Medicare Indian Health Fairness Act of 2003

Mr. President, I rise tonight to introduce, along with my good friend from Utah, Senator Hatch, the distinguished Chairman of the Judiciary Committee, the ``Anabolic Steroid Control Act of 2003.'' Over the last several weeks, we have read front-page articles on the dangerous mix of sports and steroids, including a new ``designer'' steroid tetrahydrogestrinone, known as ``THG.'' Several premier athletes have allegedly tested positive for THG, and there is a Federal grand jury investigation into the alleged manufacture and distribution of this new substance. Our bill would make THG, and several other similar substances, subject to the Controlled Substances Act. Thus, these products would no longer be available over the counter. Absent a prescription from your doctor, you will not be able to buy them legally.

First, a bit of background on how we got here. Thirteen years ago I held a number of hearings on the dangers associated with steroid use and introduced legislation to make steroids Schedule III substances. After my bill became law, a number of steroid users continued to buy and use steroids only now they were buying them through a developing illicit market. Others relied on new products being developed or rediscovered by scientists, products which may not violate the letter of the law, but certainly violate the spirit of the law.

These substances, called steroid precursors or pro-steroids, are one step removed from the substances scheduled in the law: when ingested, they metabolize into testosterone or other illicit steroids. These are products which the United States Anti-Doping Agency, the group in charge of testing Olympic athletes for performance enhancing drugs, has called ``the functional equivalent of steroids.''

In writing about the lack of testing for steroid precursor use in professional baseball, Barry Rozner of the Chicago Daily Herald described the close relationship between steroids and steroid precursors. He wrote:

There's still no testing for andro (androstenedione)

because technically it's not a steroid. It's a steroid

precursor. Technically a cake mix isn't a cake but as soon as

you pour it in a bowl and stick it in the oven, it's a cake.

You put andro in the body, mix it with the body's chemicals

and let it bake, and it turns into a powerful steroid. If it

walks like a duck and talks like a duck, baseball calls it a

sparrow.

The most well known of the steroid precursors is androstenedione often called ``andro.'' Most recently Hiram Cruz, a 2001 national judo champion, was suspended from competition for two years after testing positive for andro. And it is widely thought that some East German Olympic athletes used it in the 1970s and 1980s to improve their performance. But perhaps the substance gained the most notoriety when professional baseball player Mark McGuire admitted that he used it when he broke Roger Maris's single season record for home runs. After McGuire revealed that he had taken andro, sales of the product quadrupled.

Andro increases both testosterone and estrogen levels in the body. According to a study published in the Journal of the American Medical Association ``orally administered adrostenedione increases serum testosterone and estrogen levels in healthy men, particularly at higher doses.'' The study further notes that ``long-term administration could be hazardous, particularly in women or children.'' Another study showed that even a single 100 milligram dose of andro can yield unhealthy levels of testosterone in women and can increase estrogen levels by 80 percent. Andro has also been associated with a decrease in HDL the ``good'' cholesterol and elevated levels of estradiol which may increase women's risk of breast cancer.

As I will discuss in greater detail later, in addition to the grave health effects associated with using andro and other steroid precursors, the physical effects can also be quite serious: women can develop masculine sex characteristics including changing of the sexual organs; men can develop feminine sex characteristics including breast development; and adolescent users can stunt their growth.

The International Olympic Committee, the National Football League and the National Collegiate Athletics Association have banned andro and other steroid supplements. Other sports, particularly baseball, have been criticized for refusing to agree to test players for steroid precursors. I should note that Major League Baseball has endorsed the legislation I am introducing today. And at a hearing in the Senate Commerce Committee last year, Donald Fehr, the Executive Director of the Major League Baseball Players Association, said that ``it may well be time for the Federal Government to revisit whether steroid precursors should also be covered by Schedule III.'' I agree with him. Interestingly enough, so do the 79 percent of major league baseball players and nearly 86 percent of baseball fans who, according to surveys conducted by USA Today last year, support testing for steroids and performance-enhancing drugs.

