
greater steps to permanently re-balance their long-term
supports delivery system. Changes in the institutional bias
in the Medicaid program are long overdue. The Money Follows
the Person initiative will assist states in making a
transition for people who want to leave institutional
settings.
UCP is a national organization that works with and for
people with cerebral palsy and related disabilities and their
families. It is committed to promoting and improving supports
and services for people with disabilities so that they can
live, work, go to school and otherwise be fully included in
their communities. UCP also supports a broad range of
research and education efforts on cerebral palsy and related
disabilities.
The Arc is the national organization of and for people with
mental retardation and related developmental disabilities and
their families. It is devoted to promoting and improving
supports and services for people with mental retardation and
their families. The Arc also fosters research and education
regarding the prevention of mental retardation in infants and
young children.
We urge all Senators to join you and Senator Harkin to
support inclusion of your amendment, S. AMDT. 991, in the
Medicare Prescription Drug bill.
Sincerely,
Lynne Cleveland,
Co-Chair.
Leon Triest,
Co-Chair.
____

Oregon Paralyzed Veterans of America
Salem, OR, June 25, 2003.
Hon. Gordon Smith,
U.S. Senate, Russell Senate Office Building, Washington, DC.
Dear Senator Smith: on behalf of the Oregon Chapter of the
Paralyzed Veterans of America and other disabled citizens of
the state of Oregon, we thank you for joining Senator Harkin
in introducing Amendment 991 (``Money Follows the Person''),
to the Prescription Drug and Medicare Improvement Act of 2003
(S. 1). This amendment would authorize an initiative
contained in the President's proposed FY 2004 budget, a
critical part of the administration's New Freedom Initiative
to integrate people with disabilities into the community.
Amendment 991 includes fiscal offsets of $1.75 billion over
five years to fund Medicaid demonstrations to assist states
in developing and implementing cost-effective choices between
institutional and community services. Financing Medicaid
services for individuals who transition from institutions to
the community is a major part of this effort.
When enacted, the Federal Government would fully reimburse
states (100% Federal match) the cost of one year of Medicaid
home and community-based services for people with
disabilities who leave institutions. After the initial year,
states would be responsible for matching payments at their
usual Medicaid matching rate. $350 million would be available
in FY 2004 and in each of the following four years to
implement these changes.
PVA believes that this amendment is essential to enable
Oregon and other states to comply with the Americans with
Disabilities Act and the Supreme Court's Olmstead decision.
People with disabilities must have a meaningful choice to
receive long term services and supports in their home or
community.
Again, thank you for introducing Amendment 991 during the
prescription drug and Medicare debate.
Sincerely,
Sam Leam
President.
Patrick E. Rogers
Government Relations Director.

(At the request of Mr. DASCHLE, the following statement was ordered
to be printed in the Record.)
<bullet> Mr. KERRY. Mr. President, I have been a long-standing
supporter of the Olmstead decision to end the institutional bias in
care for people with disabilities. Unfortunately, States have been slow
to implement this landmark decision. To better help States in this
effort, I am proud to say that I am an original cosponsor of Senator
Harkin's MiCASSA legislation, S. 971, the Medicaid Community-Based
Attendant Services and Supports Act of 2003, a bill to ensure that
``the money follows the people'' and that true choice is granted for
people with disabilities to decide whether they wish to live in their
own communities instead of being institutionalized. The bill also
provides major Federal resources to assist

[[Page S8608]]

States with the costs of paying for community-based attendant and
support services. Had I been present for the vote, I would have voted
against the motion to table the Harkin amendment and would have voted
in favor of its inclusion in the Medicare prescription drug
bill.<bullet>
The PRESIDENT pro tempore. The Senator from Pennsylvania is
recognized for 1\1/2\ minutes.
Mr. SANTORUM. Mr. President, I think what the Senator from Iowa has
done is a very worthy thing. The President has focused on this. Part of
the President's plan is what the Senator from Iowa has before us. The
problem with this is that this is a Medicaid proposal that is under the
jurisdiction of the Finance Committee. The Finance Committee would like
the opportunity, in the context of looking at the Medicaid Program, to
work this through the structure. A, to have this amendment come to the
floor, not having gone through the normal process, I think is
inappropriate; B, this is a Medicare bill, not a Medicaid bill.
I say to the Senator from Iowa, I know Senator Grassley has said to
me he is willing to work with his colleague from Iowa on moving this
forward. The legislation the Senator from Iowa has put forward has
merit and will probably receive bipartisan support, but it does not
belong on this bill.
So I ask my colleagues--by the way, it is $1.75 billion. I understand
there is an offset, but this is a Medicare bill and we should defeat
this amendment.
I ask unanimous consent that the Senator from Colorado be recognized
to lay down an amendment.
The PRESIDENT pro tempore. The Senator from Colorado.
Mr. ALLARD. Mr. President, I ask that the pending amendment be
temporarily laid aside.
The PRESIDENT pro tempore. Without objection, it is so ordered.

Amendment No. 1017

Mr. ALLARD. I send amendment No. 1017 to the desk.
The PRESIDENT pro tempore. The clerk will report.
The bill clerk read as follows:

The Senator from Colorado (Mr. Allard), for himself, Mr.
Feingold, Mr. Kohl, and Mr. Leahy, proposes an amendment
numbered 1017.

Mr. ALLARD. Mr. President, I ask unanimous consent that the reading
of the amendment be dispensed with.
The PRESIDENT pro tempore. Without objection, it is so ordered.
The amendment is as follows:

(Purpose: To provide for temporary suspension of OASIS requirement for
collection of data on non-medicare and non-medicaid patients)

At the end of title VI, insert the following:

SEC. ____. TEMPORARY SUSPENSION OF OASIS REQUIREMENT FOR
COLLECTION OF DATA ON NON-MEDICARE AND NON-
MEDICAID PATIENTS.

(a) In General.--During the period described in subsection
(b), the Secretary may not require, under section 4602(e) of
the Balanced Budget Act of 1997 or otherwise under OASIS, a
home health agency to gather or submit information that
relates to an individual who is not eligible for benefits
under either title XVIII or title XIX of the Social Security
Act (such information in this section referred to as ``non-
medicare/medicaid OASIS information'').
(b) Period of Suspension.--The period described in this
subsection--
(1) begins on the date of the enactment of this Act; and
(2) ends on the last day of the 2nd month beginning after
the date as of which the Secretary has published final
regulations regarding the collection and use by the Centers
for Medicare & Medicaid Services of non-medicare/medicaid
OASIS information following the submission of the report
required under subsection (c).
(c) Report.--
(1) Study.--The Secretary shall conduct a study on how non-
medicare/medicaid OASIS information is and can be used by
large home health agencies. Such study shall examine--
(A) whether there are unique benefits from the analysis of
such information that cannot be derived from other
information available to, or collected by, such agencies; and
(B) the value of collecting such information by small home
health agencies compared to the administrative burden related
to such collection.

In conducting the study the Secretary shall obtain
recommendations from quality assessment experts in the use of
such information and the necessity of small, as well as
large, home health agencies collecting such information.
(2) Report.--The Secretary shall submit to Congress a
report on the study conducted under paragraph (1) by not
later than 18 months after the date of the enactment of this
Act.
(d) Construction.--Nothing in this section shall be
construed as preventing home health agencies from collecting
non-medicare/medicaid OASIS information for their own use.

Mr. ALLARD. Mr. President, Medicare home health providers are in a
paperwork crisis. Current regulations of the Centers for Medicare and
Medicaid Services, CMS, requires that caregivers administer voluminous
paperwork to patients when they administer care.
These paperwork requirements are too excessive for both patients and
caregivers. Caregivers must administer numerous forms including data
collection, patient privacy information, a plan of care, advance
directives, a visit schedule, a comprehensive assessment, and more.
One of these requirements, called OASIS, or the Outcome and
Assessment Information Set, is 94 questions long and takes a few hours
to fill out. Before a nurse or physical therapist administers care, she
and the patient must sit down and answer questions and fill out this
paperwork. Colorado providers have told me they spend more time filling
out paperwork than they do caring for patients.
As a result of this excessive data collection and dissemination, home
health caregivers are leaving the home health industry. Two weeks ago a
home health administrator in Colorado Springs came to share with me the
situation in her agency. On her plane trip here, three of her newly-
home health physical therapists called to tell her they were leaving
the agency because of excessive paperwork requirements. They said they
were going to leave the home health industry and return to the hospital
industry.
We cannot afford this. Home health care is a vital player in health
care for seniors and all individuals. If this paperwork crisis
continues, home health care will continue to lose caregivers and bloat
its current caregiver shortage.
Currently CMS requires that home health caregivers administer OASIS
to Medicare patients, to Medicaid patients, and to patients who have
private health insurance. The problem with this regulation, however, is
that the data collected for private health insurance patients is not
even used. This data literally sits in the offices of home health
agencies with no current purpose.
The fact is CMS requires that home health agencies encode the OASIS
data for Medicare and Medicaid patients only and to transmit it to
their States. Then the information is transmitted into the Federal
OASIS Repository.
For all private insurance patients, the home health agencies do not
have to encode or transmit the data. So these nurses, physical
therapists, occupational therapists, and nurse practitioners are
required to collect this data for no reason.
It is my understanding CMS intends to require the transmission of
data for private health patients at some point. But it has been 4 years
and they have not done it yet.
In the meantime there are still many problems with OASIS. Until CMS
issues the improved regulation, caregivers should be allowed to stop
collecting unused data that ends up in the filing cabinets of home
health agencies.
The amendment I am offering with Senators Feingold, Collins, Kohl,
and Leahy would suspend the CMS requirement of collecting OASIS data
for private insurance patients, non-Medicare and non-Medicaid patients,
until an outcome by CMS's two OASIS working groups is reached.
Specifically, OASIS would be suspended until the 2 months immediately
after HHS issues its regulations about OASIS. The regulations will be
based on the information collected from and the recommendations of
CMS's two working groups that are determining over the course of 3
years ways to improve OASIS data collection and quality assurance.
Our amendment is supported by caregivers in home health who
administer OASIS, including physical therapists, nurses, nurse
practitioners, occupational therapists, and speech therapists.
Congresswoman Nancy Johnson, chairwoman of the Oversight Subcommittee
of the House Committee on Ways and Means, also strongly supports this
amendment. In addition, our language was included in Medicare reform
bills in the Senate in the last 2 consecutive years. Further, I commend

[[Page S8609]]

Senator Feingold for introducing legislation last Congress to reform
OASIS and I commend Senator Murkowski and Senator Kerry for their work
on the MARCIA regulatory reform legislation, which included an OASIS
suspension.
My colleagues and I believe OASIS data collection is helpful and
should be applied. Even providers and patients, who must comply with
the law, believe this. Yet the requirements to collect data should be
achievable and inexcessive.
I am pleased to offer this amendment and urge my colleagues to
support this effort for caregivers and patients.
Mr. ALLARD. Mr. President, I ask unanimous consent that the two
additional cosponsors be added to the amendment, Senator Kohl and
Senator Leahy.
The PRESIDENT pro tempore. Without objection, it is so ordered.
The Senator from Pennsylvania.

Vote on Amendment No. 991

Mr. SANTORUM. Mr. President, I move to table the Harkin amendment and
ask for the yeas and nays.
The PRESIDENT pro tempore. Is there a sufficient second?
There is a sufficient second.
The question is on agreeing to the motion.
The clerk will call the roll.
The legislative clerk called the roll.
Mr. REID, I announce that 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 each vote ``nay''.
The PRESIDING OFFICER (Ms. Murkowski). Are there any other Senators
in the Chamber desiring to vote?
The result was announced--yeas 50, nays 48, as follows:

[Rollcall Vote No. 247 Leg.]

YEAS--50

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

NAYS--48

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

NOT VOTING--2

Kerry

Lieberman
The motion was agreed to.
Mr. SANTORUM. Madam President, I move to reconsider the vote.
Mr. GRASSLEY. I move to lay that motion on the table.
The motion to lay on the table was agreed to.

Amendment No. 1052

Mr. BAUCUS. Madam President, will the Chair state the regular order?
The PRESIDING OFFICER. There will be 2 minutes evenly divided before
the vote on the next amendment.
Mr. BAUCUS. I thank the Chair.
The PRESIDING OFFICER. Who yields time?
Mr. BAUCUS. The Senator from North Carolina.
Mr. EDWARDS. Madam President, yesterday we voted on the Edwards-
Harkin amendment which had two provisions. The first provision dealt
with the FDA approval process for ``me too'' drugs. There were concerns
expressed by the Members of the Senate about that provision. Even
though I disagreed with those concerns, I don't think it would have
slowed down the FDA approval process. Because of those concerns, we
have removed those provisions from this amendment.
The amendment we are about to vote on deals only with advertising. It
in no way bans advertising. All this amendment does is require that the
advertising engaged in by drug companies and pharmaceutical companies
be evenhanded. The only thing this amendment requires is that the
information be accurate and evenhanded. In other words, you can't have
kids dancing in a field as the image on television and in small print
at the bottom saying the drug can cause strokes or have other side
effects.
We want to make sure the American people in these advertisements get
accurate information and which is not misleading. This amendment does
exactly that. We have eliminated the provision so many were concerned
about yesterday.
I urge my colleagues to support this amendment. Let us make sure the
American people get true and accurate information in the advertising
they are seeing on drugs on television.
The PRESIDING OFFICER. Who yields time?
Mr. ENZI. Madam President, I rise in opposition to this amendment
submitted by my colleague from North Carolina, Senator Edwards.
Yesterday, the Senate defeated an amendment offered by my colleague
that would have restricted direct-to-consumer advertising of
prescription medicines.
This new amendment continues this effort by offering similar
advertising provisions to those already defeated.
I have a list of 14 organizations which I ask unanimous consent be
printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:

June 26, 2003
To: Members of the United States Senate:
The undersigned organizations are writing in opposition to
the amendment offered by Senator Edwards regarding changes to
Direct to Consumer advertising of pharmaceutical products.
This amendment would impose serious restrictions on
information which is of considerable value to the millions of
patients we represent.
Our organizations are advocates for millions of Americans
who suffer from a broad range of illnesses. Early detection
and treatment of these illnesses is an important factor in
helping those individuals lead longer and healthier lives.
Communication, public education and awareness are key
components in the outcomes American patients can hope to
achieve. Limiting access to credible information is bad
healthcare policy and we urge you to oppose the Edwards
amendment and any other efforts to deny Americans
information.
Respectfully,
The National Alliance for the Mentally Ill.
The National Mental Health Association.
The American Association of Diabetes Educators.
The American Foundation for Urologic Disease.
The American Lung Foundation.
The National Health Council.
The Interamerican College of Physicians and Surgeons.
The Kidney Cancer Association.
The Society for Womens Health Research.
The National Headache Foundation.
The National Coalition for Women with Heart Disease.
The National Osteoporosis Foundation.
The American Liver Foundation.
The National Stroke Association.

Mr. ENZI. Madam President, these are organizations that are advocates
for millions of Americans who suffer from a broad range of illnesses.
Early detection and treatment of these illnesses is more communication.
Public education and awareness are key components. Advertising is the
key component of it.
This amendment would require the Secretary of Health and Human
Services to promulgate new rules that would require advertisements to
provide information about a drug's effectiveness in comparison to other
drugs for ``substantially the same condition.'' In other words, you
have to advertise with your competitors as well. The unfortunate effect
would be to make the advertisements even more complex, not less, for
consumers. It would force ads to drop other information that would be
beneficial to consumers.
I ask that you reject the amendment.
The PRESIDING OFFICER. The question is on agreeing to the amendment.
Mr. SANTORUM. Madam President, I ask for the yeas and nays.
The PRESIDING OFFICER. Is there a sufficient second?
There is a sufficient second.
The clerk will call the roll.
The bill clerk called the roll.
Mr. REID. I announce that the Senator from Massachusetts (Mr. Kerry)
and the Senator from Connecticut (Mr. Lieberman) are necessarily
absent.

[[Page S8610]]

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 39, nays 59, as follows:

[Rollcall Vote No. 248 Leg.]

YEAS--39

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

NAYS--59

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

NOT VOTING--2

Kerry
Lieberman

The amendment (No. 1052) was rejected.
Mr. GRASSLEY. Madam President, 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. 1092, As Modified

Mr. GRASSLEY. Madam President, I send to the desk a modification of
the Grassley benchmark amendment filed last night. I ask that I have a
right to modify my amendment.
The PRESIDING OFFICER. Without objection, the amendment is modified.
It is not the pending amendment at this time.
The modification is as follows:
At the end of subtitle C of title II, add the following:

Subtitle D--Evaluation of Alternative Payment and Delivery Systems

SEC. 231. ESTABLISHMENT OF ALTERNATIVE PAYMENT SYSTEM FOR
PREFERRED PROVIDER ORGANIZATIONS IN HIGHLY
COMPETITIVE REGIONS.

(a) Establishment of Alternative Payment System for
Preferred Provider Organizations in Highly Competitive
Regions.--Section 1858 (as added by section 211(b)) is
amended by adding at the end the following new subsection:
``(i) Alternative Payment Methodology for Highly
Competitive Regions.--
``(1) Annual determination and designation.--
``(A) In 2008.--In 2008, prior to the date on which the
Secretary expects to publish the risk adjusters under section
1860D-11, the Secretary shall designate a limited number (but
in no case fewer than 1) of preferred provider regions (other
than the region described in subsection (a)(2)(C)(ii)) as
highly competitive regions.
``(B) Subsequent years.--For each year (beginning with
2009) the Secretary may designate a limited number of
preferred provider regions (other than the region described
in subsection (a)(2)(C)(ii)) as highly competitive regions in
addition to any region designated as a highly competitive
region under subparagraph (A).
``(C) Considerations.--In determining which preferred
provider regions to designate as highly competitive regions
under subparagraph (A) or (B), the Secretary shall consider
the following:
``(i) Whether the application of this subsection to the
preferred provider region would enhance the participation of
preferred provider organization plans in that region.
``(ii) Whether the Secretary anticipates that there is
likely to be at least 3 bids submitted under subsection
(d)(1) with respect to the preferred provider region if the
Secretary designates such region as a highly competitive
region under subparagraph (A) or (B).
``(iii) Whether the Secretary expects that
MedicareAdvantage eligible individuals will elect preferred
provider organization plans in the preferred provider region
if the region is designated as a highly competitive region
under subparagraph (A) or (B).
``(iv) Whether the designation of the preferred provider
region as a highly competitive region will permit compliance
with the limitation described in paragraph (5).

In considering the matters described in clauses (i) through
(iv), the Secretary shall give special consideration to
preferred provider regions where no bids were submitted under
subsection (d)(1) for the previous year.
``(2) Effect of designation.--If a preferred provider
region is designated as a highly competitive region under
subparagraph (A) or (B) of paragraph (1)--
``(A) the provisions of this subsection shall apply to such
region and shall supersede the provisions of this part
relating to benchmarks for preferred provider regions; and
``(B) such region shall continue to be a highly competitive
region until such designation is rescinded pursuant to
paragraph (5)(B)(ii).
``(3) Submission of bids.--
``(A) In general.--Notwithstanding subsection (d)(1), for
purposes of applying section 1854(a)(2)(A)(i), the plan bid
for a highly competitive region shall consist of a dollar
amount that represents the total amount that the plan is
willing to accept (not taking into account the application of
the comprehensive risk adjustment methodology under section
1853(a)(3)) for providing coverage of only the benefits
described in section 1852(a)(1)(A) to an individual enrolled
in the plan that resides in the service area of the plan for
a month.
``(B) Construction.--Nothing in subparagraph (A) shall be
construed as permitting a preferred provider organization
plan not to provide coverage for the benefits described in
section 1852(a)(1)(C).
``(4) Payments to preferred provider organizations in
highly competitive areas.--With respect to highly competitive
regions, the following rules shall apply:
``(A) In general.--Notwithstanding subsection (c), of the
plans described in subsection (d)(1)(E), the Secretary shall
substitute the second lowest bid for the benchmark applicable
under subsection (c)(4).
``(B) If there are fewer than three bids.--Notwithstanding
subsection (c), if there are fewer than 3 bids in a highly
competitive region for a year, the Secretary shall substitute
the lowest bid for the benchmark applicable under subsection
(c)(4).
``(5) Funding limitation.--
``(A) In general.--
``(i) In general.--The total amount expended as a result of
the application of this subsection during the period or year,
as applicable, may not exceed the applicable amount (as
defined in clause (ii)).
``(ii) Applicable amount defined.--In this paragraph, the
term `applicable amount' means--

``(I) for the period beginning on January 1, 2009, and
ending on September 30, 2013, the total amount that would
have been expended under this title during the period if this
subsection had not been enacted plus $6,000,000,000; and
``(II) for fiscal year 2014 and any subsequent fiscal year,
the total amount that would have been expended under this
title during the year if this subsection had not been
enacted.

``(B) Application of limitation.--If the Secretary
determines that the application of this subsection will cause
expenditures to exceed the applicable amount, the Secretary
shall--
``(i) take appropriate steps to stay within the applicable
amount, including through providing limitations on
enrollment; or
``(ii) rescind the designation under subparagraph (A) or
(B) of paragraph (1) of 1 or more preferred provider regions
as highly competitive regions.
``(C) Transition.--If the Secretary rescinds a designation
under subparagraph (A) or (B) of paragraph (1) pursuant to
subparagraph (B)(ii) with respect to a preferred provider
region, the Secretary shall provide for an appropriate
transition from the payment system applicable under this
subsection to the payment system described in the other
provisions of this section in that region. Any amount
expended by reason of the preceding sentence shall be
considered to be part of the total amount expended as a
result of the application of this subsection for purposes of
applying the limitation under subparagraph (A).
``(D) Application.--Notwithstanding paragraph (1)(B), on or
after January 1 of the year in which the fiscal year
described in subparagraph (A)(ii)(II) begins, the Secretary
may designate appropriate regions under such paragraph.
``(6) Limitation of judicial review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise, of designations made under subparagraph
(A) or (B) of paragraph (1).
``(7) Secretary reports.--Not later than April 1 of each
year (beginning in 2010), the Secretary shall submit a report
to Congress and the Comptroller General of the United States
that includes--
``(A) a detailed description of--
``(i) the total amount expended as a result of the
application of this subsection in the previous year compared
to the total amount that would have been expended under this
title in the year if this subsection had not been enacted;
``(ii) the projections of the total amount that will be
expended as a result of the application of this subsection in
the year in which the report is submitted compared to the
total amount that would have been expended under this title
in the year if this subsection had not been enacted;
``(iii) amounts remaining within the funding limitation
specified in paragraph (5); and
``(iv) the steps that the Secretary will take under clauses
(i) and (ii) of paragraph (5)(B) to ensure that the
application of this subsection will not cause expenditures to
exceed

[[Page S8611]]

the applicable amount described in paragraph (5)(A); and
``(B) a certification from the Chief Actuary of the Centers
for Medicare & Medicaid Services that the descriptions under
clauses (i), (ii), (iii), and (iv) of subparagraph (A) are
reasonable, accurate, and based on generally accepted
actuarial principles and methodologies.
``(8) Biennial gao reports.--Not later than January 1,
2011, and biennially thereafter, the Comptroller General of
the United States shall submit to the Secretary and Congress
a report on the designation of highly competitive regions
under this subsection and the application of the payment
system under this subsection within such regions. Each report
shall include--
``(A) an evaluation of--
``(i) the quality of care provided to beneficiaries
enrolled in a MedicareAdvantage preferred provider plan in a
highly competitive region;
``(ii) the satisfaction of beneficiaries with benefits
under such a plan;
``(iii) the costs to the medicare program for payments made
to such plans; and
``(iv) any improvements in the delivery of health care
services under such a plan;
``(B) a comparative analysis of the benchmark system
applicable under the other provisions of this section and the
payment system applicable in highly competitive regions under
this subsection; and
``(C) recommendations for such legislation or
administrative action as the Comptroller General determines
to be appropriate.
``(9) Report on budget neutrality for fiscal years after
2013.--
``(A) In general.--If the Secretary intends to designate 1
or more regions as highly competitive regions with respect to
calendar 2014 or any subsequent calendar year, the Secretary
shall submit a report to Congress indicating such intent no
later than April 1 of the calendar year prior to the calendar
year in which the applicable designation year begins.
``(B) Requirements.--A report submitted under subparagraph
(A) shall--
``(i) specify the steps (if any) that the Secretary will
take pursuant to paragraph (5)(B) to ensure that the total
amount expended as a result of the application of this
subsection during the year will not exceed the applicable
amount for the year (as defined in paragraph (5)(A)(ii)(II));
and
``(ii) contain a certification from the Chief Actuary of
the Centers for Medicare and Medicaid Services that such
steps will meet the requirements of paragraph (5)(A) based on
an analysis using generally accepted actuarial principles and
methodologies.''.
(b) Conforming Amendment.--Section 1858(c)(3)(A)(i) (as
added by section 211(b)) is amended to read as follows:
``(i) Whether each preferred provider region has been
designated as a highly competitive region under subparagraph
(A) or (B) of subsection (i)(1) and the benchmark amount for
any preferred provider region (as calculated under paragraph
(2)(A)) for the year that has not been designated as a highly
competitive region.''.

SEC. 232. FEE-FOR-SERVICE MODERNIZATION PROJECTS.

(a) Establishment.--
(1) Review and report on results of existing
demonstrations.--
(A) Review.--The Secretary shall conduct an empirical
review of the results of the demonstrations under sections
442, 443, and 444.
(B) Report.--Not later than January 1, 2008, the Secretary
shall submit a report to Congress on the empirical review
conducted under subparagraph (A) which shall include
estimates of the total costs of the demonstrations, including
expenditures as a result of the provision of services
provided to beneficiaries under the demonstrations that are
incidental to the services provided under the demonstrations,
and all other expenditures under title XVIII of the Social
Security Act. The report shall also include a certification
from the Chief Actuary of the Centers for Medicare & Medicaid
Services that such estimates are reasonable, accurate, and
based on generally accepted actuarial principles and
methodologies.
(2) Projects.--Beginning in 2009, the Secretary, based on
the empirical review conducted under paragraph (1), shall
establish projects under which medicare beneficiaries
receiving benefits under the medicare fee-for-service program
under parts A and B of title XVIII of the Social Security Act
are provided with coverage of enhanced benefits or services
under such program. The purpose of such projects is to
evaluate whether the provision of such enhanced benefits or
services to such beneficiaries--
(A) improves the quality of care provided to such
beneficiaries under the medicare program;
(B) improves the health care delivery system under the
medicare program; and
(C) results in reduced expenditures under the medicare
program.
(2) Enhanced benefits or services.--For purposes of this
section, enhanced benefits or services shall include--
(A) preventive services not otherwise covered under title
XVIII of the Social Security Act;
(B) chronic care coordination services;
(C) disease management services; or
(D) other benefits or services that the Secretary
determines will improve preventive health care for medicare
beneficiaries, result in improved chronic disease management,
and management of complex, life-threatening, or high-cost
conditions and are consistent with the goals described in
subparagraphs (A), (B), and (C) of paragraph (1).
(b) Project Sites and Duration.--
(1) In general.--Subject to subsection (e)(2), the projects
under this section shall be conducted--
(A) in a region or regions that are comparable (as
determined by the Secretary) to the region or regions that
are designated as a highly competitive region under
subparagraph (A) or (B) of section 1858(i)(1) of the Social
Security Act, as added by section 231 of this Act; and
(B) during the years that a region or regions are
designated as such a highly competitive region.
(2) Rule of construction.--For purposes of paragraph (1), a
comparable region does not necessarily mean the identical
region.
(c) Waiver Authority.--The Secretary shall waive compliance
with the requirements of title XVIII of the Social Security
Act (42 U.S.C. 1395 et seq.) only to the extent and for such
period as the Secretary determines is necessary to provide
for enhanced benefits or services consistent with the
projects under this section.
(d) Biennial GAO Reports.--Not later than January 1, 2011,
and biennially thereafter for as long as the projects under
this section are being conducted, the Comptroller General of
the United States shall submit to the Secretary and Congress
a report that evaluates the projects. Each report shall
include--
(1) an evaluation of--
(A) the quality of care provided to beneficiaries receiving
benefits or services under the projects;
(B) the satisfaction of beneficiaries receiving benefits or
services under the projects;
(C) the costs to the medicare program under the projects;
and
(D) any improvements in the delivery of health care
services under the projects; and
(2) recommendations for such legislation or administrative
action as the Comptroller General determines to be
appropriate.
(e) Funding.--
(1) In general.--Payments for the costs of carrying out the
projects under this section shall be made from the Federal
Hospital Insurance Trust Fund under section 1817 of the
Social Security Act (42 U.S.C. 1395i) and the Federal
Supplementary Insurance Trust Fund under section 1841 of such
Act (42 U.S.C. 1395t), as determined appropriate by the
Secretary.
(2) Limitation.--The total amount expended under the
medicare fee-for-service program under parts A and B of title
XVIII of the Social Security Act (including all amounts
expended as a result of the projects under this section)
during the period or year, as applicable, may not exceed--
(A) for the period beginning on January 1, 2009, and ending
on September 30, 2013, an amount equal to the total amount
that would have been expended under the medicare fee-for-
service program under parts A and B of title XVIII of the
Social Security Act during the period if the projects had not
been conducted plus $6,000,000,000; and
(B) for fiscal year 2014 and any subsequent fiscal year, an
amount equal to the total amount that would have been
expended under the medicare fee-for-service program under
parts A and B of such title during the year if the projects
had not been conducted.
(3) Monitoring and reports.--
(A) Ongoing monitoring by the secretary to ensure funding
limitation is not violated.--The Secretary shall continually
monitor expenditures made under title XVIII of the Social
Security Act by reason of the projects under this section to
ensure that the limitations described in subparagraphs (A)
and (B) of paragraph (2) are not violated.
(B) Reports.--Not later than April 1 of each year
(beginning in 2010), the Secretary shall submit a report to
Congress and the Comptroller General of the United States
that includes--
(i) a detailed description of--

(I) the total amount expended under the medicare fee-for-
service program under parts A and B of title XVIII of the
Social Security Act (including all amounts expended as a
result of the projects under this section) during the
previous year compared to the total amount that would have
been expended under the original medicare fee-for-service
program in the year if the projects had not been conducted;
(II) the projections of the total amount expended under the
medicare fee-for-service program under parts A and B of title
XVIII of the Social Security Act (including all amounts
expended as a result of the projects under this section)
during the year in which the report is submitted compared to
the total amount that would have been expended under the
original medicare fee-for-service program in the year if the
projects had not been conducted;
(III) amounts remaining within the funding limitation
specified in paragraph (2); and
(IV) how the Secretary will change the scope, site, and
duration of the projects in subsequent years in order to
ensure that the limitations described in subparagraphs (A)
and (B) of paragraph (2) are not violated; and

(ii) a certification from the Chief Actuary of the Centers
for Medicare & Medicaid Services that the descriptions under
subclauses (I), (II), (III), and (IV) of clause (i) are
reasonable, accurate, and based on generally accepted
actuarial principles and methodologies.
(C) Report on budget neutrality for fiscal years after
2013.--

[[Page S8612]]

(i) In general.--If the Secretary intends to continue the
projects under this section for fiscal year 2014 or any
subsequent fiscal year, the Secretary shall submit a report
to Congress indicating such intent no later than April 1 of
the year prior to the year in which the fiscal year begins.
(ii) Requirements.--A report submitted under clause (i)
shall--

(I) specify the steps (if any) that the Secretary will take
pursuant to paragraph (4) to ensure that the limitations
described in paragraph (2)(B) will not be violated for the
year; and
(II) contain a certification from the Chief Actuary of the
Centers for Medicare and Medicaid Services that such steps
will meet the requirements of paragraph (2) based on an
analysis using generally accepted actuarial principles and
methodologies.

(4) Application of Limitation.--If the Secretary determines
that the projects under this section will cause the
limitations described in subparagraphs (A) and (B) of
paragraph (2) to be violated, the Secretary shall take
appropriate steps to reduce spending under the projects,
including through reducing the scope, site, and duration of
the projects.
(5) Authority.--Beginning in 2014, the Secretary shall make
necessary spending adjustments (including pro rata reductions
in payments to health care providers under the medicare
program) to recoup amounts so that the limitations described
in subparagraphs (A) and (B) of paragraph (2) are not
violated.

Mr. BAUCUS. Mr. President, on behalf of Senator Conrad, I ask
unanimous consent that a letter from the Congressional Budget Office be
printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:

U.S. Congress,

Congressional Budget Office,

Washington, DC, June 26, 2003.
Hon. Kent Conrad,
Ranking Member, Committee on the Budget, U.S. Senate,
Washington, DC.
Dear Senator: The Congressional Budget Office has reviewed
a proposed amendment (GOE03.597) by Senators Grassley and
Baucus to S. 1, a bill to amend title XVIII of the Social
Security Act to make improvements in the Medicare program, to
provide prescription drug coverage under the Medicare
program, and for other purposes. That amendment would add
subtitle D to title II, establishing an alternative payment
system for preferred provider organizations in highly
competitive regions and fee-for-service modernization
projects.
CBO estimates that the amendment would add $12 billion in
outlays to the cost of the bill over the 2009-2013 period--$6
billion for payments to preferred provider organizations and
$6 billion for the fee-for-service modernization projects.
The amendment would allow the programs to continue after
2013, but under the rules the amendment specifies for the
Secretary of Health and Human Services, CBO estimates that
those programs would incur no additional net costs after that
time.
If you wish further details on this estimate, we will be
pleased to provide them.
Sincerely,
Robert A. Sunshine
(For Douglas Holtz-Eakin, Director.)
Mr. GRASSLEY. Madam President, I suggest the absence of a quorum.
The PRESIDING OFFICER. The clerk will call the roll.
The legislative clerk proceeded to call the roll.
Mr. BAUCUS. Madam President, I ask unanimous consent that the order
for the quorum call be rescinded.
The PRESIDING OFFICER. Without objection, it is so ordered.

Amendment No. 1054

Mr. BAUCUS. Madam President, I ask unanimous consent that all pending
amendments be set aside so that I might call up amendment No. 1054 on
behalf of Senator Feingold, with respect to Medicare beneficiaries.
The PRESIDING OFFICER. Without objection, it is so ordered.
The clerk will report.
The legislative clerk read as follows:

The Senator from Montana [Mr. Baucus], for Mr. Feingold,
proposes an amendment numbered 1054.

Mr. BAUCUS. 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 establish an Office of the Medicare Beneficiary Advocate)

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

SEC. 133. OFFICE OF THE MEDICARE BENEFICIARY ADVOCATE.

(a) Establishment.--Not later than 1 year after the date of
enactment of this Act, the Secretary shall establish within
the Department of Health and Human Services, an Office of the
Medicare Beneficiary Advocate (in this section referred to as
the ``Office'').
(b) Duties.--The Office shall carry out the following
activities:
(1) Establishing a toll-free telephone number for medicare
beneficiaries to use to obtain information on the medicare
program, and particularly with respect to the benefits
provided under part D of title XVIII of the Social Security
Act and the Medicare Prescription Drug plans and
MedicareAdvantage plans offering such benefits. The Office
shall ensure that the toll-free telephone number accommodates
beneficiaries with disabilities and limited-English
proficiency.
(2) Establishing an Internet website with easily accessible
information regarding Medicare Prescription Drug plans and
MedicareAdvantage plans and the benefits offered under such
plans. The website shall--
(A) be updated regularly to reflect changes in services and
benefits, including with respect to the plans offered in a
region and the associated monthly premiums, benefits offered,
formularies, and contact information for such plans, and to
ensure that there are no broken links or errors;
(B) have printer-friendly, downloadable fact sheets on the
medicare coverage options and benefits;
(C) be easy to navigate, with large print and easily
recognizable links; and
(D) provide links to the websites of the eligible entities
participating in part D of title XVIII.
(3) Providing regional publications to medicare
beneficiaries that include regional contacts for information,
and that inform the beneficiaries of the prescription drug
benefit options under title XVIII of the Social Security Act,
including with respect to--
(A) monthly premiums;
(B) formularies; and
(C) the scope of the benefits offered.
(4) Conducting outreach to medicare beneficiaries to inform
the beneficiaries of the medicare coverage options and
benefits under parts A, B, C, and D of title XVIII of the
Social Security Act.
(5) Working with local benefits administrators, ombudsmen,
local benefits specialists, and advocacy groups to ensure
that medicare beneficiaries are aware of the medicare
coverage options and benefits under parts A, B, C, and D of
title XVIII of the Social Security Act.
(c) Funding.--
(1) Establishment.--Of the amounts authorized to be
appropriated under the Secretary's discretion for
administrative expenditures, $2,000,000 may be used to
establish the Office in accordance with this section.
(2) Operation.--With respect to each fiscal year occurring
after the fiscal year in which the Office is established
under this section, the Secretary may use, out of amounts
authorized to be appropriated under the Secretary's
discretion for administrative expenditures for such fiscal
year, such sums as may be necessary to operate the Office in
that fiscal year.

Mr. BAUCUS. Madam President, 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. GRASSLEY. Madam President, I ask unanimous consent that the order
to the quorum call be rescinded.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. GRASSLEY. Madam President, I ask that the pending amendments be
set aside and that the Senator from Washington be recognized for an
amendment.
The PRESIDING OFFICER. Without objection, it is so ordered.
The Senator from Washington.

Amendment No. 942

Ms. CANTWELL. Madam President, I ask unanimous consent that amendment
No. 942 be the pending business.
The PRESIDING OFFICER. Without objection, it is so ordered. The
amendment is the pending business.

Amendment No. 942, As Modified

Ms. CANTWELL. Madam President, I ask unanimous consent that the
amendment be modified with the changes I send to the desk.
The PRESIDING OFFICER. The Senator has a right to modify her
amendment. The amendment is so modified.
The amendment (No. 942), as modified, is as follows:

On page 204, after line 22, insert the following:

SEC. 133. PHARMACY BENEFIT MANAGERS TRANSPARENCY
REQUIREMENTS.

(a) Medicare.--Subpart 3 of part D of title XVIII of the
Social Security Act (as added by section 101) is amended by
adding at the end the following new section:

``pharmacy benefit managers transparency requirements

``Sec. 1860D-27. (a) Prohibition.--
``(1) In general.--Notwithstanding any other provision of
law, an eligible entity offering a Medicare Prescription Drug
plan under this part or a MedicareAdvantage organization
offering a MedicareAdvantage plan under part C shall not
enter into a contract with any pharmacy benefit manager (in
this section referred to as a `PBM') that is owned by a
pharmaceutical manufacturing company.

[[Page S8613]]

``(2) Provision of information.--A PBM that manages
prescription drug coverage under this part or part C shall
provide the following information, on an annual basis, to the
Assistant Attorney General for Antitrust of the Department of
Justice and the Inspector General of the Health and Human
Services Department:
``(A) The aggregate amount of any and all rebates,
discounts, administrative fees, promotional allowances, and
other payments received or recovered from each pharmaceutical
manufacturer.
``(B) The amount of payments received or recovered from
each pharmaceutical manufacturer for each of the top 50 drugs
as measured by volume (as determined by the Secretary).
``(C) The percentage differential between the price the PBM
pays pharmacies for a drug described in subparagraph (B) and
the price the PBM charges a Medicare Prescription Drug Plan
or a MedicareAdvantage organization for such drug.
``(b) Failure to Disclose.--
``(1) Civil penalty.--Any PBM that fails to comply with
subsection (a) shall be liable for a civil penalty as
determined appropriate through regulations promulgated by the
Attorney General. Such penalty may be recovered in a civil
action brought by the United States.
``(2) Compliance and equitable relief.--If any PBM fails to
comply with subsection (a), the United States district court
may order compliance, and may grant such other equitable
relief as the court in its discretion determines necessary or
appropriate, upon application of the Assistant Attorney
General.
``(c) Disclosure Exemption.--Any information filed with the
Assistant Attorney General under subsection (a)(2) shall be
exempt from disclosure under section 552 of title 5, and no
such information may be made public, except as may be
relevant to any administrative or judicial action or
proceeding. Nothing in this section is intended to prevent
disclosure to either body of Congress or to any duly
authorized committee or subcommittee of the Congress.''.

Ms. CANTWELL. Madam President, I rise today to offer the Cantwell-
Lincoln Prescription drug transparency amendment to S. 1, the medicare
prescription drug bill. I thank my cosponsor, Senator Lincoln, for
working with me on this important amendment that will help protect
consumers against high prescription drug prices.
This amendment does three things.
First, it requires any PBM contracting with Medicare to disclose to
the Department of Justice how much of the rebates and discounts
negotiated for Medicare are being passed back.
Second, the disclosure of these financial arrangements to the
Department of Justice provides an incentive for PBMs to return as much
of that savings as possible to Medicare, which will in turn, help
reduce the high cost of prescription drugs.
Finally, it prohibits a pharmaceutical company from owning a pharmacy
benefit manager, an inherent conflict of interest.
By requiring transparency, the Cantwell-Lincoln amendment works to
prevent collusion on pricing and helps ensure seniors are not paying
unnecessarily high prices for their medications.
PBMs have been the target of numerous lawsuits filed in recent years
by health plans, employers and governments. The allegations in these
lawsuits are always the same: overinflated drug prices, price collusion
between PBMs and manufacturers, failure of PBMs to share discounts and
rebates, and switching patients to more expensive drugs without the
consent of the patient or the doctor.
The PBMs have denied wrongdoing and have settled in many cases.
Last year, Merck agreed to pay $42.5 million to settle lawsuits over
allegations that Medco improperly promoted higher priced Merck drugs
when less expensive options from other pharmaceutical companies were
available.
In 1998, Merck signed a settlement agreement with the Federal Trade
Commission stating that, ``Medco has given favorable treatment to Merck
drugs.''
This admission is proof that pharmaceutical companies and PBMs have
engaged in collusion on drug pricing in the past, extracting excessive
profits from people who rely on these drug services. The Cantwell-
Lincoln amendment is needed to help prevent price gouging in the
future.
Other governments have struggled to keep a close watch on PBM
practices.
In 2000, one of the big four PBMs, Advance PCS, was hired by the
state of Arkansas to provide coverage for the state's 135,000
employees. A recent audit found that the PBM was over charging the
state for numerous drugs. During one 4-month period, the PBM
overcharged the state $479,000 on generic drugs alone.
PBM executives say that my amendment makes turning a profit
impossible. It is true that PBMs are not charities but private
companies with a duty to their shareholders to earn a profit.
Let's not forget, however, that these are also private companies
charged with providing a Government-funded benefit in the best
interests of 40 million senior citizens. These private companies also
are duty bound to get the most for the Government's $400 billion
investment.
Traveling in my home State of Washington, I hear regularly from
senior citizens about the high cost of prescription drugs. While
seniors in my State, like elsewhere in the country, want a Medicare
prescription drug benefit, they also desperately want some relief from
high prescription drug prices. They say, ``Stop the price gouging. Do
something to make sure that prescription drugs are reasonably
affordable for everyone.''
PBMs have come to dominate the prescription drug benefit market.
Nearly 210 million Americans are served by one of the four largest
PBMs.
According to the Centers for Medicaid and Medicare Services, national
prescription drug spending increased by 15.7 percent in 2001. Despite
promises from pharmacy benefit managers to lower costs, prescription
drugs continue to be the fastest growing sector of health care spending
in this country.
Soaring in tandem with prescription drugs prices are PBM profits. St.
Louis-based Express Scripts--one of the four largest PBMs--provides
coverage to 40 million people. The company reported that its net income
grew 63 percent last year to $202.8 million.
Another one of the big four, Advance PCS, which covers 75 million
people, was ranked by Fortune Magazine as the ninth fastest growing
company in the nation based on its profits over the past 5 years.
Unfortunately, it has been near impossible to find out whether PBMs
are fairly sharing rebates and other savings with patients or simply
using it to boost the bottom line.
Even the General Accounting Office has been unable to find out how
rebates are being divided between PBMs and the Federal Employees Health
Benefits Plan. A GAO requested by Senator Dorgan last year failed to
discover if the PBMs were passing along the savings because none of the
PBMs financial documents were available for review.
Several private companies and employee groups that contract with PBMs
have resorted to lawsuits to get access to this information.
The Cantwell-Lincoln amendment requires the PBM to disclose to the
Department of Justice the financial arrangements that dictate what
percentage of rebates and other savings are being passed back to the
client.
This disclosure creates a major incentive for PBMs to return as much
as possible of the rebates and spread back to the Medicare program.
This incentive also will help reduce prescription drug prices.
The PBMs have argued that reporting this financial information would
kill their ability to continue to negotiate low drug prices. I am a
businesswoman, and I understand the need to keep financial agreements
confidential. That is why my amendment mandates the information be
handed over to the Department of Justice, where it remains
confidential.
Department of Justice oversight also allows for regular review of
these financial arrangements to weed out any potential collusion on
pricing. This added protection also will help lower drug costs for
seniors.
The Cantwell-Lincoln amendment also prohibits PBMs from being owned
by pharmaceutical manufacturers. This cross-ownership is problematic
because it could allow for pharmaceutical companies to collude with
PBMs to favor the manufacturers more expensive drugs over less
expensive alternatives.
A report on PBMs by the National Health Policy Forum points out the
concerns raised by close relationships between PBMs and drug
manufacturers. Close ties between the two could lead to a lack of drug
choice for consumers, with one manufacturer's drugs getting
preferential treatment by the PBM.
Actions taken this week by the U.S. attorney in Philadelphia
reinforce the