The USA Today survey also revealed that 80 percent of fans believe that steroid use is behind some of the major league records that have been broken recently. It is understandable, therefore, that some players may support testing to preserve the integrity of their records. As Yankees' shortstop Derek Jeter has been quoted as saying:

I don't have a problem with getting tested because I have

nothing to hide. Steroids are a big issue. If anything like a

home run or any injury happens, people say it's steroids.

That's not fair.

In my view, it is time for Congress to act so that we can put an end to the charade that androstenedione and similar products are any different from the anabolic steroids that are controlled under current law.

To be honest I would be less concerned about what professional athletes are doing to their bodies if their actions did not have such a profound effect on kids. A study by the Kaiser Family Foundation revealed that nearly three-quarters of kids say that they look up to and want to emulate professional athletes. Sadly, more than half of those kids believe that their sports heroes use steroids and other performance enhancing drugs to win. That may be why adolescent anabolic steroid use is at its highest level in the past decade, with 1 million teens having used them.

As Dr. Bernard Greisemer, a pediatrician and sports medicine specialist, testified before the Senate last year, many of these products are marketed to kids who want to be like their favorite sports hero. Dr. Greisemer said:

[P]rofessional athletes are major role models for our young

athletes; in the clothes they wear, the cars they drive, the

food they eat, and the drugs and dietary supplements they

take. The millions of dollars that are spent by major

corporations in linking their products to a particular

athlete, team, or sporting event, counter any argument that

professional athletes are not affecting the lifestyles of our

young athletes. Use of and media exposure of the use of,

anabolic steroids in professional athletes also directly

affects the interest in, the perception of benefits of, and

the use of these substances.

There are plenty of children and adults who believe that supplements will make them faster and stronger. That they'll have bigger muscles and be more like their favorite athlete. That they'll have a competitive advantage or have what it takes to win. In reality, they are jeopardizing their health. The ignorance of the consequences of using these substances is astounding. A study by Blue Cross/Blue Shield found that 70 percent of kids and half of parents surveyed were unable to identify even one negative side effect associated with performance- enhancing drugs. And 80 percent of kids reported that their parents have never talked to them about the dangers of steroid use. Clearly there is quite a bit of education to be done about these very dangerous substances.

Let me go through just a few of the side effects of steroid use. In both males and females it can lead to increased blood pressure, increased risk of heart attack and stroke, liver and cardiac dysfunction, increased libido, aggressiveness and appetite, and acne. For males, steroid use can lead to breast development, premature balding, testicular atrophy, decreased sperm count and prostate enlargement. Females can develop masculine sex characteristics including increased body hair, facial hair, deepening of the voice, male pattern baldness and changes to the sex organs. And among adolescent users, steroid precursor use can lead to stunted growth due to hardening of cartilage. Many of these side-effects are irreversible.

Quite troubling to me is that some people are taking these substances unwittingly. It is not unusual for manufacturers of creatine or other performance enhancing substances to put andro or another precursor into their product to give them a competitive edge over a competitor's products.

Clearly these substances are dangerous and they should not be widely available over the counter. That is why I am joining with Senator Hatch and Senator Grassley today to introduce the Anabolic Steroid Control Act of 2003.

My bill does four things. First, it amends the Anabolic Steroid Control Act of 1990 by adding THG, androstenedione and their chemical cousins to the list of anabolic steroids controlled under the Controlled Substances Act and makes it easier for the DEA to add similar substances to that list in the future. This would prohibit people from obtaining these substances over the counter without a prescription in either their pure form or as an additive to another product.

Second, it directs the U.S. Sentencing Commission to review the Federal sentencing guidelines for crimes involving anabolic steroids and consider increasing them. Currently, the maximum sentence for offenses involving anabolic steroids is only 33-41 months for first time offenders. And to receive the maximum sentence an offender would have to have between 40,000 and 60,000 units, which is defined as a 10 cc vial or 50 tablets. That means that someone trafficking 300,000 doses faces a maximum of three and a half year behind bars. That does not seem to be enough of a deterrent and I hope the Sentencing Commission will consider raising the guidelines for steroid trafficking.