[[Page S8614]]

need for greater PBM oversight as outlined in the Cantwell-Lincoln
amendment.
Madam President, I ask unanimous consent that articles from the
Washington Post and Wall Street Journal be printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:

[From the Wall Street Journal, June 24, 2003]

U.S. Is Joining Lawsuit That Says Medco Put Profits Before Patients

(By Barbara Martinez)

The Justice Department is joining a lawsuit that alleges
Merck & Co.'s Medco pharmacy-benefits subsidiary adopted an
``aggressive profits-before-patients policy.'' Medco's
approach resulted in a potentially dangerous lack of
oversight in filling prescriptions and increased
pharmaceutical costs for the federal government, the suit
says.
The department's involvement in the suit, brought by two
former Medco pharmacists, doesn't necessarily mean that it
believes all the allegations. But it signals that the
government investigated the accusations and found at least
some of them worth pursuing in court. The government, which
also joined a second lawsuit against Medco Monday that made
similar allegations, intends to file its own complaint within
90 days. Justice Department investigators have been examining
Medco and other pharmacy-benefit managers, or PBMs, for
several years, but this is the first time they have indicated
that any suit would be filed. PBMs handle prescription-drug-
card benefits for millions of employees.
The complaint alleges that after Merck--one of the world's
largest drug companies--purchased Medco in 1993, the PBM
began to make systemic changes in its mail-order
prescription-filling system--disregarding safety and instead
promoting higher profits per prescription.
In a statement, Medco said, ``We are confident that when
all the facts are presented they will show that our business
has one focus, providing the highest quality of prescription
health care to our clients and members.'' It added: We are
prepared to present a nigorous defense and believe that we
will prevail. We will prove that the allegations'' in the
complaint ``are absolutely untrue or reflect years-old
isolated issues that were identified and corrected and in no
way and at no time compromise the quality of patient care.''
The airing of previously sealed allegations in the suit
comes at a difficult time for both Merck and PBMs. Merck
plans to spin off Medco as a publicly traded company this
year, while PBMs have been angling to get a piece of a
Medicare drug benefit currently being debated in Congress.
Medco provides drug benefits to more than 60 million
Americans, including millions of federal and state employees.
Medco's annual revenue totals about $30 billion.
The case could have repercussions on Capitol Hill, too,
where PBMs are locked in a fierce lobbying battle, especially
with the retail-pharmacy industry, over details of Medicare
legislation. The measure would create a drug benefit that
PBMs would have a prominent role in providing. Already
Monday, the National Community Pharmacists Association, which
represents about 25,000 owners of independent drugstores,
stepped up its lobbying efforts. The group is pushing for
stricter disclosure requirements for PBMs.
In the newly unsealed complaint, which was filed in U.S.
District Court in Philadelphia, the two former Medco
pharmacists make detailed charges that enormous pressure was
placed on employees to falsify orders to meet goals and to
disregard complaints by patients and doctors about drug
switching or pill shortages.
Daily internal publication of prescription-error rates to
help pharmacists measure their own safety standards were
eliminated, the suit asserts. Instead, daily loudspeaker
messages announced prescription-filling costs, as well as the
stock price of parent company Merck, the suit says. Many
Medco employees are compensated in part with Merck stock
options.
To save money, the suit alleges, Medco reduced licensed
pharmacists' role in the filling and supervising of
prescription drugs at its mail-order facilities. In addition,
the job of calling a physician to discuss a potential drug
interaction--once the job of only pharmacists--ultimately
fell to employees who ``seldom have college degrees, and have
no prior training in pharmacy services other than limited on-
the-job training.'' And as a result of being pressured to
meet quotas on how many doctors to call, employees regularly
lied on physician call records to indicate they alerted
doctors about problems when they really had not, according to
the lawsuit.
The lawsuit was filed under the Federal False Claims Act.
In such lawsuits, the plaintiff, often a former employee of a
company that does business with the government, alleges that
the company has defrauded the government. If the government
considers the allegations valid, if joins the complaint,
litigates the case and shares any recovery or damages with
the person who filed the suit.
Medco has a significant amount of legal government
business, providing mail-order prescriptions to millions of
federal employees through the Federal Employee's Health
Benefit Program.
Many of the allegations in this complaint relate to Medco's
mail-order business, where patients mail in a prescription
and Medco fills it and sends it back. PBMs such as Medco have
been pushing hard to promote their mail-order facilities as a
cost-effective alternative to retail stores.
According to the suit, Medco ``boasts to its clients
nationwide that licensed pharmacists check each mail-order
prescription before it is sent out, with as many as three or
four quality checks.'' The suit says such scrutiny only
happened prior to Merck's 1993 acquisition of Medco.
After the acquisition, Medco automated more of its
prescription-filling capabilities and ``significant changes''
were instituted that ``marked a shift from prudent pharmacy
practices'' to a ``focus on profit maximization,'' the
complaint said.
One of Medco's largest and most technologically advanced
mail-order facilities is in Las Vegas, where the two former
Medco pharmacists who filed the complaint worked. According
to the suit, after Medco upgraded its Las Vegas facility in
the mid-1990s, ``pharmacists were no longer reading and
verifying mailed prescriptions prior to entry into a
computer.'' Instead, upon arrival, the prescriptions were
entered by ``data-entry clerks with no formal pharmacy
training'' and who were supervised by nonpharmacist managers.
The suit also alleges that under a special program, touted
by Medco as promoting the most cost-effective drugs, Medco
called doctors to get them to change their prescriptions
because of undisclosed payments to Medco from drug
manufacturers. The suit said patient and physician complaints
about switching prescriptions were ``common'' but that
``Medco routinely ignores these complaints, including the
health risks associated with inappropriate drug switches.''
In addition, Medco, like other PBMs, provides ``drug
utilization reviews'' of prescriptions and patients. The
process aims to prevent adverse drug interactions, verifies
appropriate drug strength, catches drug allergies or
duplicate medications.
Until 1995, such calls to physicians to alert them to
possible problems were made by pharmacists who could fully
explain the situation and suggest alternatives. Subsequently,
the suit says, these calls were being made only by ``cheaper,
non-pharmacists employees.'' The pharmacist was only brought
in at the end of a call, to verify information.
But with workers having quotas of 20 to 25 calls an hour,
the pharmacist was handling as many as 100 calls within 60
minutes. As a result of pressures to meet the quotas, the
complaint said, employees regularly fabricated records
documenting that they called doctors to alert them to
potential safety issues, among other matters, when they
really hadn't. Sometimes, the suit says, the employees would
change prescriptions without the pharmacist's intervention.
In other areas of the mail-order facility, the complaint
says, employees ``permanently delete, cancel or otherwise
falsify prescriptions orders'' to reduce back-order size. As
a result, the complaint says, many patients didn't get the
medications they needed.
____

[From the Washington Post, June 24, 2003]

U.S. Joining Suit Against Medco

(By Charles Duhigg)

The U.S. attorney in Philadelphia announced yesterday that
he is joining a complaint against Medco Health Solutions Inc.
that alleges the nation's second-largest pharmacy-benefit
manager improperly canceled prescriptions, switched
medications without physician approval and sent patients
partially filled orders.
The U.S. attorney's office has been investigating whistle-
blower allegations against the company since 1999 and intends
to file its own complaint in September, said Associate U.S.
Attorney James G. Sheehan.
The government has decided to intervene in two lawsuits
brought by three whistle-blowers. Those suits allege that
Medco changed prescriptions without a physician's approval to
favor more expensive drugs produced by Merck & Co. and
induced physicians with false information to switch to higher
cost Merck drugs. Medco also destroyed mail order
prescriptions without filling them and in other cases mailed
patients less than the number of pills ordered but charged
for the full amount, the lawsuits allege.
Medco is a subsidiary of Merck.
``We know from industry studies that almost half of mail
order participants will run out of medicine within two days
if they fail to receive their new prescriptions,'' said
Patrick L. Meehan, the U.S. attorney for the eastern district
of Pennsylvania.
Medco officials contend that the allegations are untrue or
``reflect years-old isolated issues that were identified and
corrected,'' said Ann Smith, director of public affairs at
Medco. At no time was the quality of patient care
compromised, Smith said.
Most Americans know pharmacy benefit managers, or PBMs,
from the plastic cards they hand over at local pharmacies
when filling a prescription. Major employers and health plans
hire these companies to negotiate with drug companies to
control drug costs for plan enrollees, and to oversee the
complex paperwork associated with filling prescriptions.
The Senate is considering plans to provide prescription
drug coverage to the elderly

[[Page S8615]]

that may enhance the clout of pharmacy-benefit managers,
industry analysts say. The companies are expected to
administer government drug spending under some plans,
according to congressional testimony offered by the National
Association of Chain Drug Stores, and to receive a larger
share of government reimbursements for prescription drugs.
More than 62 million Americans get prescriptions processed
through Medco, according to the company. Medco handles
pharmacy benefits totaling nearly $30 billion per year,
including $1.2 billion from Blue Cross/Blue Shield as part of
the Federal Employees Health Benefits Program.
George Bradford Hund and Walter W. Gauger, who both worked
as pharmacists in Medco's Las Vegas processing facility, and
Joseph Piacentile, a physician, allege in their complaints
that on busy days Medco would cancel or destroy prescriptions
to avoid penalties for delays in filling orders. Customers
would be told that the prescriptions had never been received,
Sheehan said.
The company is also accused of fabricating records and,
when the handwriting on prescriptions was unclear or
difficult to read, simply guessing at what they said,
according to Sheehan. The government's suit against Medco
could ask for damages in the millions of dollars and new
oversight systems.
Merck acquired Medco in 1993 at a time when other
drugmakers were purchasing pharmacy-benefit managers. By the
end of the 1990s, all pharmaceutical manufacturers but Merck
had sold their units amid concerns that the drug companies
would use the benefit managers to push their own drugs,
rather than doing what was best for clients.
I 1998 Merck signed a settlement agreement with the Federal
Trade Commission stating that ``Medco has given favorable
treatment to Merck drugs.'' Last December, Medco agreed to
pay $42.5 million to settle a class-action lawsuit alleging
that the company improperly promoted higher priced Merck
drugs rather than seeking the best price from alternative
pharmaceutical companies. Merck announced it intended to spin
off Medco last year, but delayed the initial public offering
of shares because of the depressed stock market.
Yesterday's announcement marks the first significant legal
action by a federal agency against a pharmacy-benefit
manager. Previously, attorneys general of at least 25 states
have opened inquires into Medco to determine whether it has
violated state laws, and New York State Attorney General
Eliot L. Spitzer said last Friday that his office was
investigating another company, Express Scripts Inc., for
allegedly overbilling state health plans.
Shares of Merck closed yesterday at $62.11, down 78 cents,
or 1.24 percent.
____

[From the Washington Post, June 24, 2003]

Medco Accused of Favoring Merck Drugs

(By David B. Caruso)

Federal prosecutors on Monday said a company that was
supposed to help health plans find low-cost prescription
drugs instead pressured doctors to switch patients to
medications made by its owner, pharmaceutical giant Merck &
Co.
U.S. Attorney Patrick Meehan said his office has joined a
pair of civil ``whistleblower'' lawsuits against Medco Health
Solutions, accusing the Merck subsidiary of providing
misleading information to the government in connection with
its contract to manage drug benefits for federal employees.
More than 1,000 companies have hired Medco to coordinate
prescription drug coverage for employee health plans, making
it the nation's largest manager of pharmacy benefits, and the
company is supposed to use its bulk-purchasing power to lower
drug costs.
But the suits say Medco routinely induce physicians to
switch patients to Merck drugs, even if a patient had been
doing well on another medication that cost less.
The government also says the company failed to call doctors
to explain prescriptions that were unclear, and fabricated
records to make it appear as if calls from pharmacists to
physicians had been made.
The three whistleblowers--a New Jersey doctor and two
Nevada pharmacists who once worked for Medco--claim the firm
also misled clients about its practice of accepting cash
rebates from pharmaceutical companies in exchange for
promoting their products. The suits claim the payments amount
to kickbacks.
Medco spokesman Jeffrey Simek said the charges are ``either
absolutely untrue, or they reflect years-old isolated issues
that were identified and corrected.''
He denied the firm gives preferential treatment to Merck,
or any other drug company.
``Our policy is that we will never make a drug interchange
that will not result in a benefit for either our clients, or
the members of their health plans,'' he said. ``If we
improperly favored any drug by any single company, we could
never succeed.''
Several health plans have previously sued Medco, claiming
that it improperly accepted $3.56 billion in payments from
drug companies in the late 1990s to promote their products,
but Monday's filing by the U.S. Attorney in Philadelphia is
the first such action by a federal prosecutor.
Medco, like other pharmacy benefit companies, acknowledges
participating in rebate programs. Simek said the company took
in $2.5 billion in rebates in 2001. But he said the payments
work like coupons and ultimately lower medication costs for
clients.
The suits also accuse Medco, of Franklin Lakes, N.J., of
shortchanging patients by mailing them fewer than the number
of pills they paid for. They say the company tried to avoid
penalties for delays in filling mail orders by destroying
prescriptions on days when the order volume was heavy.
Simek said the company investigated the allegations and
determined they were isolated incidents that didn't affect
patient care. Two employees were fired, he said.
Court filings identified the whistleblowers as Dr. Joseph
Piacentile, of New Jersey, and George Bradford Hunt and
Walter W. Gauger, two pharmacists who previously worked for
Medco in Las Vegas.
Attorneys general in several states have said they are also
investigating whether the company, and other pharmacy benefit
firms, broke the law.
Merck has been trying to spin off its Medco business. It
canceled an initial public offering for the company in July
after revealing that it had misstated its revenues by $12
billion in recent years by counting prescription copyaments
made to pharmacies as Medco revenue. Merck said in May that
the firm would be spun off instead to Merck shareholders.

Ms. CANTWELL. Madam President, it was reported this week that U.S.
Attorney Patrick Meehan plans to join a pair of lawsuits filed by three
former Medco Health employees. The employees--two pharmacists and a
doctor--allege that Medco provided misleading information to the
Government related to a contract to provide drug coverage for Federal
employees. The lawsuits accuse Medco of switching patients to more
expensive drugs and fabricating records to make it look as if the
prescription changes were made by doctors and not by Medco.
These are serious allegations resulting from an investigation that
began in 1999. This is the first such action taken by a U.S. attorney
against a PBM and is a strong signal that all is not right with this
industry.
U.S. Attorney Patrick Meehan told the Newark Star Ledger:

The kind of conduct alleged in the complaints threatens not
only the integrity of the system as a whole, but also the
well being of the very patients it is designed to benefit.
These allegations suggest that, somewhere along the line, the
focus became the profit instead of the patient.

The possibility of profitability trumping patient care has promoted a
number of consumer groups to favor the accountability system outlined
in my amendment. Consumers Union, Public Citizen, Families USA, AFSCME,
the National Community Pharmacy Association and the Washington State
Pharmacy Association all support my amendment.
Mr. President, I ask unanimous consent that letters of support be
printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:

Consumers Union,

Washington, DC, June 25, 2003.
Dear Senator: As the Senate continues to debate S. 1, the
``Prescription Drug and Medicare Improvement Act of 2003,''
Consumers Union urges you to redouble your efforts to improve
the legislation so that it better meets the needs of seniors
and people with disabilities, many of whom are in dire need
of meaningful protection from the devastating impact of
spiraling prescription drug costs.
Some of Consumers Union's most serious concerns about S. 1
are:
The amount set aside in the Congressional budget resolution
for a Medicare prescription drug bill, $400 billion over 10
years, is inadequate for the task and limits coverage to 22
percent of the projected prescription drug expenditures over
this time period;
Prescription drug coverage provided by S. 1 is skimpy,
leaving many beneficiaries who lack coverage in 2003 actually
paying more out of their own pockets for prescription drugs
in 2007, when they have coverage. (For more information,
please see our report, Skimpy Benefits and Unchecked
Expenditures: Medicare Prescription Drug Bills Fail to Offer
Adequate Protection for Seniors and People with Disabilities,
at
www.consumersunion.org
);
The bill lacks a standard, uniform benefit, does not
guarantee the availability of a prescription drug benefit
through the Medicare program, and leaves all beneficiaries
uncertain about what coverage will be available to them (and
uncertain about the premium they will be charged);
While the Senate has approved helpful amendments that would
accelerate the introduction of generics and possibly provide
beneficiaries access to lower-priced drugs from Canada, the
bill's reliance on hundreds of private insurance companies
and HMOs precludes the possibility of the federal government
using its purchasing power to negotiate deep discounts for
consumers. It does too little, therefore, to rein in
spiraling prescription drug expenditures;
The bill creates confusion for Medicare beneficiaries,
forcing them to sort out the

[[Page S8616]]

options in the drug-only marketplace and options in the HMO/
PPO marketplace, and it further complicates the ``comparison
shopping'' task by allowing the prescription drug benefits to
vary from the basic parameters (e.g., deductible, cost-
sharing, doughnut, catastrophic coverage). Simply-put, the
confusing options that will face Medicare beneficiaries
flunks the ``kitchen table'' test;
S. 1 will leave many Medicare beneficiaries worse off since
employers will cut back their retiree coverage because any
coverage is not counted toward retirees' out-of-pocket costs;
and
While the bill provides for a relatively generous subsidy
for low-income consumers, it requires them to get their
prescription drug benefit through Medicare instead of
the currently universal Medicare program, even though they
qualify for Medicare coverage by virtue of their age or
disability.
We are deeply troubled by discussions that are underway
that would undermine the traditional fee-for-service Medicare
program--the very program that assures beneficiaries that
they have the freedom to go to the doctor of their choice--by
providing extra subsidization to private PPOs and HMOs. By
enriching the benefits available in the private marketplace,
PPOs and HMOs will attract relatively healthy people; the
traditional fee-for-service Medicare option will erode over
time, because of the design of the subsidies and desire to
cut costs. The sickest and most vulnerable will be severely
disadvantaged.
There are several amendments that would help address some
of the problems with S. 1. We urge you to support amendments
that would:
Expand the prescription drug benefits so that they are
comparable to prescription drug coverage in employer-based
health insurance plans;
Rein in prescription drug expenditures through the use of
the federal government's buying power to negotiate deep
discounts;
Provide for scientific study of the comparative
effectiveness of alternative prescription drugs;
Guarantee that beneficiaries would have access to a
prescription drug benefit through the Medicare program at a
set premium;
Count the contributions made by employers toward
beneficiaries' out-of-pocket costs;
Maintain a level-playing field so that benefits in PPOs and
HMOs are not more generous than benefits available in
traditional fee-for-service Medicare;
Instruct the National Association of Insurance
Commissioners to adjust medigap benefit packages to allow
beneficiaries to buy additional coverage;
Increase the transparency of transactions by pharmaceutical
benefit managers;
Cut the time before the prescription drug benefits begin.
The current debate about a Medicare prescription drug
benefit has led seniors and persons with disabilities to
believe that relief is in sight. In its present form, S. 1
will be a big disappointment to beneficiaries when it is
implemented in 2006. We urge you to amend S. 1 so that it is
more effective in providing meaningful relief to Medicare
beneficiaries while addressing the pressing need to curb
prescription drug expenditures.
Sincerely,

Gail E. Shearer,

Director, Health Policy Analysis,
Washington Office.
____

Society of Professional Engineering Employees in
Aerospace,
Seattle, WA, June 5, 2003.
Hon. Maria Cantwell,
U.S. Senate,
Washington, DC.
Dear Senator Cantwell: As you know, union members and
retirees in Washington are very concerned about the current
activities involving prescription drug benefits for Medicare
seniors. We thought you should know that we are part of a
national delegation of unions that met with Secretary Tommy
Thompson to express our opposition to any PBM-based
alternative to our local pharmacies.
PBMs own much of the mail order drug service in this
country. For the past 2 years, we have been warning
congressional members that a PBM-based benefit would
potentially harm many local pharmacies that serve our
communities. Still however, lawmakers almost passed a PBM-
based benefit in the 107th Congress.
Since last year, the reputation of PBMs has grown worse.
Now they are being sued by a California based union, AFSCME.
Allegedly, four of the largest PBMs have been pocketing money
that is meant for the consumer.
SPEEA urges you and your fellow Senators to look into this
lawsuit before passing any PBM-based legislation. In this day
and age, transparency must be part of any program set up by
the United States government.
Sincerely,
Charles Bofferding,
Executive Director.
____

American Federation of State, County and Municipal
Employees, AFL-CIO,
Washington, DC, June 24, 2003.
Hon. Maria Cantwell,
U.S. Senate,
Washington, DC.
Dear Senator Cantwell: On behalf of AFSCME's 1.4 million
members, I am writing to express my strong support for your
amendment to S. 1, the Medicare prescription drug bill, that
would make certain that costs savings generated by Pharmacy
Benefit Managers (PBM) on behalf of the Medicare program are
returned to the program. We believe that this is a critical
means of controlling costs for this new benefit.
PBMs create most of their cost savings and their profits by
negotiating with drug manufacturers to receive favorable
rates on a pharmaceutical company's drugs in exchange for
including the drugs on the PBM's formulary of preferred
medicines. This bill would require that all contracts with
PBMs to provide the Medicare benefit with a private insurer
or the government itself include language that would ensure
that all savings negotiated with a pharmacy be passed back to
the government or the private insurer administering the
benefit on behalf of the government.
We believe it is crucial that PBMs be required to disclose
the percentage of rebate they have negotiated with the
pharmaceutical companies that are passed onto their clients.
Your amendment would do precisely that--giving some assurance
to consumers and the government that the savings achieved by
the PBMs are being shared.
I believe that your amendment goes a long way toward
ensuring that Medicare beneficiaries will receive their fair
share of the cost savings produced by contracts with PBMs,
and AFSCME strongly supports its adoption.
Sincerely,
Charles M. Loveless,
Director of Legislation.
____

June 18, 2003.
Hon. Maria Cantwell,
U.S. Senate,
Washington, DC.
Dear Senator Cantwell: Families USA, the national consumer
health advocacy organization, strongly endorses your
amendment to ensure that the conflicts of interest, which can
occur in the delivery of a Medicare prescription drug
benefit, are minimized or avoided.
Everyone agrees that whether Medicare directly administers
the benefit or whether it is administered through private
plans, Pharmacy Benefit Managers (PBM) will be used. They
have the expertise and knowledge necessary to help administer
this program. But in the recent past, there have been
examples of abuse in this sector. particularly troubling has
been the steering of patients to a particular prescription
drug product because it was more profitable for the
administering company and not because it was better for the
patient! In a very real sense, that is malpractice. It is
inexcusable. It must be stopped. At least one major PBM has
announced a code of ethics to prevent such abuses. But these
important consumer protections should not depend on company-
by-company internal codes of ethics. Your amendment is
needed.
Your amendment requires the confidential disclosure of the
type of information that will enable the Department of Health
and Human Services to protect against rebates and kickbacks
that would cause a company to steer people toward profitable
medicine rather than needed medicine. Your amendment helps
ensure that those who will surely be called on to help
administer the new benefit provide good health care to the
beneficiaries and not just profitable health care to their
owners.
Sincerely,
Ronald F. Pollack,
Executive Director.
____

Washington State

Pharmacy Association,

Renton, WA, June 23, 2003.
Hon. Maria Cantwell,
U.S. Senate,
Washington, DC.
Dear Senator Cantwell: The Washington State Pharmacy
Association, representing pharmacy practitioners from all
practice arenas in the State of Washington, strongly endorses
your amendment to ensure that the conflicts of interest,
which can occur in the delivery of a Medicare prescription
drug benefit through a PBM, are minimized or avoided.
Pharmacy Benefit Managers (PBM) are an integral part of the
health care delivery system. Efficient plan administration
and timely claims processing are mandatory components of a
successful health care benefit which are important to
patients, payers and providers. However, in recent years the
PBM industry has expanded their role to include benefit
design that has created significant conflicts of interest and
ethical questions of appropriate health care delivery versus
profitable health care delivery.
Your amendment, as proposed, provides the necessary
transparency that will provide patients, payers, and
regulators the necessary information to appropriately monitor
PBM business practices. Your amendment is a significant step
toward insuring that the health care provided to the citizens
of this country is focused on improving the patient's health
and wellbeing and not the fiscal wellbeing of the pharmacy
benefit managers.
Sincerely,
Rod Shafer, R.Ph.,
CEO.

[[Page S8617]]

Ms. CANTWELL. Madam President, these groups and others have been
trying to call attention to problematic PBM practices. These groups
rightly point out that strong consumer protections are needed in any
Medicare drug benefit.
The American Association of State, County and Municipal Employees
agrees that these protections provide ``a critical means of controlling
costs.''
A national coalition of workers representing more than 20 states also
are supportive of efforts to monitor PBMs. Many in this coalition
currently use PBMs to provide benefits and many of them are wondering
why drug costs continue to rise.
There is a balance to be had here, and the Cantwell-Lincoln amendment
makes sure the scale is not tipped too far one way. It is a good
amendment that will lower prescription drug prices, provide much needed
consumer protections and ensure strong government oversight. I urge my
colleagues to support it.
Mr. GRASSLEY. Is the amendment before us now?
The PRESIDING OFFICER. The amendment is before us.
Mr. GRASSLEY. We have looked at the amendment on this side. It has
been modified, and I urge we accept it on a voice vote.
Mr. BAUCUS. We have looked at this amendment. I agree with Senator
Grassley. We accept the amendment.
The PRESIDING OFFICER. The question is on agreeing to amendment No.
942, as modified.
The amendment (No. 942), as modified, 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.
Mr. BAUCUS. 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. BYRD. Madam President, I ask unanimous consent that the order for
the quorum call be rescinded.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. BYRD. Madam President, I ask unanimous consent that I may speak
out of order.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. BYRD. I thank the Chair.
(The remarks of Mr. BYRD are printed in today's Record under
``Morning Business.'')

Amendment No. 1095

The PRESIDING OFFICER. The Senator from Nevada.
Mr. REID. Mr. President, I ask unanimous consent the pending
amendments be temporarily set aside.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. REID. On behalf of the Senator from South Dakota, Senator
Johnson, I send an amendment to the desk.
The PRESIDING OFFICER. The clerk will report.
The assistant legislative clerk read as follows:

The Senator from Nevada [Mr. Reid], for Mr. Johnson, for
himself and Mr. Cochran, proposes an amendment numbered 1095.

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

(Purpose: To provide for a 1-year medication therapy management
assessment program)

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

SEC. ____. MEDICATION THERAPY MANAGEMENT ASSESSMENT PROGRAM.

(a) Establishment.--
(1) In general.--The Secretary shall establish an
assessment program to contract with qualified pharmacists to
provide medication therapy management services to eligible
beneficiaries who receive care under the original medicare
fee-for-service program under parts A and B of title XVIII of
the Social Security Act to eligible beneficiaries.
(2) Sites.--The Secretary shall designate 6 geographic
areas, each containing not less than 3 sites, at which to
conduct the assessment program under this section. At least 2
geographic areas designated under this paragraph shall be
located in rural areas.
(3) Duration.--The Secretary shall conduct the assessment
program under this section for a 1-year period.
(4) Implementation.--The Secretary shall implement the
program not later than January 1, 2005, but may not implement
the assessment program before October 1, 2004.
(b) Participants.--Any eligible beneficiary who resides in
an area designated by the Secretary as an assessment site
under subsection (a)(2) may participate in the assessment
program under this section if such beneficiary identifies a
qualified pharmacist who agrees to furnish medication therapy
management services to the eligible beneficiary under the
assessment program.
(c) Contracts With Qualified Pharmacists.--
(1) In general.--The Secretary shall enter into a contract
with qualified pharmacists to provide medication therapy
management services to eligible beneficiaries residing in the
area served by the qualified pharmacist.
(2) Number of qualified pharmacists.--The Secretary may
contract with more than 1 qualified pharmacist at each site.
(d) Payment to Qualified Pharmacists.--
(1) In general.--Under an contract entered into under
subsection (c), the Secretary shall pay qualified pharmacists
a fee for providing medication therapy management services.
(2) Assessment of payment methodologies.--The Secretary
shall, in consultation with national pharmacist and pharmacy
associations, design the fee paid under paragraph (1) to test
various payment methodologies applicable with respect to
medication therapy management services, including a payment
methodology that applies a relative value scale and fee-
schedule with respect to such services that take into account
the differences in--
(A) the time required to perform the different types of
medication therapy management services;
(B) the level of risk associated with the use of particular
outpatient prescription drugs or groups of drugs; and
(C) the health status of individuals to whom such services
are provided.
(e) Funding.--
(1) In general.--Subject to paragraph (2), the Secretary
shall provide for the transfer from the Federal Supplementary
Insurance Trust Fund established under section 1841 of the
Social Security Act (42 U.S.C. 1395t) of such funds as are
necessary for the costs of carrying out the assessment
program under this section.
(2) Budget neutrality.--In conducting the assessment
program under this section, the Secretary shall ensure that
the aggregate payments made by the Secretary do not exceed
the amount which the Secretary would have paid if the
assessment program under this section was not implemented.
(f) Waiver Authority.--The Secretary may waive such
requirements of titles XI and XVIII of the Social Security
Act (42 U.S.C. 1301 et seq.; 1395 et seq.) as may be
necessary for the purpose of carrying out the assessment
program under this section.
(g) Availability of Data.--During the period in which the
assessment program is conducted, the Secretary annually shall
make available data regarding--
(1) the geographic areas and sites designated under
subsection (a)(2);
(2) the number of eligible beneficiaries participating in
the program under subsection (b) and the level and types
medication therapy management services used by such
beneficiaries;
(3) the number of qualified pharmacists with contracts
under subsection (c), the location of such pharmacists, and
the number of eligible beneficiaries served by such
pharmacists; and
(4) the types of payment methodologies being tested under
subsection (d)(2).
(h) Report.--
(1) In general.--Not later than 6 months after the
completion of the assessment program under this section, the
Secretary shall submit to Congress a final report summarizing
the final outcome of the program and evaluating the results
of the program, together with recommendations for such
legislation and administrative action as the Secretary
determines to be appropriate.
(2) Assessment of payment methodologies.--The final report
submitted under paragraph (1) shall include an assessment of
the feasibility and appropriateness of the various payment
methodologies tested under subsection (d)(2).
(i) Definitions.--In this section:
(1) Medication therapy management services.--The term
``medication therapy management services'' means services or
programs furnished by a qualified pharmacist to an eligible
beneficiary, individually or on behalf of a pharmacy
provider, which are designed--
(A) to ensure that medications are used appropriately by
such individual;
(B) to enhance the individual's understanding of the
appropriate use of medications;
(C) to increase the individual's compliance with
prescription medication regimens;
(D) to reduce the risk of potential adverse events
associated with medications; and
(E) to reduce the need for other costly medical services
through better management of medication therapy.
(2) Eligible beneficiary.--The term ``eligible
beneficiary'' means an individual who is--
(A) entitled to (or enrolled for) benefits under part A and
enrolled for benefits under part B of the Social Security Act
(42 U.S.C. 1395c et seq.; 1395j et seq.);
(B) not enrolled with a Medicare+Choice plan or a
MedicareAdvantage plan under part C; and
(C) receiving, in accordance with State law or regulation,
medication for--

[[Page S8618]]

(i) the treatment of asthma, diabetes, or chronic
cardiovascular disease, including an individual on
anticoagulation or lipid reducing medications; or
(ii) such other chronic diseases as the Secretary may
specify.
(3) Qualified pharmacist.--The term ``qualified
pharmacist'' means an individual who is a licensed pharmacist
in good standing with the State Board of Pharmacy.

Mr. McCONNELL. Mr. President, I ask unanimous consent that
immediately following Senator Kennedy's comments I be recognized to
offer an amendment regarding cancer. I further ask unanimous consent
that this morning the Senate proceed to a vote in relation to the
McConnell amendment, to be followed immediately by a vote in relation
to the Boxer amendment numbered 1036, to be followed immediately by a
vote in relation to the Bingaman amendment numbered 1065, with no
second degrees in order to the three above amendments prior to the
vote, with 2 minutes equally divided prior to the vote, and with 10
minutes equally divided before the first vote.
Mr. REID. Mr. President, it is my understanding that as soon as
Senator Kennedy finishes his speech Senators McConnell and Boxer will
be recognized for 10 minutes with the time equally divided, and then we
go into the series of votes. Is that right?
Mr. McCONNELL. That is my understanding.
The PRESIDING OFFICER. Is there objection? Without objection, it is
so ordered.
The Senator from Massachusetts is recognized.

Amendment No. 1092

Mr. KENNEDY. Mr. President, we will have a chance to have greater
discussion and debate on one of the important amendments that is before
the Senate. But I wanted to bring to the attention of our Members as we
go through the course of the day the Grassley-Baucus amendment, which
has two different parts to it. I would like to address the part of the
amendment which I find enormously compelling and which deserves the
broad support of all the Members of this body.
This amendment provides equal funding for Medicare and the private
plan demonstration plans. That is effectively what will be in the
Grassley-Baucus amendment. The Republicans say the private sector can
do a better job providing health care for seniors and we say Medicare
can do a better job. This amendment tests both. This amendment improves
the coordination of care for seniors with multiple chronic conditions
who remain in Medicare. Republicans have said we need to move seniors
into private plans if we want to provide chronic care coordination,
disease management, or enhanced preventive services.
I am confident this demonstration program will show Medicare can do
an even better job than private plans in providing preventive health
services and ensuring care coordination. Care for patients with chronic
conditions is especially critical. These patients account for 95
percent of Medicare spending, according to ``Care Coordination for
People with Chronic Conditions'', an analysis published this year by
Johns Hopkins University.
Currently, 60 million Americans have multiple chronic conditions, and
that number is expected to grow to 157 million by the year 2020.
Sixty-two percent of seniors have multiple chronic conditions, but
their care is often fragmented. A senior citizen may get treatment for
her diabetes from one doctor, care for her arthritis from a second
doctor and attention for her high blood pressure from a third.
Study after study shows that improving the coordination of care for
those with multiple chronic conditions can improve outcomes and reduce
costs.
For example, in Laconia, NH, the Home and Community Based Care
program improved disease management for seniors with multiple
conditions. This program saved an average of $8,100 in health care
costs for each senior served and decreased admission to nursing homes.
In Georgia, the Service Options Using Resources in a Community
Environment--SOURCE--program improved disease management for 1,600
beneficiaries in 80 counties. The costs of caring for those seniors in
the SOURCE program over two years was over $4,000 lower than for those
who were not in the program.
My own state of Massachusetts is part of the New England States
Consortium, a multi-state effort funded by the Robert Wood Johnson
Foundation to study the improvements that can be made in health care
through better care coordination.
Expert groups in health care have said that care coordination should
be one of the highest priorities for our health care system. For
example, in its recent report, Priority Areas for National Action:
Transforming Health Care Quality, the Institute of Medicine identified
20 ``priority areas'' for improving health care.
The Institute of Medicine has carefully examined the issue of care
quality. The Institute's recent report, ``Priority Areas for National
Action'' has a series of recommendations on improving the quality of
health care in America. We have included in our amendment 13 of the 20
priority items that have been identified by the Institute of Medicine
that will make a significant difference in quality. The amendment will
have an important impact in reducing costs by improving care
coordination and providing needed preventive services.
A recent study funded by the Robert Wood Johnson Foundation reaches
the same conclusion. The study examined the effect of care coordination
on outcomes for patients with diabetes. Care coordination and simple
preventive services dramatically improved the outcome for patients with
diabetes in terms of their blood glucose levels. Elevated blood glucose
is a major concern for patients with diabetes, and preventive services
are effective in keeping blood glucose levels down. As we know,
diabetes is one of the principal health concerns for our country, and
is of particular concern for our seniors.
A decrease of even one percentage point in the blood glucose level of
a patient with diabetes can have a profound effect on health. That
seemingly small decrease results in a 21 percent drop in mortality from
the disease, a 12 percent decrease in strokes, a 24 percent decrease in
renal failure, and a remarkable 43 percent drop in the amputations that
so many patients face as a result of this cruel disease. More effective
management of blood glucose levels is also effective in keeping
patients out of hospitals or nursing homes and thus reducing costs. A
reduction in blood glucose levels of just one percent reduces health
care costs by $800 per patient.
These kinds of extraordinary improvements in health care quality are
what this amendment is all about. We are going to provide some $6
billion nationwide over a 5-year period to give life to these kinds of
quality improvement efforts, and we are going to challenge the private
sector to do it as well.
We believe that the kinds of quality improvement initiatives included
in this amendment will be a major factor for the support for this
legislation. Health care quality and its impact on health care costs is
an aspect of the health care debate that has not received sufficient
attention.
This amendment will give us an opportunity to take dramatic steps
forward in Medicare which will strengthen and improve the quality of
health care for our seniors. The amendment will also have a very
positive impact in terms of cost reductions.
This amendment also addresses the whole question of prevention which
is equally critical to keeping people healthy. Immunizations, managing
high blood pressure, cancer screening, and patient education can all
have an enormous impact on keeping people healthy and reducing costs.
Too often Medicare pays huge amounts to care for people who are sick
but fails to invest adequately in keeping them healthy.
Failure to invest adequately in preventive services is a tragic
consequence of the repayment system we now have under the Medicare
system. When the original Medicare system was established, we did not
have the knowledge, awareness, and understanding of the importance of
prevention nearly to extent we have it today. Preventive care was not
reimbursed the way it should be.
Under this amendment, we will have the opportunity to provide the
kinds of real, effective support for prevention programs they deserve.
Increased support for preventive services will mean

[[Page S8619]]

lower costs and better quality of care for our seniors under Medicare.
As I mentioned, too often we pay huge amounts to care for people who
are sick, but fail to invest in keeping people healthy. This amendment
gives Medicare the tools to invest in keeping people healthy. Too often
the care for people with the highest cost, the most serious illnesses,
such as cancer and stroke, is not optimal.
This demonstration will help Medicare assure the highest quality care
for the sickest patients. Medicare is a fine program. It has kept our
senior citizens secure for 40 years. Today let us make Medicare even
better with this amendment.
I will include the selective parts of the studies I referred to
previously in the Record. I ask unanimous consent that the selective
parts be printed in the Record at the conclusion of my remarks.
The PRESIDING OFFICER. Without objection, it is so ordered.
(See exhibit 1).
Mr. KENNEDY. Mr. President, as I mentioned, the New England Journal
of Medicine--in a major study published just today--focuses on the
issue of quality. The study demonstrates that the problem most likely
to occur in our health care system is not overutilization of services,
but underutilization. This point bears repeating. Patients all over
America are not receiving the services they need to keep them healthy.
46 percent of patients did not receive the recommended care, while only
11 percent received care that was not recommended and was potentially
harmful. That means that four times as many patients did not receive
the care they needed as received care they did not need. The problem in
our health care system is not overutilization of services, but
underutilization.
The problem of not receiving needed care is particularly acute for
some of the most serious disorders that affect seniors. The New England
Journal article states that less than a quarter of patients with
diabetes received recommended blood tests. Fewer than two-thirds of
patients with high blood pressure received the recommended care. These
two diseases alone take an extraordinary toll on the lives of our
citizens. Nearly 600,000 seniors die each year from heart disease, and
complications of diabetes kill over 50,000 seniors. We could
dramatically reduce the serious toll of these diseases--and many
others--by improving access to preventive services and enhancing the
quality of care.
Modern medicine--and a strong Medicare program--have been effective
in allowing seniors to live with chronic conditions that once were
fatal. Millions of seniors are alive today because of advances in the
treatment of heart disease, high cholesterol, cancer and other serious
illnesses. As a result of this success, however, millions of seniors
have multiple chronic conditions which put them at higher risk for
illness and hospitalization. The Institute of Medicine reports that
only 0.7 percent of seniors with just one chronic condition require
hospitalization in any given year. 6.2 percent of seniors with 4
chronic conditions are hospitalized, and over 25 percent of those with
10 or more chronic conditions require a hospital stay. Currently, 60
million Americans have multiple chronic conditions, and that number is
expected to grow to 157 million over the next two decades.
Improving the coordination of care for those with multiple chronic
conditions can markedly improve outcomes. Yet the average Medicare
beneficiary sees more than six different doctors in a year. Clearly, we
need to do more to see that seniors receive the most appropriate care
for all their conditions--not just the one that any particular doctor
among these six is treating individually. Study after study cited by
the Institute of Medicine indicates that care is inadequately
coordinated for patients with some of the most serious diseases.
Our health care system also fails to provide adequate preventive
services. Survival rates for many forms of cancer increase dramatically
if the disease is detected early--yet far too few patients receive the
type of early screening that can literally mean the difference between
life and death. For example, early diagnosis of colon cancer results in
a survival rate of 90 percent, but that survival rate drops
precipitously if the cancer spreads or grows before it is detected.
Early detection not only saves lives--it reduces costs too. Proper
screening can save up to $25,000 for every patient who avoids painful
and lengthy treatment through early detection of cancer. Despite this
compelling evidence of the value of preventive services, only a third
of patients receive the recommended form of colon cancer screening.
The story is the same with adult immunization. Pneumonia and
influenza are the seventh leading cause of death in the United States,
and the fifth leading cause of death among seniors. Over a third of
seniors with invasive pneumonia will die of the disease. Many cases of
these diseases are preventable with a simple immunization--yet one-
third to one-half of all seniors do not receive needed immunizations.
Coverage rates for high-risk seniors are particularly poor. Tragically,
only about a quarter of seniors with chronic disease receive a flu
shot.
This very important amendment will address these challenges which the
Institute of Medicine, the Robert Wood Johnson Foundation, and the New
England Journal of Medicine have all commented on as being critical if
we are going to strengthen quality and begin to get a greater handle on
costs.
I will refer to the part of the amendment that addresses these
questions. Page 13 of the amendment describes the enhanced benefits
that will now be available to beneficiaries in terms of care
coordination, disease management and preventive services not otherwise
covered under section 18 of the Social Security Administration. I ask
unanimous consent to include the section of the bill containing this
provision in the Record.
The amendment provides chronic care coordination services, disease
management services and other benefits that the Secretary will
determine to improve preventive health care for Medicare beneficiaries.
These services will improve chronic disease management and management
of complex life-threatening or high-cost conditions. The amendment will
make a real difference in improving the health of millions of seniors.
This is really a historic opportunity. I can say, having been here
for some period of time, the idea that you would get $6 billion over 5
years to be able to support prevention and the coordination of care for
our seniors--I didn't believe it would ever be realized. We have that
chance with this amendment.
I think one of the most important aspects of this legislation is its
emphasis on the area of prevention, which is so important, as I have
just described. Increased support for preventive health care services
will improve and strengthen the quality of health care and also result
in savings for the Medicare system. We have seen how these services
help the intensely ill and sick and fragile elderly. And we will
increase the coordination of services as well. All of this makes a
great deal of sense. And we have the evidence--ample evidence--to show
that action in this area can make a very important difference to the
elderly.
I will let others describe the other part of the amendment dealing
with private plans. But we challenge them, after the 5 years in which
the resources will be spent--with a GAO study that will report back how
the money has been spent--we challenge them to see which will make the
greatest difference in terms of quality of care for our senior
population and will make a difference in terms of the savings in the
Medicare system. There is no question in my mind--no question in my
mind--what that GAO report will demonstrate. We have clear
documentation and scientific information that talks about the various
studies that have been done to date, and also the conclusions that have
been reached by the thoughtful, nonpartisan groups in this very area.
We welcome the opportunity to show to the American people which
system is really going to work effectively. At the end of that period
of time, we will have the chance to enhance and improve on that, to
make sure the future generations' health care will be strengthened.
So I hope this amendment, which will be before us very soon, will
receive overwhelming support because I think it will have a real chance
to evaluate the different approaches and see what

[[Page S8620]]

is going to be most effective in terms of quality and cost.

Blood Glucose--Reductions Pay Off

Longitudinal studies demonstrate that a one percentage
point reduction in Hemoglobin A1C (blood glucose) results in:
14% decrease in total mortality; 21% decrease in diabetes-
related deaths; 14% decrease in myocardial infarction; 12%
decrease in strokes; 43% decrease in amputations; 24%
decrease in renal failure; and $800 reduction in health care
costs.

Problems with Quality of Care

The problem with quality that is most likely to occur, is
underuse: 46.3 percent of participants did not receive
recommended care. With overuse, 11.3 percent of participants
received care that was not recommended and was potentially
harmful.

Variations in Quality

There is substantial variability in the quality-of-care
patients receive for the 25 conditions for which at least 100
persons were eligible for analysis. Persons with senile
cataracts received 78.7 percent of the recommended care;
persons with alcohol dependence received 10.5 percent of the
recommended care. The aggregate scores for individual
conditions were generally not sensitive to the presence or
absence of any single indicator of quality.