Third, the bill authorizes $15 million for the Secretary of Health and Human Services to award grants to public and non-profit entities to carry out science-based education programs in elementary and secondary schools to highlight the harmful effects of anabolic steroids. Preference will be given to programs based on the Athletes Training and Learning to Avoid Steroids program (ATLAS), the Athletes Targeting Healthy Exercise and Nutrition Alternatives (ATHENA) program, and other programs which the National Institute on Drug Abuse has determined to be effective. ATLAS, which is aimed at male student athletes, has been named as one of the Department of Education's Exemplary Programs and is one of the Substance Abuse and Mental Health Services Administration's Model Programs. ATHENA is ATLAS's companion program designed for female athletes.

Finally, the bill directs the Secretary of Health and Human Services to include questions about steroid use in the National Survey on Drug Use and Health, an annual survey to measure the extent of alcohol, drug and tobacco use in the United States. The bill authorizes $1 million for this purpose.

I'm proud to say that the bill has been endorsed by a wide range of medical, athletic and drug policy organizations including: American Academy of Family Physicians; American Academy of Pediatrics; American College of Obstetricians and Gynecologists; American College for Sports Medicine; American Council on Exercise; American Medical Association; Association of Tennis Professionals; Blue Cross Blue Shield Association; Boys and Girls Clubs; Community Anti-Drug Coalitions of America; Consumer Healthcare Products Association; Council for Responsible Nutrition; The Endocrine Society; The Hormone Foundation; Little League; Major League Baseball; National Athletic Trainers Association; The National Center on Addiction and Substance Abuse at Columbia University; National Collegiate Athletic Association; National Federation of State High Schools Association;

National Football League; National High School Athletic Coaches Association; National Junior College Athletic Association; National Nutritional Foods Association; Pharmacists Planning Services, Inc.; United States Anti-Doping Agency; U.S. Olympic Committee; U.S. Biathlon Association; U.S. Soccer Federation; USA Cycling; USA Luge; USA Swimming; USA Track and Field and Utah Natural Products Alliance.

I urge my colleagues to support this legislation and I hope that it will be enacted into law soon.

I ask unanimous consent that the text of the bill be printed in the Record.

Mr. President, I am pleased to introduce the Federal Employee Commuter Benefits Act of 2003, which is cosponsored by my colleagues Senators Mikulski, Warner, and Allen. This bill will guarantee transit benefits to all Federal employees in the National Capital Area and will remove a restriction that currently forbids Federal agencies from providing employee shuttles to and from transit stations. This measure is an important step forward in our efforts to encourage transit ridership and improve the quality of life for Federal employees in the Washington, D.C. region and throughout the nation.

All across the Nation, congestion and gridlock are taking their toll in terms

of economic loss, environmental impact, and personal frustration. According to the Texas Transportation Institute, in 2001 Americans in 75 urban areas spent 3.6 billion hours stuck in traffic, with an estimated cost to the nation of $69.5 billion in lost time and wasted fuel. In response, Americans are turning to alternative transportation options in record numbers. The American Public Transportation Association estimates that Americans now take over 9 billion trips on transit per year, the highest level in more than 40 years.

Transit benefit programs are playing a vital role in increasing transit ridership, which benefits both transit users and drivers. In 1998, the Transportation Equity Act for the 21st Century amended the tax code to allow financial incentives related to commuting costs for employers and employees. These transit benefits allowed employers to offer a tax-free financial incentive toward the costs of transit commuting, starting at $65 per month and raised in 2002 to $100 per month.

Based upon the findings of the Environmental Protection Agency and the U.S. Department of Transportation, there are clear improvements to congestion, energy efficiency, and air quality from transit benefit programs. According to their findings, an employer with 1,000 employees that participates in a combination of transit benefits, carpool, and telecommuting programs can take credit for taking 175 cars off the road, saving 44,000 gallons of gasoline per year, and cutting global warming pollution by 420 tons per year on average.

In April 2000, an Executive Order was signed requiring all executive branch agencies in the National Capital Region to offer transit benefits to their employees. As a result, Federal employees commuting to Washington, D.C. from Montgomery, Prince George's, and Frederick Counties, Maryland, several counties in Northern Virginia, and as far away as West Virginia, are encouraged to choose transit as their means to get to work.