Discussion

Overall, participants received about half of the
recommended processes involved in care. These deficits in
care have important implications for the health of the
American public. For example, only 24 percent of participants
in our study who had diabetes received three or more
glycosylated hemoglobin tests over a two-year period. This
routine monitoring is essential to the assessment of the
effectiveness of treatment, to ensuring appropriate responses
to poor glycemic control, and to the identification of
complications of the disease at an early stage so that
serious consequences may be prevented.
In our study, persons with hypertension received 64.7
percent of the recommended care. We have previously
demonstrated a link between blood-pressure control and
adherence to process-related measures of quality of care for
hypertension. Persons whose blood pressure is persistently
above normal are at increased risk for heart disease, stroke,
and death. Poor blood-pressure control contributes to more
than 68,000 preventable deaths annually.

final list of priority areas

The committee's selection process yielded a final set of 20
priority areas for improvement in health care quality.
Improving the delivery of care in any of these areas would
enable stakeholders at the national, state, and local levels
to begin setting a course for quality health care while
addressing unacceptable disparities in care for all
Americans. The committee made no attempt to rank order the
priority areas selected. The first 2 listed--care
coordination and self-management/health literacy--are cross-
cutting areas in which improvements would benefit a broad
array of patients. The 17 that follow represent the continuum
of care across the life span and are relevant to preventive
care, inpatient/surgical care, chronic conditions, end-of-
life care, and behavioral health, as well as to care for
children and adolescents (see boxes ES-1 to ES-6). Finally,
obesity is included as an ``emerging area'' that does not at
this point satisfy the selection criteria as fully as the
other 19 priority areas.
Recommendation 3: The committee recommends that DHHS, along
with other public and private entities, focus on the
following priority areas for transforming health care:
Care coordination (cross-cutting);
Self-management/health literacy (cross-cutting);
Asthma--appropriate treatment for persons with mild/
moderate persistent asthma;
Cancer screening that is evidence-based--focus on
colorectal and cervical cancer;
Children with special health care needs;
Diabetes--focus on appropriate management of early disease;
End of life with advanced organ system failure--focus on
congestive heart failure and chronic obstructive pulmonary
disease;
Frailty associated with old age--preventing falls and
pressure ulcers, maximizing function, and developing advanced
care plans;
Hypertension--focus on appropriate management of early
disease;
Immunization--children and adults;
Ischemic heart disease--prevention, reduction of recurring
events, and optimization of functional capacity;
Major depression--screening and treatment;
Medication management--preventing medication errors and
overuse of antibiotics;
Nosocomial infections--prevention and surveillance;
Pain control in advanced cancer;
Pregnancy and childbirth--appropriate prenatal and
intrapartum care;
Severe and persistent mental illness--focus on treatment in
the public sector;
Stroke--early intervention and rehabilitation;
Tobacco dependence treatment in adults; and
Obesity (emerging area).

Care Coordination--Rationale for Selection

Impact

Nearly half of the population--125 million Americans--lives
with some type of chronic condition. About 60 million live
with multiple such conditions. And more than 3 million--2.5
million women and 750,000 men--live with five such conditions
(Partnership for Solutions, 2001). For those afflicted by one
or more chronic conditions, coordination of care over time
and across multiple health care providers and settings is
crucial. Yet in a survey of over 1,200 physicians conducted
in 2001, two-thirds of respondents reported that their
training was not adequate to coordinate care or education for
patients with chronic conditions (Partnership for Solutions,
2001).
More than 50 percent of patients with hypertension (Joint
National Committee on Prevention, 1997), diabetes (Clark et
al., 2000), tobacco addition (Perez-Stable and Fuentes-
Afflick, 1998), hyperlipidemia (McBride et al., 1998),
congestive heart failure (Ni et al., 1998), chronic atrial
fibrillation (Samsa et al., 2000), asthma (Legorreta et al.,
2000), and depression (Young et al., 2001) are currently
managed inadequately. Among the Medicare-eligible population,
the average beneficiary sees 6.4 different physicians in a
year, 4.6 of those being in the outpatient setting (Anderson,
2002a).

Cancer Screening That is Evidence-Based--Rationale for Selection

Impact

Colorectal cancer is the third most common cancer among men
and women in the United States, with an estimated incidence
of 148,300 cases annually. In 2002, 56,600 Americans died
from colorectal cancer, making it the nation's second leading
cause of cancer-related death. Lifetime risk for developing
colorectal cancer is approximately 6 percent with over 90
percent of cases occurring after age 50 (American Cancer
Society, 2002). The estimated long-term cost of treating
stage II colon cancer is approximately $60,000 (Brown et al.,
2002).
Cervical cancer is the ninth most common cancer among women
in the United States, with an estimated incidence of 13,000
cases annually. Cervical cancer ranks thirteenth among all
causes of cancer death, with about 4,100 women dying of the
disease each year (American Cancer Society, 2002). The
incidence of cervical cancer has steadily declined, dropping
46 percent between 1975 and 1999 from a rate of 14.8 per
100,000 women to 8.0 per 100,000 women (Ries et al., 2002).
Despite these gains, cervical cancer continues to be a
significant public health issue. It has been estimated that
60 percent of cases of cervical cancer are due to a lack of
or deficiencies in screening (Sawaya and Grimes, 1999).

Prevention--Cancer Screening

Improvability

Early diagnosis of colorectal cancer while it is still at a
localized state results in a 90 percent survival rate at 5
years (Ries et al., 2002). The American Cancer Society's
(ACS) guidelines recommend screening for colorectal cancer
beginning at age 50 for adults at average risk using one of
the following five screening regimens: fecal occult blood
test (FOBT) annually; flexible sigmoidoscopy every 5 years;
annual FOBT plus flexible sigmoidoscopy every 5 years; double
contrast barium enema every 5 years; or colonoscopy every 10
years (American Cancer Society, 2001). The United States
Preventive Services Task Force strongly recommends screening
for men and women 50 years of age and or older for colorectal
cancer. Screening has been found to be cost-effective in
saving lives, with estimates ranging from $10,000 and $25,000
life-year saved.

immunization (adult)--rationale for selection

Impact

Pneumonia and influenza are the seventh leading cause of
death in the United States (The Commonwealth Fund, 2002).
Pneumococcal disease causes 10,000 to 14,000 deaths annually;
influenza causes an average of 110,000 hospitalizations and
20,000 deaths annually (United States Department of Health
and Human Services, 2000). Approximately 30-43 percent of
elderly people who have invasive pneumonia will die from the
disease (United States Preventive Services Task Force, 1996).
The elderly are also at increased risk for complications
associated with influenza, and approximately 90 percent of
the deaths attributed to the disease are among those aged 65
and older (Vishnu-Priya et al., 2000).
To decrease the burden of these diseases, including
incapacitating malaise, doctor visits, hospitalizations, and
premature deaths, experts recommend vaccination. Yet one-
third to one-half of older adults (aged 65 and over) do not
receive these vaccinations (The Commonwealth Fund, 2002).
Coverage rates for high-risk adults who suffer from chronic
disease are especially poor, with only 26 percent receiving
an influenza vaccination and 13 percent a pneumococcal
vaccination (Institute of Medicine, 2000).

Mr. KENNEDY. Mr. President, I suggest the absence of a quorum.
The PRESIDING OFFICER. The clerk will call the roll.
The legislative clerk proceeded to call the roll.
Mr. McCONNELL. Mr. President, I ask unanimous consent that the order
for the quorum call be rescinded.
The PRESIDING OFFICER. Without objection, it is so ordered.

[[Page S8621]]

Amendment No. 1097

Mr. McCONNELL. Mr. President, I send an amendment to the desk and ask
for its immediate consideration.
The PRESIDING OFFICER. The clerk will report the amendment.
The legislative clerk read as follows:

The Senator from Kentucky [Mr. McConnell] proposes an
amendment numbered 1097.

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

(Purpose: To protect seniors with cancer)

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

SEC. ____. PROTECTING SENIORS WITH CANCER.

Any eligible beneficiary (as defined in section 1860D(3) of
the Social Security Act) who is diagnosed with cancer shall
be protected from high prescription drug costs in the
following manner:
(1) Subsidy eligible individuals with an income below 100
percent of the federal poverty line.--If the individual is a
qualified medicare beneficiary (as defined in section 1860D-
19(a)(4) of such Act), such individual shall receive the full
premium subsidy and reduction of cost-sharing described in
section 1860D-19(a)(1) of such Act, including the payment
of--
(A) no deductible;
(B) no monthly beneficiary premium for at least one
Medicare Prescription Drug plan available in the area in
which the individual resides; and
(C) reduced cost-sharing described in subparagraphs (C),
(D), and (E) of section 1860D-19(a)(1) of such Act.
(2) Subsidy eligible individuals with an income between 100
and 135 percent of the federal poverty line.--If the
individual is a specified low income medicare beneficiary (as
defined in paragraph 1860D-19(4)(B) of such Act) or a
qualifying individual (as defined in paragraph 1860D-19(4)(C)
of such Act) who is diagnosed with cancer, such individual
shall receive the full premium subsidy and reduction of cost-
sharing described in section 1860D-19(a)(2) of such Act,
including payment of--
(A) no deductible;
(B) no monthly premium for any Medicare Prescription Drug
plan described paragraph (1) or (2) of section 1860D-17(a) of
such Act; and
(C) reduced cost-sharing described in subparagraphs (C),
(D), and (E) of section 1860D-19(a)(2) of such Act.
(3) Subsidy-eligible individuals with income between 135
percent and 160 percent of the federal poverty level.--If the
individual is a subsidy-eligible individual (as defined in
section 1860D-19(a)(4)(D) of such Act) who is diagnosed with
cancer, such individual shall receive sliding scale premium
subsidy and reduction of cost-sharing for subsidy-eligible
individuals, including payment of--
(A) for 2006, a deductible of only $50;
(B) only a percentage of the monthly premium (as described
in section 1860D-19(a)(3)(A)(i)); and
(C) reduced cost-sharing described in clauses (iii), (iv),
and (v) of section 1860D-19(a)(3)(A).
(4) Eligible beneficiaries with income above 160 percent of
the federal poverty level.--If an individual is an eligible
beneficiary (as defined in section 1860D(3) of such Act), is
not described in paragraphs (1) through (3), and is diagnosed
with cancer, such individual shall have access to qualified
prescription drug coverage (as described in section 1860D-
6(a)(1) of such Act), including payment of--
(A) for 2006, a deductible of $275;
(B) the limits on cost-sharing described section 1860D-
6(c)(2) of such Act up to, for 2006, an initial coverage
limit of $4,500; and
(C) for 2006, an annual out-of-pocket limit of $3,700 with
10 percent cost-sharing after that limit is reached.
(5) Construction.--Notwithstanding the preceding provisions
of this section, nothing in this section shall be construed
in a manner that would provide an individual who is diagnosed
with cancer with benefits under part D of title XVIII of the
Social Security Act (as added by section 101) that are
different from the benefits that the individual would have
been eligible for if such individual was not diagnosed with
cancer.

Mr. McCONNELL. Mr. President, the amendment I just sent to the desk
ensures protection of seniors diagnosed with cancer from the high
prescription drug costs associated with that illness.
My amendment states specifically that any senior in Medicare and
diagnosed with cancer shall have the right to a drug plan in which the
beneficiary shall pay no deductible, no monthly premium, no more than a
2.5-percent copayment for any drug spending up to $4,500 a year, no
more than a 5-percent copayment for drug spending between $4,500 and
$5,800 a year, and no more than a 2.5-percent copayment for any drug
spending over $5,800 if their income is below the poverty level.
My amendment states that any senior in Medicare who is also diagnosed
with cancer, with an income between 100 percent and 135 percent of the
poverty level, shall have the right to a drug plan in which the
beneficiary shall pay no deductible, no monthly premium, no more than a
5-percent copayment for drug spending up to $4,500, no more than a 10-
percent copayment for drug spending between $4,500 and $5,800, and no
more than a 2.5-percent copayment for any drug spending over $5,800.
My amendment provides that any senior in Medicare diagnosed with
cancer, with an income between 135 percent and 160 percent of the
poverty level, shall have the right to a drug plan in which the
beneficiary shall pay no more than a $50 deductible, an average monthly
premium not greater than $35, no more than a 10-percent copayment for
drug spending up to $4,500, no more than a 20-percent copayment for
drug spending between $4,500 and $5,800, and no more than a 10-percent
copayment for any drug spending over $5,800.
My amendment also provides that any senior in Medicare and diagnosed
with cancer, with an income above 160 percent of the poverty level,
shall have the right to a drug plan in which the beneficiary shall pay
no more than a $275 deductible, an average monthly premium not greater
than $35, no more than a 50-percent copayment for drug spending up to
$4,500, and no more than a 10-percent copayment for drug spending over
$5,800.
With this amendment, which conforms to the provisions within the
bill, all seniors with cancer get help with prescription drug costs,
especially the poor and moderate-income seniors.
Mr. President, how much time do I have remaining?
The PRESIDING OFFICER. Two minutes.
Mr. McCONNELL. Mr. President, I reserve the remainder of my time.
The PRESIDING OFFICER. Who yields time?
The Senator from Nevada.
Mr. REID. Mr. President, the Boxer amendment is very simple. It says
if a person is receiving cancer drugs and they come to a period of
time--as this bill is written--where they run out of the ability to get
help from the Medicare Program, that they, in effect, are covered.
We want a cancer patient to have no donut hole, no gap in coverage.
That is what the Boxer amendment is all about.
Mr. KENNEDY. Mr. President, do we have any time?
Mr. REID. We have at least 4 minutes.
Mr. KENNEDY. Will the Senator yield me a minute?
Mr. REID. Of course.
The PRESIDING OFFICER. The Senator from Massachusetts.
Mr. REID. Mr. President, I yield 2 minutes to the Senator from
Massachusetts.
Mr. KENNEDY. Mr. President, the Boxer amendment provides the
additional resources for the treatment of cancer. I think all of us
understand the importance of the continuity of care in the treatment of
disease generally. That is why I am going to continue to vigorously
fight for additional resources to fill in this gap in the future for
all diseases. But it is particularly important to fill this gap for
people who are afflicted with the disease of cancer. They are waiting
for Congress to fill in this gap.
It does seem to me, because of the compelling reasons for the
continuity of care in terms of diseases generally we ought to be able
to find the additional resources to fill this gap.
The Boxer amendment does not replace the fundamental structure of
this legislation. It finds the additional resources to be able to make
sure there will be continuity of care for what is, for many families,
their Number 1 health concern. So that is a very compelling reason. I
hope the amendment will be favorably considered.
I suggest the absence of a quorum.
Mr. REID. Mr. President, I ask the Senator to withhold the suggestion
of a quorum.
Mr. KENNEDY. I withhold.
The PRESIDING OFFICER. Who yields time?
If no one yields time, time will be charged equally to both sides.
Who yields time?
The minority leader.
Mr. DASCHLE. Mr. President, I ask unanimous consent that all time be
yielded back.

[[Page S8622]]

The PRESIDING OFFICER. Without objection, it is so ordered.
The question is on agreeing to the McConnell amendment No. 1097.
Mr. McCONNELL. I ask for the yeas and nays.
The PRESIDING OFFICER. Is there a sufficient second?
There is a sufficient second. The clerk will call the roll.
The legislative clerk called the roll.
Mr. REID. I announce that 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. Burns). Are there any other Senators in
the Chamber desiring to vote?
The result was announced--yeas 97, nays 1, as follows:

[Rollcall Vote No. 249 Leg.]

YEAS--97

Akaka
Alexander
Allard
Allen
Baucus
Bayh
Bennett
Biden
Bingaman
Bond
Boxer
Breaux
Brownback
Bunning
Burns
Byrd
Campbell
Cantwell
Carper
Chafee
Chambliss
Clinton
Cochran
Coleman
Collins
Conrad
Cornyn
Corzine
Craig
Crapo
Daschle
Dayton
DeWine
Dodd
Dole
Domenici
Dorgan
Durbin
Edwards
Enzi
Feingold
Feinstein
Fitzgerald
Frist
Graham (FL)
Graham (SC)
Grassley
Gregg
Hagel
Harkin
Hatch
Hollings
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--1

Ensign

NOT VOTING--2

Kerry
Lieberman

The amendment (No. 1097) was agreed to.

Amendment No. 1036

The PRESIDING OFFICER (Mr. Graham of South Carolina). By previous
order, there are 2 minutes evenly divided prior to the vote on the
Boxer amendment.
The Senator from California is recognized.
Mrs. BOXER. The Senator from Kentucky and I agreed to an extra 30
seconds each, so I ask unanimous consent for that.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mrs. BOXER. Mr. President, I want to speak to the hearts and the
minds of each and every one of my colleagues and friends, so I will
speak straight from the shoulder.
The amendment we just voted for did nothing, not one thing, for
cancer patients, except reiterate what is already in the underlying
bill.
What my amendment does, and why I hope we will rise to the occasion
and support it, is to send a strong message to anyone diagnosed with
cancer, and to their families, friends, and loved ones, that if and
when they are diagnosed with cancer, they will not face the benefit
shutdown that is now in this bill.
I will show my colleagues on this chart that at $4,500 of drug costs,
the benefit shuts down. I want my colleagues to think about someone
they know with cancer, someone who is battling cancer. Do we want to
put this burden on them? They must take their drugs. They cannot cut
their pills in half in order to survive.
The Cancer Society tells us that 6 million to 7 million Medicare
beneficiaries are battling some form of cancer, and 380,000 of them
will die of cancer. Please, let us relieve this burden of them having
to pay 100 percent of their drug costs during this benefit shutdown. I
beg my colleagues to take a stand. I beg my colleagues to be
compassionate. I beg my colleagues to be independent for once on an
amendment and support the cancer patients who are counting on us today
to at least relieve them of this terrible financial burden that will
hit them just when they are the sickest.
I urge an aye vote.
The PRESIDING OFFICER. The Senator from Iowa.
Mr. GRASSLEY. Before I use my time, I have a unanimous consent
request. That unanimous consent request is that the time lapse between
the next two votes be 10 minutes instead of 15 minutes.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. GRASSLEY. Mr. President, first, from a parliamentary point of
view, this amendment, if adopted, would subject the entire bill to a
budget point of order. We have enough people in this body who maybe do
not want a prescription drug bill that could take down the whole bill.
The other reason is, all the concerns the Senator has mentioned we
have taken into account within the $400 billion capability of our
legislation. We have before us this $400 billion to provide
prescription drug benefits to our seniors. We have used that $400
billion to help low-income seniors with prescription drug costs if they
have cancer, diabetes, or anything else for which they need drugs.
We have used the $400 billion to limit the catastrophic costs of
prescription drugs to all seniors. We do not create two drug classes
for the sick and the ill, and that is why we should move forward with
this amendment so it does not bring down the whole bill on a potential
budget point of order.
I move to table the amendment, and I ask for the yeas and nays.
The PRESIDING OFFICER. All time has expired. 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 bill clerk called the roll.
Mr. REID. I announce that 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 54, nays 44, as follows:

[Rollcall Vote No. 250 Leg.]

YEAS--54

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
Kyl
Lott
Lugar
McCain
McConnell
Miller
Murkowski
Nickles
Roberts
Santorum
Sessions
Shelby
Smith
Snowe
Specter
Stevens
Sununu
Talent
Thomas
Voinovich
Warner

NAYS--44

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

NOT VOTING--2

Kerry
Lieberman

The motion was agreed to.

Amendment No. 1065

The PRESIDING OFFICER. There are now 2 minutes equally divided prior
to the vote on the amendment offered by the Senator from New Mexico.
The Senate will please be in order. The Senator from New Mexico will
suspend until the Senate is in order.
The Senator from New Mexico.
Mr. BINGAMAN. I ask unanimous consent that the Record reflect we are
updating the asset test to a limit of $10,000 per individual and
$20,000 per couple.
The PRESIDING OFFICER. Is there objection?
Mr. GRASSLEY. Reserving the right to object, have we seen this? We do
not seem to know about this.
The PRESIDING OFFICER. The Senate will be in order.
Mr. GRASSLEY. Reserving the right to object, we do not know about the

[[Page S8623]]

modification--or do we? We do not seem to.
Mr. BINGAMAN. Mr. President, this is what the bill was intended to
say. It is exactly what we have shared with your staff. It is just that
there was a typo in it.
Mr. GRASSLEY. I withdraw the reservation.
The PRESIDING OFFICER. Without objection, it is so ordered.
The Senator from New Mexico.
Mr. BINGAMAN. I ask unanimous consent that the Senator from Florida,
Mr. Graham, be added as a cosponsor.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. BINGAMAN. I also ask unanimous consent that we be allowed 2
minutes to advocate for the amendment and the opposition get 2 minutes
as well.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. BINGAMAN. Mr. President, I will take one of those 2 minutes and
Senator Domenici the other.
This is a Bingaman-Domenici amendment. The purpose of it is not to
eliminate the asset test. That was an earlier amendment I offered and
then withdrew. Instead, it is to update the asset test, where you would
still be required to demonstrate that your income was below poverty or
in that range, but instead of having to demonstrate that your total
combined assets were only $4,000, you would be able to show that they
were less than $10,000.
This also eliminates the paperwork burden that currently is imposed
in most States on people who are required to itemize their assets and
essentially provide a full financial statement to get the full low-
income benefit.
We think this is a needed update on the asset test. It will allow a
lot more people to get the full benefit.
I yield the remaining time to Senator Domenici.
Mr. DOMENICI. Mr. President, this is a very simple amendment. I
believe it is absolutely fair and nothing more than simple equity. We
have had an asset test under Medicaid, which applies here, since 1988.
It is $4,000. That means there is an income test and an asset test of
$4,000. I believe the time has come to change that $4,000 to something
more reasonable--not gigantic, just $10,000. It says the income test
still applies, but you can own assets up to $10,000.
It also says you do not have to fill out all kinds of forms. You can
sign an affidavit under penalty of felony, as to what your assets are,
and that suffices. If there is anything this bill needs it is
simplicity. So this adds simplicity to this form. But most of all, for
the poor people, it permits them to own a car today. You know, hardly
any cars are worth less than $4,000. I think you can be poverty
stricken and still own an automobile.
The PRESIDING OFFICER. The time of the Senator has expired.
Mr. DOMENICI. I believe the amendment should be adopted.
The PRESIDING OFFICER. The Senate will come to order.
The Senator from Maine.
Ms. SNOWE. Mr. President, I urge my colleagues to vote against the
amendment offered by Senator Bingaman. We are not here to alter the
guidelines for the Medicaid Program because it certainly would have an
impact on the underlying Medicaid Program.
Let me be clear. We did not create a new asset test for this benefit.
We followed the asset test that exists in current law and that governs
existing low-income assistance programs under Medicaid and Medicare.
Actually, we learned our lesson from the last debate last fall on the
tripartisan bill. We realized in constructing that approach that we
excluded 40 percent of low-income Medicare beneficiaries. So this time
we built on the existing Medicaid and Medicare Programs. We created a
new program for those under 160 percent of the poverty level that has
no asset test. By doing so, we capture 8.5 million more Medicare
beneficiaries for a total of 17.5 million Medicare beneficiaries or 43
percent of the overall program.
We target our assistance, the most assistance to those most in need.
So it is important for our colleagues to understand, we are using asset
tests that already exist in current law to maximize the most assistance
to those most in need of this benefit.
Mr. President, 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 the amendment.
The clerk will call the roll.
The assistant legislative clerk called the roll.
Mr. REID. I announce that 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 69, nays 29, as follows:

[Rollcall Vote No. 251 Leg.]

YEAS--69

Akaka
Alexander
Allen
Baucus
Bayh
Bennett
Biden
Bingaman
Boxer
Breaux
Brownback
Byrd
Campbell
Cantwell
Carper
Chafee
Chambliss
Clinton
Coleman
Collins
Conrad
Corzine
Daschle
Dayton
DeWine
Dodd
Domenici
Dorgan
Durbin
Edwards
Ensign
Feingold
Feinstein
Graham (FL)
Graham (SC)
Hagel
Harkin
Hollings
Hutchison
Inouye
Jeffords
Johnson
Kennedy
Kohl
Landrieu
Lautenberg
Leahy
Levin
Lincoln
Lugar
McCain
Mikulski
Miller
Murray
Nelson (FL)
Nelson (NE)
Pryor
Reed
Reid
Roberts
Rockefeller
Sarbanes
Schumer
Smith
Specter
Stabenow
Stevens
Warner
Wyden

NAYS--29

Allard
Bond
Bunning
Burns
Cochran
Cornyn
Craig
Crapo
Dole
Enzi
Fitzgerald
Frist
Grassley
Gregg
Hatch
Inhofe
Kyl
Lott
McConnell
Murkowski
Nickles
Santorum
Sessions
Shelby
Snowe
Sununu
Talent
Thomas
Voinovich

NOT VOTING--2

Kerry
Lieberman

The amendment (No. 1065) was agreed to.
Mr. BINGAMAN. Mr. President, I move to reconsider the vote.
I move to lay that motion on the table.
The motion to lay on the table was agreed to.

Change of Vote

Ms. LANDRIEU. Mr. President, on rollcall vote No. 251, I voted nay. I
intended to vote yea. It does not change the outcome of the vote. I ask
unanimous consent that the Record reflect as I have stated.
The PRESIDING OFFICER. Without objection, it is so ordered.
(The foregoing tally has been changed to reflect the above order.)
Mr. FRIST. Mr. President, 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. FRIST. Mr. President, I ask unanimous consent that the order for
the quorum call be rescinded.
The PRESIDING OFFICER (Mr. Bunning). Without objection, it is so
ordered.
Mr. FRIST. Mr. President, I ask unanimous consent that at 2:30 the
Senate proceed to a vote in relation to a McConnell or designee
amendment regarding Alzheimer's, to be followed immediately by a vote
in relation to the Durbin amendment on the same subject, again, with no
second degrees in order to either amendment prior to the votes;
provided further that the Senate then proceed to a vote in relation to
the Dorgan second-degree amendment on premiums to the Grassley-Baucus
amendment No. 1092. Finally, I ask unanimous consent that following
disposition of the Dorgan amendment, the Senate then proceed to a vote
in relation to the underlying Grassley-Baucus amendment, with no other
amendments in order to amendment No. 1092 other than the mentioned Kyl
and Dorgan amendments. I also ask unanimous consent that there be 2
minutes equally divided for debate between each of the votes in this
series as well.
Mr. REID. Reserving the right to object, everyone here is working in
the best of faith to try to work through

[[Page S8624]]

this situation. We don't have the actual document of the Durbin
amendment. I have been told what is in that. I related that to the
majority and to the two managers of the bill. It is very similar to the
Boxer amendment. If it is anything different than that, I will make
sure that we vitiate this agreement.
Mr. McCONNELL. So if the Durbin amendment is other than we
anticipate, I will obviously reserve the right to modify mine as well.
Mr. REID. Absolutely.
Mr. DORGAN. Mr. President, reserving the right to object, I ask the
majority leader if in the period between now and when the first vote
occurs, there will be provided 30 minutes for the offering and
discussion of my amendment. I had previously talked with the Senator
from Nevada. Senator Pryor and I wish to be recognized for 30 minutes
to offer our amendment. I simply ask if that timeframe allows that
opportunity so that we have 30 minutes of debate.
Mr. McCONNELL. Mr. President, I would like to make sure I am
protected to lay down my amendment now.
The PRESIDING OFFICER. The Senator from Nevada has the floor.
Mr. REID. Mr. President, we have approximately an hour and a half. I
would ask, as Senator Dorgan asked earlier, that he and Senator Pryor
be given 30 minutes of that hour and a half, and Senator Durbin be
given a half hour.
The PRESIDING OFFICER. The majority leader has the floor.
Mr. FRIST. Mr. President, I yield to the Senator from Kentucky.
Mr. McCONNELL. Mr. President, we are talking about how to divide up
an hour and a half. How about a consent that we divide the time
equally?
Mr. REID. That will be fine. I ask unanimous consent that the
agreement give each side an extra 5 minutes, so the vote would occur at
2:40, rather than 2:30, and the time be divided equally.
The PRESIDING OFFICER. Is there objection?
Mr. DORGAN. Reserving the right to object, I don't care what the vote
is. Senator Pryor and I wish to speak for 30 minutes. If that is not
provided for in the unanimous consent, I will object.
Mr. REID. That is fine on this side.
Mr. FRIST. Mr. President, we have no objection.
The PRESIDING OFFICER. Without objection, it is so ordered.
The PRESIDING OFFICER. The Senator from Kentucky is recognized.

Amendment No. 1102

Mr. McCONNELL. Mr. President, pursuant to the consent agreement just
entered into, I send an amendment to the desk.
The PRESIDING OFFICER. The clerk will report.
The assistant legislative clerk read as follows:

The Senator from Kentucky [Mr. McConnell] proposes an
amendment numbered 1102.

Mr. McCONNELL. 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 protect seniors with Alzheimer's disease)

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

SEC. ____. PROTECTING SENIORS WITH ALZHEIMER'S DISEASE.

Any eligible beneficiary (as defined in section 1860D(3) of
the Social Security Act) who is diagnosed with Alzheimer's
disease shall be protected from high prescription drug costs
in the following manner:
(1) Subsidy eligible individuals with an income below 100
percent of the federal poverty line.--If the individual is a
qualified medicare beneficiary (as defined in section 1860D-
19(a)(4) of such Act), such individual shall receive the full
premium subsidy and reduction of cost-sharing described in
section 1860D-19(a)(1) of such Act, including the payment
of--
(A) no deductible;
(B) no monthly beneficiary premium for at least one
Medicare Prescription Drug plan available in the area in
which the individual resides; and
(C) reduced cost-sharing described in subparagraphs (C),
(D), and (E) of section 1860D-19(a)(1) of such Act.
(2) Subsidy eligible individuals with an income between 100
and 135 percent of the federal poverty line.--If the
individual is a specified low income medicare beneficiary (as
defined in paragraph 1860D-19(4)(B) of such Act) or a
qualifying individual (as defined in paragraph 1860D-19(4)(C)
of such Act) who is diagnosed with Alzheimer's disease, such
individual shall receive the full premium subsidy and
reduction of cost-sharing described in section 1860D-19(a)(2)
of such Act, including payment of--
(A) no deductible;
(B) no monthly premium for any Medicare Prescription Drug
plan described paragraph (1) or (2) of section 1860D-17(a) of
such Act; and
(C) reduced cost-sharing described in subparagraphs (C),
(D), and (E) of section 1860D-19(a)(2) of such Act.
(3) Subsidy-eligible individuals with income between 135
percent and 160 percent of the federal poverty level.--If the
individual is a subsidy-eligible individual (as defined in
section 1860D-19(a)(4)(D) of such Act) who is diagnosed with
Alzheimer's disease, such individual shall receive sliding
scale premium subsidy and reduction of cost-sharing for
subsidy-eligible individuals, including payment of--
(A) for 2006, a deductible of only $50;
(B) only a percentage of the monthly premium (as described
in section 1860D-19(a)(3)(A)(i)); and
(C) reduced cost-sharing described in clauses (iii), (iv),
and (v) of section 1860D-19(a)(3)(A).
(4) Eligible beneficiaries with income above 160 percent of
the federal poverty level.--If an individual is an eligible
beneficiary (as defined in section 1860D(3) of such Act), is
not described in paragraphs (1) through (3), and is diagnosed
with Alzheimer's disease, such individual shall have access
to qualified prescription drug coverage (as described in
section 1860D-6(a)(1) of such Act), including payment of--
(A) for 2006, a deductible of $275;
(B) the limits on cost-sharing described section 1860D-
6(c)(2) of such Act up to, for 2006, an initial coverage
limit of $4,500; and
(C) for 2006, an annual out-of-pocket limit of $3,700 with
10 percent cost-sharing after that limit is reached.

Mr. McCONNELL. Mr. President, very briefly, the amendment I just sent
to the desk ensures protection of seniors diagnosed with Alzheimer's
from the high prescription drug costs associated with that illness.
My amendment states specifically that any senior on Medicare
diagnosed with Alzheimer's shall have the right to a drug plan in which
the beneficiary shall pay no deductible, no monthly premium, no more
than a 2.5-percent copayment for drug spending up to $4,500, no more
than a 5-percent copayment for drug spending between $4,500 and $5,800,
and no more than a 2.5-percent copayment for any drug spending over
$5,800 if their income is below the poverty level.
My amendment states that any senior on Medicare diagnosed with
Alzheimer's with an income between 100 and 135 percent of the poverty
level shall have the right to a drug plan in which the beneficiary
shall pay no deductible, no monthly premium, and no more than a 5-
percent copayment for drug spending up to $4,500, no more than a 10-
percent copayment for drug spending between $4,500 and $5,800, and no
more than a 2.5-percent copayment for any drug spending over $5,800.
My amendment provides that any senior in Medicare diagnosed with
Alzheimer's with an income between 135 percent and 160 percent of the
poverty level shall have the right to a drug plan in which the
beneficiary shall pay no more than a $50 deductible, an average monthly
premium not greater than $35, no more than a 10-percent copayment for
drug spending up to $4,500, no more than a 20-percent copayment for
drug spending between $4,500 and $5,800, and no more than a 10-percent
copayment for any drug spending above $5,800.
My amendment also provides that any senior on Medicare diagnosed with
Alzheimer's with an income above 160 percent of the poverty level shall
have the right to a drug plan in which the beneficiary shall pay no
more than a $275 deductible, an average monthly premium not greater
than $35, no more than a 50-percent copayment for drug spending up to
$4,500, and no more than a 10-percent copayment for drug spending over
$5,800.
With this amendment, which conforms to the provisions within the
bill, all seniors with Alzheimer's get help with drug costs, especially
the poor and moderate-income seniors.
I yield the floor.
The PRESIDING OFFICER. Who yields time? The Senator from Iowa.

Amendment No. 1093 Withdrawn

Mr. GRASSLEY. Mr. President, I ask unanimous consent, on behalf of
Senator Kyl, to withdraw the Kyl amendment to the Grassley amendment.
The PRESIDING OFFICER. Is there objection? Without objection, it is
so ordered.

[[Page S8625]]

Mr. REID. Mr. President, I ask unanimous consent that the Dorgan
amendment be offered now and the pending amendment be set aside.
The PRESIDING OFFICER. Is there objection? Without objection.
The Senator from North Dakota.

Amendment No. 1103 to Amendment No. 1092

Mr. DORGAN. Mr. President, I send an amendment to the desk and ask
for its immediate consideration.
The PRESIDING OFFICER. The clerk will report.
The assistant legislative clerk read as follows:

The Senator from North Dakota [Mr. Dorgan] for himself and
Mr. Pryor, proposes an amendment numbered 1103.

Mr. DORGAN. 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 reduce aggregate beneficiary obligations by $2,400,000,000
per year beginning in 2009)

In lieu of the matter proposed to be inserted, insert the
following:

SEC. ____. AGGREGATE REDUCTION IN MONTHLY BENEFICIARY
OBLIGATIONS.

Section 1860D-17, as added by section 101, is amended by
adding at the end the following:
``(d) Aggregate Reduction in Monthly Beneficiary
Obligations.--The Administrator shall for each year
(beginning with 2009) determine a percentage which--
``(1) shall apply in lieu of the applicable percent
otherwise determined under subsection (c) for that year, and
``(2) will result in a decrease of $2,400,000,000 for that
year in the aggregate monthly beneficiary obligations
otherwise required of all eligible beneficiaries enrolled in
a Medicare Prescription Drug Plan or a Medicare Advantage
plan that provides qualified prescription drug coverage.
This subsection shall not apply in determining the applicable
percent under subsection (c) for purposes of section 1860D-
21.''.

Mr. DORGAN. Mr. President, this is an amendment that deals with the
question of what to do about the $12 billion of remaining available out
of the $400 billion Congress set aside for a prescription drug benefit
plan in the Medicare Program. According to CBO, the underlying bill is
$12 billion of that $400 billion, so what do we do with that $12
billion? If the bill on the floor of the Senate to add prescription
drugs to the Medicare Program costs $388 billion, and we have allocated
$400 billion, the question is, what do you do with the other $12
billion? So we had a group of people--I am not quite sure who they
were--negotiate over a period of time, and they have now developed a
plan for what to do with the $12 billion.
By far, the simplest, most direct, and most appropriate use of the
$12 billion would be to improve the prescription drug benefit for
Medicare recipients. After all, that is why we are here. That is the
purpose of this discussion and debate. That is the purpose of writing
this legislation--to provide a prescription drug benefit to the
Medicare Program that serves the interests of our senior citizens.
Regrettably, the Grassley amendment before us, to which I have just
offered a second-degree amendment, does not accomplish those goals. So
I offer an amendment that is very simple. It says let's try to improve
this prescription drug benefit plan for senior citizens with the $12
billion that is available.
Let me just mention a word generally about Medicare. We have people
on the floor of the Senate who don't like Medicare. They don't say it,
I know. One of their colleagues said it yesterday in New York City. It
is the only flash of candid comment that I have seen recently.
Congressman Thomas, in the New York Times, dated 6/26, says:

Some of our friends on the other side of the aisle are
saying that if this bill becomes law [meaning the Medicare
prescription drug bill] it will be the end of Medicare as we
know it. Our answer to that is, we certainly hope so.

Let me read it again so we understand what he is saying: ``Some of
our friends [Democrats, he means] . . . are saying if this bill becomes
law, it will be the end of Medicare as we know it. Our answer to that
is, we certainly hope so.''
When I was a young boy in a town of 400 people, my dad asked me to
drive an old fellow to the hospital in Dickinson, ND. He was a man with
a very serious health problem, and he had no relatives, had no vehicle,
had no resources. So I was a teenager just about out of high school. I
got him in my car and drove him to St. Joseph's Hospital in Dickinson,
ND, and dropped him off there to be treated. He had a serious health
problem but no insurance, no money, nothing.
The fact is, that was at a period of time in the late 1950s and early
1960s when a good many senior citizens had no capability to get health
care. They had no insurance coverage. It wasn't the case that insurance
companies were running after old folks to ask them: Can we please sell
you a health insurance policy? They want to insure 22-year-olds--
healthy, vibrant, young 22-year-olds.
That is where they make money. They don't make money by chasing 75-
year-old people and selling them health insurance policies. Back in the
early 1960s, one-half of America's elderly had no health insurance--
none. None at all.
Then along came Medicare. The Congress had a real debate about that.
I wasn't here then, but you know there were naysayers who say no to
everything for the first time. They said no, no, no; you cannot create
Medicare. Well, we did create Medicare, and now 99 percent of the
senior citizens in this country don't have to go to bed at night
worrying about whether they can get medical care because they have
health care coverage under Medicare. God bless them for that. They
needed it, they deserved it, and this country provided it through the
Medicare Program.

Some say: We have incredible problems financing this program. Yes, we
have some financial problems, no question about that. Do you know how
we solve those problems? Go back to the old life expectancy. Go back
100 years and, on average, you were expected to live to 48 years of age
in this country. Now people live to 76 to 77 years of age.
Life expectancy has increased dramatically in this country. That is
good news. Our financing problems with Medicare are born of good news.
People are living longer. Good for them. Good for us. Good for our
country.
Is it a problem to have good news? I do not think so. We will solve
these issues. But even as we have done that, even as people are living
longer and better lives, these new miracle medicines that have been
created since Medicare was created are very expensive but very
necessary for people to continue their lifestyle. And we have no
prescription drug coverage in the Medicare Program.
Clearly, if we wrote Medicare starting from scratch today, we would
have prescription drug coverage. That is clear to everyone. But
prescription drugs were not a key medical expense when Medicare was
created, so now we have to put that coverage in the Medicare Program.
Because some people do not like the Medicare Program--to wit my
colleague, Congressman Thomas who said, ``certainly we hope this will
be the end of Medicare as we know it,''--they want to privatize
Medicare. Now, keep in mind that the private sector is the sector that
would not insure old people in the first place, which is the reason why
Congress had to develop the Medicare Program.
That brings us back to this question of what to do with the $12
billion. We are struggling to put together a benefit that means
something to the people who need it. This is not theory. It is not a
debate in the abstract. It is about some 85-year-old widow who, today,
is going to the pharmacy in the back of a grocery store and trying to
figure out how much her prescription drugs are going to cost so she can
figure out how much money she has left for groceries. That is happening
in a real sense today all across this country.
We have $12 billion. We also have a bill that says to senior
citizens: You pay $35 a month on an optional basis if you want this
program of ours, and after $35 a month, you pay the first $275 in
prescription drugs. Between $275 and $4,500, the Federal Government
will help you by paying 50 percent of your prescription drug costs. And
then between $4,500 and $5,800, there is what is famously called the
donut hole, which means you receive no coverage.
So you are not covered until you spend $275, then you are partially
covered, then you are not covered again, and then you get catastrophic
coverage. This is the most byzantine, complicated system we could
possibly put together. It clearly is done by committee. We could not
have done this so

[[Page S8626]]

badly if it were done without a committee.
Having said all of that, the question is, What do we do with the $12
billion? We are told today, with the Grassley amendment, that we will
provide $6 billion of the $12 billion to test a new alternative bidding
system for paying PPOs--and if this is not complicated enough, just
stay with me--that would reimburse these PPOs based on the median
amount of the three lowest bids. There is nothing here that protects
American taxpayers by ensuring we are not paying private health plans
substantially more than traditional Medicare costs.

Here is what it means in English. It means we are going to have an
experiment with private sector delivery, but we are going to
incentivize insurance companies. We are going to provide them some of
this money so that they will actually want to offer this plan, so we
can say at the end of it that somehow the plan is a good plan.
We already know that does not work. My colleague, Senator Hollings,
says there is no education in the second kick of a mule. We know this
does not work. We know what happens. We know the Medicare Payment
Advisory Committee, MedPAC, which is a nonpartisan committee that
advises Congress on Medicare payment policies, says private plans cost
15 percent more than traditional Medicare. We know that. We do not have
to spend $6 billion giving money to private insurers to do an
experiment. We know what does not work. We know the cost advantage of
Medicare, and yet our colleagues continue to resist and continue to
insist that we move Medicare beneficiaries into the private sector. And
now with half of the $12 billion, they say let's do this little
experiment.
Will it enhance the health of senior citizens? No. Will it improve
health care? No, not at all. Will it actually improve the underlying
bill, improve the benefits, reduce the costs? No, not at all. This is
just like a puppy dog following the master home. It is putting more and
more money down this chute to pursue this dream of trying to
demonstrate something we already know does not work.
Mr. DURBIN. Will the Senator yield?
Mr. DORGAN. I will be happy to yield.
Mr. DURBIN. Do I understand that senior citizens, given the choice
between traditional Medicare and Medicare HMOs, have already voted and
that 88 or 89 percent of them want traditional Medicare; that they do
not want to put their medical fate in the hands of these HMO private
insurers who are unreliable, who may or may not cover the procedures
they need? Haven't the seniors of this country, with their experience,
already voted on this issue we are considering?
Mr. DORGAN. Seniors have already made that judgment. They have
already decided that. So we want to take $6 billion and give it to
private health insurers at a time when Senators have been coming to the
Chamber and saying we cannot improve this plan because we do not have
any money. I have quotes of all the Senators, and I shall not name them
all. I could read lots of quotes from the last 2 weeks of Senators. Why
can't we improve it? Because we are limited by money. So now we have
$12 billion more? That is what happens when you go into a room, shut
the door, make a little deal, and say this is how we want to use this
money: We are going to take $6 billion and try an experiment that we
failed at previously. It makes no sense to me. It is a byzantine
failure, in my judgment, to do it this way.
What I am proposing in my amendment is use the money to actually
improve the program for senior citizens. We can drive down the cost of
the prescription drug policies and improve the coverage.
Mr. DURBIN. I ask the Senator, if he will yield further, is the
Senator aware of a recent survey of seniors--over 600 across the United
States--where they were told what this plan, S. 1, is all about? They
said the fact that the $35 premium is not mandated in this law but is
simply a suggestion; it may go higher; the fact private
insurance companies that provide the prescription drug benefit may
decide to change the benefit or go out of business every 2 years; the
fact there is a $275 deductible and a huge gap in coverage for the
sickness of the senior citizens--when they looked at all those items,
is the Senator aware of the fact that most of the seniors, when asked,
said they did not believe that S. 1 really answered the need in America
that seniors are looking for?

Mr. DORGAN. I know that is the case. I have seen the same survey to
which the Senator referred. I think there are some provisions in this
bill that have some merit. I prefer we do something rather than do
nothing, but when we do something, let's do something right and
something that benefits senior citizens. This is the case when you cite
the polls, when you cite what our previous experience has been. It is a
case, especially with respect to the use of this $6 billion, of the old
joke from the movies: What are you going to believe, me or your own
eyes?
The fact is, we have already had these experiments. We understand how
much additional costs are involved in the private sector delivery of
this benefit, and we also know what Medicare does and how Medicare
works. We know the private insurers have about a 14-percent overhead in
administrative costs and delivering their service. We know that. We
also know Medicare has about a 4-percent cost, a dramatic advantage.
For that reason alone, you would want to provide this benefit through
the traditional Medicare delivery system. Against all odds, we have
people in this Chamber who, I guess, although they do not say it,
believe along with Congressman Thomas that this bill ought to be the
end of Medicare as we know it. Congressman Thomas said: Our answer to
that is, we certainly hope so.
Mr. DURBIN. I ask the Senator, is it possible Halliburton is going to
pay some of these services with the six--I will withdraw that question.
I ask the Senator, if one believes in privatization and competition,
why does the private sector need a $6 billion subsidy to compete with
Medicare? If they are good, if they are efficient, if they are customer
friendly, why do they need this Federal subsidy of $6 billion to offer
an attractive health care package to seniors?
Mr. DORGAN. First, they do not need it, and no subsidy is warranted.
The point of my amendment is to say if you have $12 billion, and they
say let's take $6 billion and use it for an experiment that we know
does not work, let's instead use that money to help seniors. Then the
underlying amendment says let's take another $6 billion and test
whether focusing on wellness will work, which we know it does work. We
do not exactly have to have an experiment on that. Do things that
promote wellness and the fact is you save money on the acute care side
by not having people go into the hospital because they are taking care
of themselves and have the kind of preventive care that is necessary to
take care of themselves.