According to the Washington Metropolitan Area Transit Authority and the U.S. Department of Transportation, by 2001 more than 110,000 employees--approximately one-third of all Federal employees in the National Capital Region--joined the Federal transit benefit program created by the Executive Order. These program participants alone have eliminated an estimated 12,500 single-occupancy vehicles from Washington, D.C. area roads, helping to reduce congestion and improve air quality for our region.

The Executive Order, however, is limited. It does not cover the more than 100,000 Federal employees in the legislative and judicial branches, and the dozens of independent Federal agencies located in the Washington, D.C. region. While many of these organizations provide transit benefits to their employees, the implementation and level of benefit is up to the discretion of individual offices. As such, many of these organizations provide limited benefits or do not provide any benefits at all. Guaranteed transit benefits would give these employees more choice in their commuting options and provide an additional incentive to move off our congested roadways and onto public transit.

Of course, such incentives will be ineffective if employees lack access to transit services. In my own state of Maryland, the United States Food and Drug Administration planned to use its own resources to provide a shuttle service for its employees from its new White Oak facility to an area Metro station. When they investigated providing this service, FDA officials found that the current law does not allow Federal agencies to use their own vehicles to shuttle employees to mass transit stations.

The potential impact of this restriction on regional congestion is not insignificant. By 2005, FDA estimates 1,700 employees will work at the new White Oak facility, and plans have been made to eventually house more than 7,000 FDA researchers and administrators at the new facility. The lack of access from FDA's new campus to a transit station represents a lost opportunity for reducing congestion, improving our environment and elevating the quality of life for employees.

This type of lost opportunity occurs across the nation. Nationally, the Federal Government employs more than 2.6 million civilian workers at more than 3,000 Federal government office buildings. At Federal offices throughout the country, transit use is often limited as a commuting option due to lack of employee access to a transit station or a bus stop.

The Federal Employee Commuter Benefits Act would address both of these issues faced by Federal employees. First, the bill would put into law the Executive Order's requirement that transit pass benefits be made available to all qualified Federal employees in the National Capital Region. The bill also extends the requirement beyond executive branch agencies to include the legislative and judicial branches and independent agencies, providing guaranteed transit benefits to an additional 100,000 employees in the Washington, DC region.

Second, the Federal Employee Commuter Benefits Act would remove the restriction that prohibits a Federal agency from operating a shuttle service to a public transit facility. With this legislation, any Federal agency, anywhere in the United States, can choose to provide a transit shuttle service for their employees. By providing access to commuting alternatives, Federal agencies will be able to provide a benefit to their employees that can make getting to work easier, more affordable, and more employee-friendly. It will also provide an opportunity to help reduce congestion and improve air quality across the Nation.

Since 1982, the U.S. population has grown 20 percent, but the time spent by commuters in traffic has grown 236 percent. Each year, traffic congestion wastes nine billion gallons of fuel. By encouraging Federal employees to look to transit and by providing access to transit stations, we can help reduce congestion, improve the environment, and promote an improved quality of life.

I am introducing the Federal Employee Commuter Benefits Act because of the opportunities it will give Federal agencies to support public transportation, both by providing employee access to transit facilities across the nation, and by providing transit benefits to Federal employees in the Washington, D.C. region. Both of these improvements will aid our efforts to fight congestion and pollution by encouraging the use of transportation alternatives. This legislation is strongly supported by Federal employees, transit providers, and local elected officials, and I ask unanimous consent that the text of the bill, along with their letters of support, be printed in the Record. I encourage my colleagues to join me in supporting the Federal Employee Commuter Benefits Act.

Mr. President, I rise today to introduce the ``Methamphetamine Blister Pack Loophole Elimination Act of 2003,'' along with my colleagues Senators Grassley, Kohl, Biden, Kyl and Harkin.

This is a simple bill, and directly follows recommendations made by the United States Drug Enforcement Administration in a 2002 study requested by Congress.

All this legislation does is make it harder for meth dealers to get the precursor pseudoephedrine products necessary to make this illegal drug.