I have another amendment pending. It has been pending for nearly a
week. I hope it will be approved by the end of this process. It is a
very inexpensive amendment that deals with that very kind of wellness
approach.
If senior citizens have heart disease, Medicare covers cholesterol
screening. It makes sense, does it not? But Medicare does not cover
cholesterol screening if one does not know they have heart disease. It
does not make sense.
Heart disease is our biggest killer in this country. We ought to
cover cholesterol screening across the board. That is the way one can
discover who is at risk for heart disease at a point when steps can be
taken to prevent it. Yet Medicare does not cover that screening unless
a person already has evidence of heart disease.
There are many things we should do to improve Medicare's preventive
coverage. My hope is that perhaps we will have that amendment approved
before the end of this process.
My colleague from Illinois talked about HMOs a moment ago. We are not
in the trenches of the HMO debate as it was first envisioned by the
White House, which said to senior citizens, here is a Faustian bargain:
we will give you a prescription drug benefit but only if you enroll in
an HMO. Talk about a goofy proposal; that is it.
I have been talking about HMOs. There were some HMOs that did some
good things, held down some prices. I understand that. But we have all
also heard the stories of HMOs not taking

[[Page S8627]]

good care of people. I guess we do not need to review the HMO stories
about what happens to patients when profits were at stake. For
instance, a woman falls off a cliff in the Shenandoah Mountains,
sustains very serious head injuries and body injuries. She is hauled
into an emergency room on a gurney in a coma. After a long
convalescence, she finally gets out of the hospital only to be told by
her HMO that they will not cover her emergency room treatment because
she did not have prior approval to use the emergency room. This is a
woman who is hauled in on a gurney in a coma.
I will not revisit all of those HMO stories because it will take too
much time, but I will say this: With Medicare, we know what works. Some
of my colleagues make the case that it costs too much. Do my colleagues
really know what costs too much in Medicare? It costs too much because
people are living too long. What a wonderful set of victories we have
in this country. With great health care, people are living longer.
I probably should not talk about my uncle again, but I have an 81-
year-old uncle who runs the 400 meter and 800 meter in the Senior
Olympics. He is probably out running today. He runs 3 miles a day at 81
years old. Forty years ago, one reached 81 years old and they had to be
in a chair someplace, but not any longer. People live longer, doing
things no one ever expected them to do. And that includes my uncle.
Good for them. Good for him. But because people live longer, Medicare
costs more. That is not a sign of failure; it is a sign of success.
Now we are trying to add to Medicare that which should have been
added some long while ago: The miracle drugs that do provide miracles
but only if one can afford them. We are talking about covering the
drugs that keep seniors out of the hospital and they do not have to go
into an acute care hospital bed. That is what we are dealing with.
With this amendment, we are dealing with $12 billion. Instead of
bifurcating it into two different experiments, one of which failed and
one of which we do not need because we know the answer, what I propose
we do is use that $12 billion to reduce from $43 to $38 the premium our
senior citizens will have to pay for this prescription drug benefit,
starting in 2009.
There are people who live on $350 or $450 a month, their total income
from their miserable little Social Security payment, who are living
alone in a small town, are struggling to buy food, struggling to buy
the necessities of life. There are people who have been told by their
doctor: Oh, by the way, you have heart disease and diabetes, and here
are the prescription drugs you need; and they sit at home knowing they
do not have a penny to pay for those prescription medicines. Talk to
those seniors and understand how important this coverage is. The
coverage ought to be good and extensive coverage, and it ought to
provide what we know we should provide for senior citizens.
Second, it ought to be done in an affordable way. Unfortunately,
another weakness of this plan is that there is no defined benefit,
which means the premiums can vary. The monthly premiums will increase
year after year because we have not done enough to put downward
pressure on prescription drug prices--and as prescription drug prices
increase, the monthly premium will increase. The expectation is that
the monthly premium starts at $35 and goes to $60 in a 10-year period.
My amendment proposes about a $6 reduction in the monthly premium for
senior citizens. That is a more effective way to use this $12 billion.
Either that, or I would propose we extend the coverage through the
$1,300 gap that exists in coverage, which I think would also represent
a meritorious way of using this amount of money.
My colleague, Senator Pryor from Arkansas, is in the Chamber and he
may wish to address this issue as well. I have offered this amendment
on behalf of myself and my colleague Senator Pryor, so I yield the
floor in the hope that Senator Pryor will wish to make some comments as
well.
Mr. GRASSLEY. Mr. President, it is unfair for Members of the other
side of the aisle to give us statistics that say 89 percent of the
seniors are in for fee-for-service Medicare and only 11 percent are in
Medicare+Choice and that is a nationwide average. It is an accurate
statistic, but it does not speak to the seniors of America who like
Medicare+Choice and I have figures from four cities--Miami, New York,
San Francisco, and Chicago.
In Miami, 45 percent of the senior citizens have chosen managed care,
the Medicare+Choice option, as opposed to fee-for-service; New York, 22
percent; San Francisco, 29 percent. In Chicago, it was only 6 percent.
That may be one reason why Senator Durbin keeps bringing this up quite
regularly. This data is from the Congressional Research Service, and it
is as recent as March 2003.
When people, wherever they are in the Senate, want to denigrate
Medicare+Choice by saying only 11 percent of the people in this country
join in and that is such a small percentage and that these figures are
evidence it is not liked, go to Miami and ask 45 percent of the
citizens who belong to Medicare+Choice why they like it.
I yield the floor.
The PRESIDING OFFICER. The Senator from Arkansas.
Mr. PRYOR. Mr. President, last night was a difficult night for me
because I was lying in bed worrying about the insurance companies and
how we were not getting them enough money during this Congress. Of
course, I am being facetious because I think we have a very clear
choice.
I commend Senator Dorgan, Senator Durbin, and a number of others who
have shown national leadership on this effort to try to make this bill
better. I think there is a broad consensus that we want to add a
prescription drug benefit to Medicare. We want to help seniors all over
this country, but at the same time we have to make sure it is set up
the right way. It has to make sense.
Quite frankly, one of the things that to me does not make sense, and
probably to most people around the country does not make sense, is that
we might give a pretty healthy sum of money to the insurance industry.
All over the country--and I know it is certainly true in my State--
insurance companies are raising premiums. It may be health care
premiums--everybody knows those are going up. It may be property and
casualty; it may be homeowners policies, auto policies, medical
malpractice, legal malpractice. You name it, across the board, as far
as I know, the price of every single kind of insurance in this country
is going up.
Nonetheless, there are some in this Congress who want to actually
give them a sizable chunk of money that could go to people who really
need the help.
I take my hat off to Senator Dorgan for his leadership. One thing he
has figured out is a way to make the monthly premium less for people.
Now, saving $6 a month to someone at my income level, and all of our
income levels, that is not a lot of money, but for those senior
citizens all over this country who live below the poverty level--the
only money they get every month is Social Security, maybe a little help
from the family--$6 is a lot of money. Six dollars may make this
program affordable for them. It is real money. It is money that at the
end of the year, if you add it up, is only $72 a year, but that is real
money to so many Americans all over this country.
The purpose of the bill, not just this amendment but the whole bill,
is to help Americans afford their prescription drugs. I know that
Senator Durbin, who is in the Chamber, and Senator Dorgan and a number
of others in this Chamber have tried to make prescription drugs more
affordable in this legislation. There have been different efforts tried
in different ways. One of the things I tried was to strengthen
reimportation from Canada to try to make prescription drugs more
affordable, but certainly making the premiums more affordable makes the
program more accessible to more Americans. That is a win/win/win for
everybody.
So I thank the Senator from North Dakota for yielding me some of his
time. I know he is frantically talking to colleagues to try to have
them adopt this amendment when we vote on it this afternoon.
Let's run through the numbers very quickly one more time so we
understand clearly what we are talking about. This amendment expends
$2.4

[[Page S8628]]

billion per year to make premiums cheaper. It will reduce the typical
premium--this is average--by $6 a month.

I take my hat off to the folks in this Chamber who worked out
compromise after compromise after compromise trying to come up with
solutions to make this bill something that will become law, something
that the majority of Members can vote for, not just in this Chamber but
the House, something the President can sign.
I believe strongly people in this country deserve to have access to
these wonderful prescription medications that are in many ways miracle
drugs. It is a shame for this country to have these drugs available on
the marketplace but so expensive that people cannot afford them. That
is what we are trying to accomplish.
I yield the floor.
The PRESIDING OFFICER. The Senator from Illinois.
Mr. DURBIN. I thank my colleague from Arkansas as well as my
colleague from North Dakota. They have come to the floor and said to
the Members of the Senate, look, we found $12 billion. Imagine $12
billion over a period of time. We are in the middle of debating a
prescription drug bill. What would the Senate do with new found money,
$12 billion worth?
We took a look at the underlying bill, the prescription drug bill.
There are a lot of problems with it. There is no guaranteed monthly
premium. It has a deductible. It has a period of time when there is no
coverage. You are paying prescription drug bills and you have no
protection, no coverage. There are a lot of uncertainties in this bill.
You would think the first thing you would do with the $12 billion is
make this a stronger bill, try to take care of some of the weaknesses,
the deficiencies.
Wrong. Given $12 billion, an agreement has been reached not to give
the money to the seniors to help them pay for prescription drugs but to
give $6 billion to HMOs and private insurance companies, a $6 billion
Federal subsidy so they can experiment with alternatives to Medicare.
I am like my colleague from Arkansas; I could not get a moment's rest
last night for fear that we just were not going to give enough money to
the insurance companies when this was all over with. I lost all my
sleep the night before worried about the fact that maybe pharmaceutical
companies would not get all the money that we could possibly throw
their way. Then along comes this amendment. We can rest easy tonight
because we will give $6 billion to HMOs. This industry which
manufactures the milk of human kindness for seniors and families across
the America by denying basic health care coverage so they can run up
profits is going to need a Federal subsidy.
What a delicious irony that we cannot help poor seniors trying to pay
for prescription drugs because, Senator, we just do not have enough
money. And we cannot help our schools, we cannot pay for President
Bush's No Child Left Behind, this unfunded mandate on everybody's local
schools because, Senator, we just do not have enough money. But the $6
billion we just found we are going to give to the HMO insurance
industry.
When they write the history of this debate, this amendment will stand
out. This amendment is a tribute to selfishness, a tribute to
shortsightedness. Why in the world aren't we helping the people who
need it the most? Why are we giving the money to the HMOs so they can
experiment with an effort to end Medicare?
I just ran into Bill Thomas in the hallway, chairman of the House
Ways and Means Committee, most powerful man when it comes to Medicare
in the House of Representatives. He said in today's New York Times:

Some of our friends on the other side of the aisle are
saying if this bill becomes law, it will be the end of
Medicare as we know it. Our answer to that is, we certainly
hope so.

Well, thank you, Congressman Thomas, for your candor. And your candor
is the reason why so many Senators have now come to the Senate and said
the only way to end Medicare is to subsidize HMOs with even more money
so they can be more profitable and try to force Medicare out of
business. That is what it is all about.
My colleagues will have two choices. They can join me in voting with
Senator Dorgan, Senator Pryor, and others and say if you have $12
billion, for goodness' sake, put it into this bill. Make this bill a
little better for seniors. Reduce the cost for seniors. Give them some
assurance of what they will pay. Provide more prescription drug
coverage. That is one option. I will support it.

If it does not succeed, I will offer a second option. It reaches a
point under the bill we are debating, during the course of a year, when
there is a gap in coverage where the Federal Government will not help
pay one penny on your prescription drugs, and about $3,700 into the
year out-of-pocket expenses for prescription drugs, this plan cuts off.
The underlying plan says you are on your own until you get in the range
of $5,500. Then we will start paying you again. So there is a gap in
coverage where that senior citizen, that widow living by herself, has
to pay all of the prescription drug bills until she reaches the
catastrophic coverage level.
This would not be a problem if you did not have over $3,700 in
prescription drugs a year. But a lot of seniors do. I have run into
them, met them in Illinois, heard their testimony on Capitol Hill from
across the country.
I will offer an alternative to my colleagues in the Senate that says
simply this: We want to make sure people who suffer from some of the
most expensive diseases that afflict senior citizens can pay for their
medication. So we will take the $12 billion and we will put it into the
basic bill and cover heart disease, cancer, Alzheimer's, diabetes and
its complications.
We are not going to leave you high and dry. At the end of $3,700 of
subsidy from the Government, we are going to take the $12 billion and
put them back in there to try to keep helping you if you are afflicted
with one of these diseases.
I will readily concede to my colleagues that I can think of a half a
dozen other diseases where people have horrendous prescription drug
bills and need help but I will try to appeal to my colleagues. Here is
your choice. You have a parent or a grandparent, suffering from cancer,
who has to buy expensive drugs to stay alive. The Government program
that we are proposing stops paying for those drugs halfway through the
year because they have reached a point where they spent $3,700 and now
they have to wait and spend another $1,500 to $1,800 of their own money
before they have coverage. You can help them pay for those cancer
therapies or you can send $6 billion in Federal subsidies to HMO
insurance companies.
That is the choice. It is a fairly straightforward choice.
According to a July 2002 study, heart disease and hypertension are
the most expensive conditions to treat. Millions of Medicare
beneficiaries are suffering from them and struggling to pay for their
medications. That is one of the conditions we would help pay for with
the $12 billion, $6 billion of which is headed for these private
insurance companies' subsidy.
The majority of America's cancer patients are on Medicare. They are
your parents and grandparents. They are struggling with all forms of
cancer. Nearly 60 percent of new cancer diagnoses and 50 percent of all
cancer-related deaths occur in people 65 years and older.
I am not identifying a problem that does not exist. It exists. Ask
any family about cancer, my family included. We all have stories to
tell. And you know how expensive it is now to keep that loved one alive
to try to give them a chance to survive. This bill cuts them off and
leaves them high and dry. My amendment gives them a chance.
More than 2 million of all Medicare beneficiaries will have cancer in
2003. Let me give an example of a couple who wrote to my office. They
wrote a couple years ago from a downstate community, a small community.
It is one of the letters that Senators get every day, one that we
saved. It was sent to us in September of 2002.

Dear Senator Durbin:
My wife has multiple myeloma, which is a cancer of the bone
marrow. This disease, while controllable, is not curable. As
a result, she has to take a great deal of drugs for physical
as well as mental anxiety.
Last year our combined prescription drug bill [and this is
the year 2000] was $4,500. This year our regular prescription
drug bills will be more.
Now my wife Marion has been put on Thalidomide. A great
many multiple myeloma

[[Page S8629]]

patients are now on Thalidomide. Said drug is very expensive.
With a low dose [and this is in the year 2000] it is $455.99
a month.

Incidentally, we checked. That same low dose now costs $645 a month.
So in 3 years it has gone up over 40 percent. It costs them $5,500 a
year just for that drug. This is an elderly couple in their retirement
on a fixed income, fighting cancer, putting every dollar in their
savings into keeping one of them alive. Think about $644 a month. Think
about seniors trying to survive on $1,100 a month on Social Security.
And think about this bill which says to this family from Illinois and
others just like them: I am sorry, but at some point we are going to
stop paying.
Doesn't it make more sense for us to take the $6 billion and not give
it in a subsidy to these private insurance companies but instead give
it to these seniors to help them pay these bills? I think it does.
I don't have to tell you the story of Alzheimer's. Is there a family
in America that does not have a loved one or a friend who is struggling
with some form of Alzheimer's? God bless us; we are living longer, but
as we do life gets more complicated. Let me give an example of a
gentleman in Maplewood, MN. His annual out-of-pocket drug costs for
Alzheimer's are $7,000--annual cost. This man is 78 years old. He pays
as much out of pocket for prescription drugs as he does for all of his
other household expenses combined. He is a World War II vet, father of
three. He is a full-time caregiver for his wife. He hasn't had a
vacation in 5 years. He has given up what he loves to do because he
just can't afford them.
``I am managing the cost, but I'm pretty nervous about it,'' he says.
Medicare can do something to help. Yes, it can. That is our choice. Are
we going to do something to help these seniors facing the most
expensive medical conditions or are we going to give $6 billion to
private HMOs in a Federal subsidy?
The last one I include is diabetes and its complications. I am sad to
report to you, those who are following this debate, diabetes is
reaching epidemic proportions in America. Over 6 percent of the
American population suffers from some form of diabetes. In the late
stages of diabetes, the complications become horrible: Amputations,
blindness, severe problems.
Faced with this in your senior retirement years, depending on a
prescription drug plan, do you really want to say to these people and
these families battling diabetes and its complications: We are going to
cut you off. We would love to give you more but frankly we have to help
the HMO insurance companies. Those are the ones who really need a
helping hand.
You couldn't take that argument to any town in America. You couldn't
take it to any public meeting. You couldn't take it to any senior
citizens. You couldn't take it to any family with a loved one
struggling with one of these diseases.
So my friends on the floor of the Senate are going to have a choice:
$6 billion in Federal subsidies for HMOs or $6 billion to help seniors
struggling with these terrible, life-threatening, expensive conditions,
to pay their prescription drug bills. I think that choice is easy. I
hope the majority of the Senate agrees.

I reserve the remainder of my time.
The PRESIDING OFFICER. Who yields time? The Senator from Iowa.
Mr. GRASSLEY. Mr. President, I yield myself such time as I might
consume to address the issue of the amendment by the Senator from North
Dakota and his attempt to take money from the $12 billion that is the
bipartisan compromise that is a major compromise on this amendment
between Republicans and Democrats. The $12 billion is being divided: $6
billion to make the marketplace provider organizations more
competitive, to save money, and to get people into organizations that
will manage particularly chronic disease; and the other $6 billion to
go for Medicare demonstration projects to do the same, have about the
same result, to have chronic disease management.
The reason for this compromise is both approaches deal with the issue
that 5 percent of the sick people under Medicare are responsible for
about 50 percent or 55 percent of the cost of Medicare. It is a small
segment of people. If we were in business and we found 5 percent of our
employees, or a certain problem we had with our business that was just
5 percent of it, but it was 50 percent of the cost of our business, we
would hone in on that problem with the particular business.
The Federal Government is in the business of providing health care
for our seniors. If we have 5 percent of our senior population who, for
various reasons, are the cause of 50 percent of the costs of Medicare,
then quite obviously we ought to concentrate on that 5 percent. We have
plans to do that. This is how we use this $12 billion, and we do it in
a bipartisan way.
Honestly, the Senator from North Dakota is very open about it; he has
a better idea how to use that money. He would take it to lower the
monthly premium paid by beneficiaries in the new Part D prescription
drug program.
I have at least two problems with that. First of all, the
Congressional Budget Office's rule of thumb is that it costs around $5
billion to lower the estimated $35-a-month premium by just $1. You
spend $5 billion and reduce the monthly premium from $35 down to $34.
So if you take the $12 billion that is available in the Grassley-Baucus
amendment and use that to lower the premium for the people he wants to
lower the premium for, instead of paying $35 a month they will be
paying $32.50 a month.
My colleagues have to weigh that against the use of this money where
we want to focus in on fee for service as well as the new Medicare
Program, zeroing in on trying to save Medicare money by managing the
chronic disease situations of the 5 percent of the most sick people
under Medicare.
So the underlying Grassley-Baucus amendment, I remind my colleagues,
authorizes the Secretary to establish a number of projects in fee-for-
service Medicare Programs that would provide these enhanced services
and benefits for beneficiaries. These enhanced services or benefits
include preventive services, chronic care coordination, and disease
management services. These are very worthwhile projects and have the
potential to help many beneficiaries get better care and considerably
reduce the cost in the Medicare Program.
I don't know how many Members on the other side of the aisle have
worked with this issue we are trying to put $6 billion toward, chronic
disease management. A lot of people who have the same political
philosophy as the Senator from North Dakota are very concerned about
doing that. We are concerned on this side about doing it as well. That
is why it is a bipartisan piece of legislation.
I don't know how, in good conscience, the Senator from North Dakota
can take money that would reduce a monthly premium by $2.50, still
costing $32.50, away from chronic disease management and a lot of other
things that people on his side of the aisle are very concerned about.
It would not be possible to do these projects that we have in the
underlying amendment. It seems to me that the Grassley-Baucus amendment
with this bipartisan compromise of $6 billion enhanced membership in
PPOs as well as $6 billion for chronic disease management in the older
fee-for-service Medicare Program is preferable to the second-degree
amendment offered by the Senator from North Dakota.
I urge my colleagues to not support the amendment by the Senator from
North Dakota.
This is the second or third time I have heard that seniors have voted
on whether they like fee for service or Medicare+Choice, the argument
being 89 percent of the people in this country are in fee for service.
Eleven are in managed care, Medicare+Choice, HMO, whatever you want to
call it. That is true for the Nation as a whole.
But remember that in the vast geographical part of America HMOs are
not available. In the State of Iowa, only 1 county out of 99 has an HMO
for our seniors to join. We have 4,000 Iowans in Medicare+Choice. No
place else in Iowa can my citizens get it. The Des Moines Register is
always editorializing why more of Iowa cannot have Medicare+Choice so
the seniors of our country have that opportunity.
But what is unfair about the 89 percent versus the 11 percent, and
Senators making statements that it is so overwhelming that seniors do
not like Medicare+Choice, is the fact that if more had that choice more
would take it.

[[Page S8630]]

I use, as a basis for my statement, that in the larger cities of
America a much higher percentage of seniors have decided to join
Medicare+Choice. They do it voluntarily. They can go in one year and
get out the next, if they don't like it. They have voted by a much
higher percentage in favor of Medicare+Choice. They like it because
they get more for their money. First, they do not have to pay Medigap
insurance. Second, they might get things such as eye glasses and a
better deal on prescription drugs than people who are in traditional
Medicare fee for service. Where they have had a chance to have that
option, a much higher percentage of seniors than 11 percent will join.
All you have to do is talk to people in my State who go to Arizona,
California, and Florida for maybe the winter and find out about what
people in those States have when they join Medicare+Choice. They ask,
Why can't we have that in more places in the country?
A couple of speakers on the other side of the aisle have talked about
wasting money with Medicare+Choice. I think you ought to ask the
seniors who join and who like it. That is a much higher percentage than
11 percent in a lot of the cities. It is not a fair comparison to imply
that since only 11 percent of the people in the country have it and
because such a high percentage can't get it that Medicare+Choice is not
desired by seniors of America.
Our underlying legislation, the Grassley-Baucus bill, is going to
make that opportunity more available for people down the road as we
bring in new options. What we want to do in the underlying bill is give
our seniors the right to choose. Not enough of them have a right to
choose. They have a right to choose prescription drugs. They don't want
to join for prescription drugs if they don't have to. They have a right
to choose between traditional Medicare. If seniors say they are
satisfied with what they have, I can say to those seniors that they can
keep what they have. It is their choice. But it you want to go over
here and join something that has more options, you will have that right
to choose. You should have that right to choose.
One of the complaints people made about the President's program was
that if you were going to get prescription drugs you had to go over to
a new type of Medicare. In traditional Medicare, you could not get
prescription drugs--or at least not much of a program; at least not
equal to what you could get over here in the new program.
That is where Senator Baucus and I disagree with the President of the
United States. We believe in equal benefits. If you want prescription
drugs, if you want to join it voluntarily, and if you want to stay in
traditional Medicare fee for service, you can have prescription drugs.
If you want to go over here and choose a new form and have prescription
drugs with it, that is your choice.
The right to choose and fairness and equality and no pressure is the
basis for this bipartisan Grassley-Baucus legislation. That is the
basis for the compromise amendment that is before us which the Senator
from North Dakota wants to detract from and use the money someplace
else.
I think we need to keep this balanced approach. We need to keep the
fairness, the equality, and no pressure and the right to choose.
Seniors should have options just as other people have.
I yield the floor.
The PRESIDING OFFICER. The Senator from Illinois.