Making it harder for meth dealers to make and obtain their drugs is something beneficial not just to California, but to the entire Nation.

Once predominantly found in the American Southwest, methamphetamine's presence now stretches from coast to coast.

I'm sorry to say that my home State of California has been referred to as the ``Colombia of meth production.'' In fact, our State is known as the ``source country'' for the drug, producing roughly 80 percent of the Nation's methamphetamine supply.

According to the DEA, 1,847 clandestine meth labs were found in California in 2001 alone.

In each of these meth labs across the country, those who make methamphetamine combine a number of precursor drugs, from red phosphorus, which is difficult to obtain, highly flammable and toxic, to pseudoephedrine, which can be found in common cold medicine in every supermarket, pharmacy, and convenience store in America.

Recognizing the easy availability of pseudoephedrine, Congress has acted several times to make it more difficult for meth dealers to purchase it in bulk.

First, we placed a 24-gram limit, which represented almost 1000 pills. Then, just a few years ago, we reduced this threshold to just 9 grams--still some 366 30-milligram pills. Anyone buying more than this amount of pseudoephedrine at one time would be required to give his or her name and address.

As it turns out, this reporting requirement is considered too burdensome by most retail stores, so instead of keeping track of purchasers, most retailers simply limit single transaction sales of pseudoephedrine pills to less than 9 grams. This is an even more beneficial result than the reporting requirements. Such limits, which now often go as low as three or even two packages of cold medicine, make it much harder for meth manufacturers to get this precursor drug. Instead of simply going to the local WalMart or Costco and clearing the shelves of thousands of packages at once, they must now buy just a few packages at a time.

But through all of this, there is one gaping loophole in the law, that allows any of this product packaged in so-called ``blister-packs'' to avoid these reporting requirements. Only loose pills in bottles face the 9-gram restrictions in the law.

Blister packs are the most common form of packaging for cold medicine, as anyone who goes grocery shopping knows. Most people who buy pseudoephedrine will find it in blister packs, as will most meth dealers. As a result, the 9-gram limit in the law has become fairly useless--we limited the sales of pills, so meth dealers simply migrated to blister packs.

This loophole in the law exists because of previous doubts, by some, that meth dealers would bother to use blister-packed products. These foil and plastic containers hold each pill individually, and as a result it is harder to gather the thousands of pills necessary to manufacture methamphetamine in bulk.

Those of us from California have known for some time that blister packs are a problem, because California's Bureau of Narcotic Enforcement has been finding blister packs at meth lab sites for years.

But to answer the doubts of those not lucky enough to come from my home state, we authorized DEA to do a study into this issue in 1999.

Well, that study is back, and guess what--DEA has given us clear, incontrovertible evidence that these blister packs are making up an increasing percentage of the pseudoephedrine found at lab sites.

In some instances, meth manufacturers use sophisticated, industrial ``deblistering'' machines to quickly extract pills from blister packs.

In others, I have been told, children are employed to sit in the meth lab and pop out thousands of pills, by hand, into nearby buckets.

According to the report we requested from the DEA, which was released in March of 2002, blister packaged pseudoephedrine products seized at clandestine methamphetamine laboratories and other locations, such as dumpsites, have involved seizures of over a million tablets.

The seizure of so many blister packaged pseudoephedrine products shows convincingly that blister packaging is not a deterrent to ordinary, over-the-counter pseudoephedrine use in clandestine methamphetamine laboratories.

So clearly, what we argued in 1999, and in 1996, is true. Meth manufacturers are using blister packs, and something must be done to stop them as best we can.

In order to address this problem, DEA recommended in its report that the blister pack loophole be closed, and that the current retail sales limit of 9 grams for bottled pseudoephedrine be extended to blister packed products as well.

And that, is all that this bill would do.

According to DEA, this is the single best thing we can do to help them in the fight against methamphetamine.

This legislation will clear up confusion among retailers who may find it hard to train employees to limit the sales of certain cold medicine if sold in bottles, but not the same medicine in other packaging.

This legislation will help DEA enforce the retail sales thresholds by making it harder for sellers to claim ignorance or confusion about the law.

This legislation might make it less likely that meth dealers will employ young children to pop pills out of the blister packs, all within harms reach in meth labs around the country.

This legislation will not negatively impact the ability of pharmaceutical manufacturers to make legitimate profits.

This legislation will not be a burden on consumers, because the 9 gram limit still represents 366 pills--30 packages of 12 pills, or 15 packages of 24 pills, two of the most common amounts.

It is hard for me to imagine that an average person--or even a large family--needs to buy more than 366 cold pills at one time. In fact, many stores throughout the country have already voluntarily limited pseudoephedrine sales to just a few packages at a time, and there has been little outcry from consumers unable to purchase more.

This bill is not a panacea for the meth problem in the United States--far from it. I have been working on various parts of the meth problem for many years, and I know that this must be a multi-faceted approach--tougher penalties, money for training, enforcement and clean- up, restrictions on precursor chemicals, tools for prosecutors, and so on.

But to fail to enact this legislation is to make it far easier for meth dealers to continue to easily ply their trade.

I urge my colleagues to look at this bill, join us in supporting it, and help us to pass it as soon as possible to assist the DEA in the very uphill battle

against the illegal and pervasive manufacture and sale of methamphetamine.

I ask unanimous consent that the text of the bill be printed in the Record.

Mr. President, I am introducing today the Medicare Indian Health Fairness Act of 2003 with Senators Inouye, Daschle, Murray, Dayton, Johnson, Cantwell, and Stabenow. This legislation would take a number of steps to improve the delivery of health care to Native Amerians through Medicare and the Indian Health Service, IHS, system.

First and foremost, Indian Health Service and tribal hospitals and clinics, which provide health care to American Indians on or near reservations and to Alaska Natives, are currently unable to bill for all Medicare Part B services. In effect, the Indian Health Service is subsidizing the Medicare program because those services, which would otherwise be paid for by Medicare, are instead paid for by IHS, which is horribly underfunded.

In 2000, IHS hospitals and clinics were made eligible to bill Medicare for certain Part B services for the first time, including services delivered by physicians and certain other practitioners, but those services were limited and denied payment for Part B items and services, such as the following: Durable medical equipment--this includes such items as wheelchairs, as well as blood testing strips and blood monitors for diabetes patients, which is a severe problem among Native Americans; home and some institutional dialysis supplies and equipment--since the prevalence of diabetes in American Indians--Alaska Natives is three times the rate in the general U.S. population, Indian people experience a high rate of renal disease, including end state renal disease; cancer screening; pap smears; glaucoma screening; clinic or hospital-based ambulance services; prosthetic devices; covered vaccines, including hepatitis B, pneumococcal and influenza chemotherapy drugs; and clinical laboratory services.

This legislation would simply make these Indian health facilities and providers eligible for payment for all Part B Medicare-covered items and services to the same extent that any other provider would be eligible for payment.

Furthermore, the bill assures that Native Americans should have the same access to Medicare services as any other American. If IHS providers are unable to bill for such Medicare services, IHS budget shortfalls may result in rationing and delays in treatment. For some, it means going out of the IHS system to get prompt service, as other providers are able to bill the Medicare program. Native Americans and IHS providers should not be subject to such barriers to care and payment. Nor should they be subject to such complexity, as they are only prohibited from billing and receiving payment for certain Part B services.

There is absolutely no policy rationale for limiting the payment to IHS, tribal hospitals and clinics to only certain Medicare Part B services. I urge the Senate to end this unfortunate disparity.

Fortunately, identical language has been included in S. 1, the Medicare prescription drug bull that passed the Senate earlier this month. I offered an amendment with Senator Daschle, amendment No. 973, on the Senate floor and was pleased that it was accepted by Chairman Grassley and Ranking Member Baucus accepted it as part of the manager's amendment prior to final passage of the bill.

In addition to that important provision, the ``Medicare Indian Health Fairness Act'' includes another provision that was adopted as part of S. 1 as a Bingaman amendment during the Finance Committee mark-up. This provision requires Medicare providers to charge no more than Medicare rates for inpatient hospital services provided to Indians who are eligible for contract health services from the Indian Health Service, tribally operated health programs, and urban Indian organizations.