Amendment No. 1108

Mr. DURBIN. Mr. President, I call up my amendment, which I send to
the desk pursuant to the unanimous consent request.
The PRESIDING OFFICER. The clerk will report.
The assistant legislative clerk read as follows:

The Senator from Illinois [Mr. Durbin] proposes an
amendment numbered 1108.

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

(Purpose: To provide additional assistance for certain eligible
beneficiaries under part D)

At the appropriate place insert the following:

SEC. ____. ADDITIONAL ASSISTANCE FOR CERTAIN ELIGIBLE
BENEFICIARIES UNDER PART D.

Section 1860D-26, as added by section 101, is amended by
adding at the end the following:
``(d) Additional Assistance for Certain Eligible
Beneficiaries.--
``(1) Program.--Subject to paragraph (2), the Administrator
shall implement a program (for the period beginning on
January 1, 2009, and ending on September 30, 2013) to provide
additional assistance to applicable eligible beneficiaries
who have reached the initial coverage limit described in
section 1860D-6(c)(3) for the year but have not reached the
annual out-of-pocket limit under section 1860D-6(c)(4)(A))
for the year in order to reduce the cost-sharing requirement
during this coverage gap.
``(2) Funding limitation.--The Administrator shall
implement the program described in paragraph (1) in such a
manner that will result in a decrease of $12,000,000,000 in
cost-sharing for covered drugs under part D by applicable
eligible beneficiaries during the period described in such
paragraph. The Administrator shall take appropriate steps to
ensure that the costs of the program during such period do
not exceed $12,000,000,000.
``(3) Applicable eligible beneficiary.--For purposes of
this subsection, the term `applicable eligible beneficiary'
means an eligible beneficiary with cardiovascular disease,
diabetes and its complications, cancer, or Alzheimer's
disease who is enrolled under part D.''.

Mr. DURBIN. Mr. President, I will speak briefly because I have to go
to another meeting and return for the vote.
I have great respect for the Senators from Iowa and Montana, but I
struggle to understand why we are giving a $6 billion subsidy to the
HMOs in America. If they are so good, if they are so efficient, if the
free market is truly better than the Government-run Medicare system,
why in the world do they need $6 billion worth of the taxpayers' money?
You know that of that $6 billion hundreds of millions of dollars are
going to go to them in profits. We are literally subsidizing the
profits of these companies. We are creating this artificial environment
that suggests these companies can do just as good a job or better than
Medicare with the $6 billion Federal subsidy to make it work.
I can't understand why my colleagues on the conservative side who are
hidebound apostles of the free market system don't even wince when it
comes to sending $6 billion to the HMOs and the private insurance
industry in order to let them play on the field for health care for
seniors in America. I don't get it. I certainly don't understand why
you wouldn't take that same money to protect the most vulnerable people
in America--our senior citizens who are struggling with heart disease,
cancer, Alzheimer's, and diabetes and its complications. Why is the
money for the boardrooms of the HMOs a good expenditure of tax dollars
and the money for the family rooms of senior citizens struggling with
these deadly diseases not a good investment with taxpayer dollars?
The underlying bill is the biggest breakthrough for the American
pharmaceutical industry since the establishment of patents in the
Constitution. This amendment with $6 billion in flatout tax subsidies
to HMOs is the answer to the prayers of the insurance companies in
America.
Is that what the Senate is all about? Are we supposed to come here to
make certain that the wealthiest corporations in America get wealthier?
I don't think so. They are doing quite well. The rate of return for
pharmaceutical companies across America is 18 percent. The average for
the S&P companies is 3 percent. These companies are immensely wealthy
and profitable. We help them even more with this bill. We know how well
the insurance companies are doing. We know the bonuses they give their
executives and we are going to plow in $6 billion to make it even
wealthier.
There is something else wrong. We know that a lot of average citizens
in America--particularly senior citizens--are struggling. Pick up the
morning papers. Whether it is the Washington Post or the New York
Times, they go to speak to seniors in their real-life environment and
talk to them about how they survive. Some of them are well off. Some
are lucky. They have saved a lot of money or they have a good and
generous retirement but a lot of them do not. A lot of them are
literally struggling month to month, some even week to week, just to
get by.

[[Page S8631]]

This morning in the Washington Post there was a story about a widow
lady who said: At the end of the month, I'm lucky if I have a dollar
left over. At the end of the article she said: I wonder how many
Senators have ever thought about trying to live on $1,100 a month.
I don't know how she does it. I don't know how a lot of people do it
in my State. Why wouldn't we want to help these people? Why is it the
pharmaceutical companies and the HMOs are more important than the most
vulnerable people in society? I don't get it.
Frankly, I think a lot of our colleagues, as I said earlier, ought to
take these arguments, which sound so good on the floor of the Senate,
back to the real world of the State they represent, take them into the
town of their choice, the public meeting of their choice, and explain
to people why HMOs need a subsidy but seniors do not need a helping
hand. It just does not work.
So I will be offering an amendment that says we will take this $12
billion and focus it on the elderly people who suffer from some of the
worst and most demanding diseases.
I reserve the remainder of my time.
The PRESIDING OFFICER (Mr. Alexander). Who yields time?
The Senator from Montana.
Mr. BAUCUS. Mr. President, I listened quite closely to the Senator
from Illinois, as well as to the Senator from North Dakota. They are
each offering a separate amendment, but they are both similar in an
attempt, generally, to accomplish the same result.
I say to my good friend from Illinois, as well as my good friend from
North Dakota, who is presently not in the Chamber, I am very
sympathetic. If I had my way, we would be spending this newly found $12
billion very much in the way the Senator suggested. In fact, there are
a lot of good ways. It is not only helping those with Alzheimer's, but
it is also lowering the premium. There are a lot of ways we could be
spending dollars to help get more drug benefits to more seniors. There
is no doubt about that. But, unfortunately, we are 100 Senators.
The Senator from Illinois, the Senator from North Dakota, and I have
a view of how some of these dollars should be spent in a perfect world,
but the world is not perfect. This is a democracy. It is messy. As
Winston Churchill once said--I will paraphrase very poorly, but the
Senator knows this quote--basically, Winston Churchill said: A
democracy, for all its fits and starts and delays and inefficiencies
and herky-jerky jolting, and all that, is the world's worst form of
government, except for all the others.
Here we are, in a democratic process, trying to figure out how to get
prescription drug benefits to seniors. We have 100 Senators. I don't
know of very many timid Senators. We don't have many Senators who don't
speak their views. I don't know very many Senators who don't
have strong views about subjects. I don't know of many Senators who are
not thoughtful, articulate, and fighting hard for their constituents.
And we have, as it turns out, Senators from two political parties: 51
Republicans, 48 Democrats, and 1 Independent; and at this time we are
attempting to finally get prescription drug benefits to seniors.

This issue has been debated for 4 years, at least. It has been a
politicized issue for 4 years. There has been a lot of talk for 4
years, a lot of rhetoric on both sides of the aisle for 4 years, and
during all the talking there has not been any action; it has been all
words, no deeds.
Well, here we are, at a time--after 4 years of just political
posturing, to a large degree--where we are on the brink of getting
prescription drug benefits passed for our seniors in our country.
Is it the best bill in the world? No. Could it be better? Yes. Do all
Senators wish it could be better? Yes. But is it a good start? Is it a
beginning? Is it a platform on which we can begin to build? Absolutely.
If we go back and look at the history of health care and assistance
by the Government in providing health care to the needy and to
Americans generally, it is a history of building, of starting
somewhere, building on it, and making it better and better all the
time.
Back in the 1930s it was the Wagner-Murray-Dingell legislation that
was introduced to provide national health insurance for Americans. That
was the idea: We need national health insurance for Americans.
Well, it was debated and debated. Not a lot more really happened.
Then suddenly things changed in the 1960s. The idea of Medicare came
along: Why not help at least our seniors? If we can't get national
health insurance, the very least we can do is help our senior citizens
get a break with respect to their health care bills. That is a good
place to at least begin--by helping a good, solid segment of the
population. And we did, back in 1965, by providing Medicare. And look
what has happened since then. We have kept building on Medicare to make
it better.
When Medicare was first enacted, 50 percent of a Part B premium was
paid by the senior and the Government paid the other 50 percent of the
premium for Part B. That is for doctor services. Now it is 25 percent.
It has been improved over time. We also have added more benefits, some
screening provisions. End-stage renal treatment has been added. There
is a list of new additions to help our senior citizens.
Here we are now, on the brink of adding another major benefit:
prescription drugs. After all these years, all the years of talking and
talking and politicking and giving statements and speeches, we are
finally on the brink of getting prescription drug benefits passed.
It has not been easy. Why has it not been easy? It has not been easy
because there are two competing philosophies on the floor of the Senate
on how to get prescription drug benefits to seniors. Even though the
two competing philosophies are very different from each other, Senators
on both sides of the aisle--most Senators, maybe even all Senators, but
certainly most Senators--still want to work as hard as they can to try
to fit these competing philosophies together in order to pass
legislation this year to begin finally getting prescription drug
benefits to seniors.
Also, these two competing philosophies are very different. One is
competition. The argument is: Let private companies, themselves, with
assistance from the Government, design how they give prescription drug
benefits to our senior citizens, make them available at a big discount
for senior citizens. The other philosophy is: Medicare should be the
agency that should be the way--traditional Medicare, basically--to
provide discounts for senior citizens to get drugs.
Essentially, the competing philosophies are 50-50. You have 51
Republicans, 48 Democrats, and 1 Independent. What are we going to do?
Well, all we can do, if we want to get this done, is to just try our
best to put these two together in a fair, balanced way--and the private
competition model gets a break, gets a fair chance to see the degree to
which it might work--so that senior citizens really do get the benefits
and are not taken advantage of during our efforts to pass legislation.
It is a balance. It is trying to find the right way to accomplish
that balance. It has been extremely difficult. I do not have to tell
the Presiding Officer just how hard this has been. But we are right on
the brink.
We are limited to $400 billion in providing the drug benefits for
seniors over the next 10 years. Why are we limited to $400 billion?
Well, this body passed a budget resolution not too long ago--both the
House and the Senate--saying we are going to set aside $400 billion for
prescription drug benefits for seniors. We never set aside anything
like that in the past. So we have an opportunity now to use it. I don't
think Senators want to miss this opportunity. I think they want to use
the dollars that are there to get prescription drug benefits for
seniors.
Well, as it turned out, when the Senate Finance Committee wrote this
bill, trying its hardest to be balanced--and it is balanced; the best
evidence of that is it passed by a large majority from both parties in
the Finance Committee--we found it actually cost only about $388
billion. There was $12 billion remaining.
So the question before us is how we can spend that $12 billion. That
is the question. In an attempt to maintain a balance and to work on two
competing models and in an attempt to get the legislation passed so we
can provide a prescription drug benefit to seniors, we

[[Page S8632]]

have decided to split it, 6 and 6; $6 billion to the PPOs, have it
available potentially for PPOs, if that is needed for the bidding
process, beginning in the year 2009. I don't know how many Senators are
going to be here in 2009, but at least beginning then. The other $6
billion, beginning in 2009, will then go, under Medicare fee for
services, for disease management, chronic care, to help particularly
seniors who really need that disease management and chronic care. It is
really needed because there is very little disease management today
under traditional Medicare. That is one of its shortcomings. That is
what we have done.
Again it is a balance, a start, a beginning. I have a lot of sympathy
with my friends on this side of the aisle. If I had my druthers and I
were the only one writing this bill, I would take that $12 billion and
spend it along the lines they are suggesting. But I am not the only
Senator here. I am one of 100. It is my job and that of the chairman of
the committee, Senator Grassley, to try to find a balance--not for the
sake of balance but for the sake of getting legislation passed so we
can finally get prescription drugs to seniors.
If the amendments offered by the Senators from North Dakota or
Illinois were to pass, guess what would happen. First of all, those are
killer amendments. If those amendments were to pass, that would mean
this bill is in jeopardy of passage. That would mean senior citizens
may not get the prescription drug benefits we are all trying to get;
albeit just a first step, or it could also mean, on the other hand--and
this is perhaps even more likely--if that amendment were to pass, I
will bet you dollars to donuts--which is not a good phrase to use
because we are trying to put dollars in the donut hole--the
conservative part of this body, the Republican side of the aisle, would
say: We are going to take that $12 billion and spend it our way. And
they have the votes. They have the White House. So this amendment puts
in jeopardy a very delicate, very balanced kind of deal between
competing philosophies, fairly and evenly, so that we can get
prescription drug legislation passed, so that we are just not talking
about it anymore and finally doing something about it.
If it were to pass or looked like it would pass, the other side,
which has more votes than this side has, would say: We will spend it
our way.
Then colleagues on my side of the aisle would be quite distressed.
They would be forced to ask themselves if they would support on final
passage a bill way off to the right for competition instead of the bill
which currently exists, particularly with the underlying amendment. I
wish we could do more but at least it is a first step. If the history
of Medicare is any guide, in future years we will continue to make it
better. We will work on that donut hole. We will fill in the gaps. We
will make sure premiums are not too high. We will try to help with
Alzheimer's and all the other measures we desperately need to pay
attention to as the days and years go by.
I implore my colleagues to think a little bit. Resist the siren song
of doing something that sounds good but which very well could put the
bill in real jeopardy. This is fair. It has $6 billion which may or may
not be used for PPOs, depending upon what the bids are. This bill cuts
off after a 5-year period; no more $6 billion can be spent. And $6
billion for disease management under traditional Medicare which will be
spent. That is the question. Do you want balance or do you want to try
to get something else passed right now that you like in the short term
but could very well jeopardize the whole bill, which means another
year, year 5, Congress is talking about this issue, Congress is not
doing anything about it. Rather, we want year 1, we have finally got it
done.
We are very close to getting it done. It is not perfect, but we will
keep working on it over the years.
The PRESIDING OFFICER. Who yields time?

Amendment No. 1037, As Modified

Mr. BAUCUS. Mr. President, on behalf of the Senator from New Jersey,
Mr. Corzine, I ask unanimous consent that amendment No. 1037 be
modified with the text that I send to the desk.
The PRESIDING OFFICER. Without objection, it is so ordered.
The amendment, as modified, is as follows:

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

SEC.   . CONFORMING CHANGES REGARDING FEDERALLY QUALIFIED
HEALTH CENTERS.

Exclusion From Per Visit Limit.--Section 1833(a)(3)) (42
U.S.C. 13951(a)(3)) is amended by inserting ``(which
regulations shall exclude any cost incurred for the provision
of services pursuant to a contract with an eligible entity
(defined in section 1860D(a)(4)) operating a plan under Part
D, for which payment is made by such entity)'' after
``including those authorized under section 1861(v)(1)(A)''.

Mr. BAUCUS. Mr. President, I ask unanimous consent that the pending
amendments be temporarily laid aside.
The PRESIDING OFFICER. Without objection, it is so ordered.

Amendment No. 1110

Mr. BAUCUS. Mr. President, on behalf of the Senator from Michigan,
Mr. Levin, I send an amendment to the desk and ask for its immediate
consideration.
The PRESIDING OFFICER. The clerk will report.
The legislative clerk read as follows:

The Senator from Montana [Mr. Baucus], for Mr. Levin,
proposes an amendment numbered 1110.

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

(Purpose: To ensure that beneficiaries initially covered by a private
insurer under this act who are subsequently covered by a Medicare
fallback plan have the option of retaining a Medicare fallback plan)

Insert the following in the appropriate place: The
Secretary of Health and Human Services shall retain or
designate one or more Medicare backup plans so that
beneficiaries initially covered by a private insurer under
this act who are subsequently covered by a Medicare fallback
plan have the option of retaining a Medicare fallback plan or
entering private insurance under this act.

Amendment No. 1111

Mr. BAUCUS. Mr. President, I ask unanimous consent that the pending
amendments be set aside so that I may send to the desk on behalf of
Senator Levin an amendment to ensure that current retirees who have
prescription drug coverage, who will loose their coverage as a result
of enactment of this legislation, would have the option of drug
coverage under Medicare fallback.
The PRESIDING OFFICER. Without objection, it is so ordered.
The clerk will report.
The legislative clerk read as follows:

The Senator from Montana [Mr. Baucus], for Mr. Levin,
proposes an amendment numbered 1111.

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

(Purpose: To ensure that current retirees who have prescription drug
coverage who will lose their prescription drug coverage as a result of
the enactment of this legislation have the option of drug coverage
under the Medicare fallback)

Insert the following in the appropriate place: The
Secretary of Health and Human Services shall retain or
designate one or more Medicare backup plans so that the 37%
of current retirees who have prescription drug coverage,
estimated by the Congressional Budget Office who will lose
their current employer retiree coverage as a result of the
enactment of this legislation will have the option to enter
either a Medicare backup plan or private insurance under this
act.

Mr. BAUCUS. Mr. President, I ask unanimous consent that time under
the quorum call be charged equally against both sides.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. BAUCUS. I suggest the absence of a quorum.
The PRESIDING OFFICER. The clerk will call the roll.
The legislative clerk proceeded to call the roll.
Mr. BAUCUS. Mr. President, I ask unanimous consent that the order for
the quorum call be rescinded.
The PRESIDING OFFICER. Without objection, it is so ordered.

Amendments Nos. 1027 and 1041, En Bloc

Mr. BAUCUS. Mr. President, I ask unanimous consent that the pending
amendments be temporarily laid aside and amendments numbered 1027 and
1041 be immediately considered.
The PRESIDING OFFICER. Without objection, it is so ordered.

[[Page S8633]]

The clerk will report.
The legislative clerk read as follows:

The Senator from Montana [Mr. Baucus] proposes amendments
numbered 1027 and 1041, en bloc.

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

amendment no. 1027

(Purpose: To express the sense of the Senate regarding the
implementation of the Prescription Drug and Medicare Improvement Act of
2003)

At the end of title VI, insert the following:

SEC. ____. SENSE OF THE SENATE REGARDING IMPLEMENTATION OF
THE PRESCRIPTION DRUG AND MEDICARE IMPROVEMENT
ACT OF 2003.

(a) In General.--It is the sense of the Senate that the
Committee on Finance of the Senate should hold not less than
4 hearings to monitor implementation of the Prescription Drug
and Medicare Improvement Act of 2003 (hereinafter in this
section referred to as the ``Act'') during which the
Secretary or his designee should testify before the
Committee.
(b) Initial Hearing.--It is the sense of the Senate that
the first hearing described in subsection (a) should be held
not later than 60 days after the date of the enactment the
Act. At the hearing, the Secretary or his designee should
submit written testimony and testify before the Committee on
Finance of the Senate on the following issues:
(1) The progress toward implementation of the prescription
drug discount card under section 111 of the Act.
(2) Development of the blueprint that will direct the
implementation of the provisions of the Act, including the
implementation of title I (Medicare Prescription Drug
Benefit), title II (MedicareAdvantage), and title III (Center
for Medicare Choices) of the Act.
(3) Any problems that will impede the timely implementation
of the Act.
(4) The overall progress toward implementation of the Act.
(c) Subsequent Hearings.--It is the sense of the Senate
that the additional hearings described in subsection (a)
should be held in each of May 2004, October 2004, and May
2005. At each hearing, the Secretary or his designee should
submit written testimony and testify before the Committee on
Finance of the Senate on the following issues:
(1) Progress on implementation of title I (Medicare
Prescription Drug Benefit), title II (MedicareAdvantage), and
title III (Center for Medicare Choices) of the Act.
(2) Any problems that will impede timely implementation of
the Act.

amendment no. 1041

(Purpose: To require the Secretary of Health and Human Services to
conduct a frontier extended stay clinic demonstration project)

On page 529, between lines 8 and 9, insert the following:

SEC. 455. FRONTIER EXTENDED STAY CLINIC DEMONSTRATION
PROJECT.

(a) Authority To Conduct Demonstration Project.--The
Secretary shall waive such provisions of the medicare program
established under title XVIII of the Social Security Act (42
U.S.C. 1395 et seq.) as are necessary to conduct a
demonstration project under which frontier extended stay
clinics described in subsection (b) in isolated rural areas
of Alaska are treated as providers of items and services
under the medicare program.
(b) Clinics Described.--A frontier extended stay clinic is
described in this subsection if the clinic--
(1) is located in a community where the closest short-term
acute care hospital or critical access hospital is at least
75 miles away from the community or is inaccessible by public
road; and
(2) is designed to address the needs of--
(A) seriously or critically ill or injured patients who,
due to adverse weather conditions or other reasons, cannot be
transferred quickly to acute care referral centers; or
(B) patients who need monitoring and observation for a
limited period of time.
(c) Definitions.--In this section, the terms ``hospital''
and ``critical access hospital'' have the meanings given such
terms in subsections (e) and (mm), respectively, of section
1861 of the Social Security Act (42 U.S.C. 1395x).

Amendments Nos. 936, 938, 988, 1027 and 1041 en bloc

Mr. BAUCUS. Mr. President, on behalf of the chairman of the
committee, Senator Grassley, I ask unanimous consent that the pending
amendments be set aside and that the following amendments be agreed to
en bloc, and that the motions to reconsider be laid on the table en
bloc: Amendments Nos. 936, 938, 988, 1027, and 1041.
The PRESIDING OFFICER. Without objection, it is so ordered.
The amendments were agreed to en bloc.
Mr. BAUCUS. Mr. President, I ask unanimous consent that the time I
used be charged equally to both sides.
The PRESIDING OFFICER. Without objection, it is so ordered.
Mr. BAUCUS. Mr. President, I suggest the absence of a quorum.
The PRESIDING OFFICER. The clerk will call the roll.
The legislative clerk proceeded to call the roll.
Mr. GRASSLEY. 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. GRASSLEY. I ask unanimous consent to proceed as in morning
business.
The PRESIDING OFFICER. Without objection, it is so ordered.

____________________