This allows IHS to maximize its purchase of contract health services, just as is done by the Department of Veterans Affairs and the Department of Defense. Since the contract health services, CHS, account is chronically underfunded, IHS and the tribes seriously ration and often exhaust those funds before the end of the fiscal year. In fiscal year 2001 alone, the Indian Health Service had insufficient funding to provide services for over 100,000 cases that met its medical priority criteria and denied 22,000 other cases of medically necessary care which did not meet IHS medical priorities. Therefore, this section of the bill would enable IHS and tribes to achieve greater economy for the provision of contract health services.

The Department of Health and Human Services Office of Inspector General's Cost-Saver Handbook has annually made this recommendation. As per its 2003 Red Book or cost-saver handbook reads:

As a federal purchaser of inpatient health care from the

private sector, IHS should receive rates commensurate with

those received by other federal agencies that engage in

similar purchases [such as the VA and DOD].

The Inspector General adds:

If the favorable Medicare rates were legislatively

required, the dollars saved could be applied to the backlog

of patient services that cannot be accommodated in the

Contract Health Services program.

And last, the legislation includes a section intended to bring a measure of consistency, rationality and efficiency to the Medicare payment rate for all clinics in the Indian Health Service-supported health care system. This language creates a uniform payment methodology that would be available to all IHS and tribal clinics and corrects the current situation where payment rates differ widely--based not on the nature of the services a clinic provides, but on whether the facility is operated by the IHS or operated by a tribe, and whether the clinic is considered provider-based or free-standing. Since all clinics provide primary patient care and arrange for secondary, tertiary and specialty care on a referral basis, there is no rational reason for the wide disparity in the Medicare payment methodologies for these facilities.

The legislation would give all Indian clinics the ability to collect reimbursement from the same IHS-CMS all-inclusive rate. Application of the same

all-inclusive rate to all clinics would have the added value of being efficient and economical to use at the clinic level and would apply the same payment method in Medicare, by which IHS-funded clinics are reimbursed, as they receive in Medicaid.

This section of the bill was the only one not included in S. 1, but the rationale for it makes it an important component of this bill and something we hope to see passed into law as well.

Although these provisions address a diversity of problems IHS providers and clinics have with respect to the Medicare program, they are critical and we should pass all of these provisions either as part of a conference agreement on S. 1, as part of the ``Indian Health Care Improvement Act,'' or on their merits through passage of this freestanding bill.

I would like to thank Senators Inouye, Daschle, Murray, Dayton, Johnson, Cantwell, and Stabenow for being original cosponsors of this important legislation. I ask for unanimous consent that the text of the bill be printed in the Record.

Mr. President, I am introducing today the Medicare Indian Health Fairness Act of 2003 with Senators Inouye, Daschle, Murray, Dayton, Johnson, Cantwell, and Stabenow. This legislation would take a number of steps to improve the delivery of health care to Native Amerians through Medicare and the Indian Health Service, IHS, system.

First and foremost, Indian Health Service and tribal hospitals and clinics, which provide health care to American Indians on or near reservations and to Alaska Natives, are currently unable to bill for all Medicare Part B services. In effect, the Indian Health Service is subsidizing the Medicare program because those services, which would otherwise be paid for by Medicare, are instead paid for by IHS, which is horribly underfunded.

In 2000, IHS hospitals and clinics were made eligible to bill Medicare for certain Part B services for the first time, including services delivered by physicians and certain other practitioners, but those services were limited and denied payment for Part B items and services, such as the following: Durable medical equipment--this includes such items as wheelchairs, as well as blood testing strips and blood monitors for diabetes patients, which is a severe problem among Native Americans; home and some institutional dialysis supplies and equipment--since the prevalence of diabetes in American Indians--Alaska Natives is three times the rate in the general U.S. population, Indian people experience a high rate of renal disease, including end state renal disease; cancer screening; pap smears; glaucoma screening; clinic or hospital-based ambulance services; prosthetic devices; covered vaccines, including hepatitis B, pneumococcal and influenza chemotherapy drugs; and clinical laboratory services.

This legislation would simply make these Indian health facilities and providers eligible for payment for all Part B Medicare-covered items and services to the same extent that any other provider would be eligible for payment.

Furthermore, the bill assures that Native Americans should have the same access to Medicare services as any other American. If IHS providers are unable to bill for such Medicare services, IHS budget shortfalls may result in rationing and delays in treatment. For some, it means going out of the IHS system to get prompt service, as other providers are able to bill the Medicare program. Native Americans and IHS providers should not be subject to such barriers to care and payment. Nor should they be subject to such complexity, as they are only prohibited from billing and receiving payment for certain Part B services.

There is absolutely no policy rationale for limiting the payment to IHS, tribal hospitals and clinics to only certain Medicare Part B services. I urge the Senate to end this unfortunate disparity.

Fortunately, identical language has been included in S. 1, the Medicare prescription drug bull that passed the Senate earlier this month. I offered an amendment with Senator Daschle, amendment No. 973, on the Senate floor and was pleased that it was accepted by Chairman Grassley and Ranking Member Baucus accepted it as part of the manager's amendment prior to final passage of the bill.

In addition to that important provision, the ``Medicare Indian Health Fairness Act'' includes another provision that was adopted as part of S. 1 as a Bingaman amendment during the Finance Committee mark-up. This provision requires Medicare providers to charge no more than Medicare rates for inpatient hospital services provided to Indians who are eligible for contract health services from the Indian Health Service, tribally operated health programs, and urban Indian organizations.

This allows IHS to maximize its purchase of contract health services, just as is done by the Department of Veterans Affairs and the Department of Defense. Since the contract health services, CHS, account is chronically underfunded, IHS and the tribes seriously ration and often exhaust those funds before the end of the fiscal year. In fiscal year 2001 alone, the Indian Health Service had insufficient funding to provide services for over 100,000 cases that met its medical priority criteria and denied 22,000 other cases of medically necessary care which did not meet IHS medical priorities. Therefore, this section of the bill would enable IHS and tribes to achieve greater economy for the provision of contract health services.

The Department of Health and Human Services Office of Inspector General's Cost-Saver Handbook has annually made this recommendation. As per its 2003 Red Book or cost-saver handbook reads:

As a federal purchaser of inpatient health care from the

private sector, IHS should receive rates commensurate with

those received by other federal agencies that engage in

similar purchases [such as the VA and DOD].

The Inspector General adds:

If the favorable Medicare rates were legislatively

required, the dollars saved could be applied to the backlog

of patient services that cannot be accommodated in the

Contract Health Services program.

And last, the legislation includes a section intended to bring a measure of consistency, rationality and efficiency to the Medicare payment rate for all clinics in the Indian Health Service-supported health care system. This language creates a uniform payment methodology that would be available to all IHS and tribal clinics and corrects the current situation where payment rates differ widely--based not on the nature of the services a clinic provides, but on whether the facility is operated by the IHS or operated by a tribe, and whether the clinic is considered provider-based or free-standing. Since all clinics provide primary patient care and arrange for secondary, tertiary and specialty care on a referral basis, there is no rational reason for the wide disparity in the Medicare payment methodologies for these facilities.

The legislation would give all Indian clinics the ability to collect reimbursement from the same IHS-CMS all-inclusive rate. Application of the same

all-inclusive rate to all clinics would have the added value of being efficient and economical to use at the clinic level and would apply the same payment method in Medicare, by which IHS-funded clinics are reimbursed, as they receive in Medicaid.

This section of the bill was the only one not included in S. 1, but the rationale for it makes it an important component of this bill and something we hope to see passed into law as well.

Although these provisions address a diversity of problems IHS providers and clinics have with respect to the Medicare program, they are critical and we should pass all of these provisions either as part of a conference agreement on S. 1, as part of the ``Indian Health Care Improvement Act,'' or on their merits through passage of this freestanding bill.

I would like to thank Senators Inouye, Daschle, Murray, Dayton, Johnson, Cantwell, and Stabenow for being original cosponsors of this important legislation. I ask for unanimous consent that the text of the bill be printed in the Record.