Preserving Patient Access to Physicians Act of 2005

Mr. President, I rise today to introduce the Preserving Patient Access to Physicians Act of 2005. This bill updates Medicare physician reimbursement for 2006 and 2007 according to the recommendations of the Medicare Payment Advisory Committee (MedPAC). There would be a 2.7 percent increase to the physician payment schedule for 2006 and using the Medicare Economic Index update for the price of inputs, a 2.6 percent increase in 2007.

If the schedule is left alone, the consequences for physicians will be a negative. Instead of the 1.5 percent payment increase for 2004 and 2005 which I helped author in the Medicare Modernization Act, there would be a 4.3 percent decrease.

The sustainable growth rate (SGR) formula used to calculate physician payment depends on a number of factors: the number of Medicare fee-for- service beneficiaries, the volume and type of services provided, the price of services rendered, changes in regulations and laws. The formula also incorporates other factors such as prescription-drug prices and the gross domestic product. The SGR was intended to control expenditures by basing a given year's physician payment rate on the previous year's performance. Instead, it creates an arbitrary deficiency that continues to force Congress to intervene.

There is a debate going on, her CMS has the authority to alter the SGR formula by removing drugs. Setting that aside, though, the fact of the matter is that without Congress stepping in to provide for a physician payment update, it probably will not occur. My Senate colleagues and I have talked for many years about ensuring adequate physician payment because current and past administrations have failed to modify the formula. This formula is not doing what it was intended to do. Therefore, I believe we need to scrap it and start again. My bill is a starting point and proposes amounts for an update, but I would really like to see us go all the way back to the drawing board and answer the fundamental question of how to pay physicians appropriately for their services.

I want doctors to be able to continue to assist our nation's seniors, but it is unfair to expect them to practice and to have their reimbursement decrease. Practice expenses, the costs of medical technology, wages for administrative and clinical staff, and medical liability premiums are all increasing while physicians are on track to receive a payment decrease. They cannot afford to continue practicing medicine while receiving reimbursements that do not allow them to even break even. Many are retiring early or threatening to limit the number of Medicare patients they treat.

The service of physicians all across the country is vital to our seniors. Almost half a million doctors provide treatment to the 42 million people under the Medicare program. Physicians are often the gateway for access to other medical services and treatments. Not being able to consult a physician results in delayed referrals, delayed treatment and delayed care. In sum, the quality of health care continues to erode and our system does not operate efficiently.

Should the scheduled physician reimbursement cuts take effect, the result will be a $710 million decrease in payments to doctors in Arizona over 2006 through 2010. I have heard from virtually every physician with whom I have spoken about the constraints that inadequate payments are placing on their practice of medicine. While many work for hospitals and health systems, in the rural areas, a large number are solo practitioners or in small practices. For these physicians, poor payment hits their practice especially hard.

If Medicare rates for doctors are inadequate, many other health care payors will also lack for adequate reimbursement. Other payors such as Medicaid and private insurers often base their payments on Medicare rates. While this bill only addresses Medicare physician payment, the problem of access to services will be compounded if physicians receive reimbursement from other payors that is below the appropriate levels.

The cost of addressing the physician payment update is not cheap. Estimates on the cost of this bill are between $25 billion to $35 billion over five years. I await an official score from the Congressional Budget Office. But I point out, that doing nothing to solve this problem may cost us more: more money, more health and access problems, and more physicians leaving the profession. Although this legislation provides for a two year update, we must develop a long range mechanism to pay physicians appropriately.

I am grateful for the support of this legislation by my colleague, Senator

Stabenow of Michigan, and encourage my other colleagues to support the Preserving Patient Access to Physicians Act of 2005.

I ask unanimous consent that a letter of support be printed in the Record.

Mr. President, I rise today to introduce the Streamlined Procedures Act. This legislation will reduce delays in federal courts' review of habeas corpus petitions filed by State prisoners.

Currently, many Federal habeas corpus cases require 10, 15, or even 20 years to complete. These delays burden the courts and deny justice to defendants with meritorious claims. They also are deeply unfair to victims of serious, violent crimes. A parent whose child has been murdered, or someone who has been the victim of a violent assault, cannot be expected to ``move on'' without knowing how the case against the attacker has been resolved. Endless litigation, and the uncertainty that it brings, is unnecessarily cruel to these victims and their families. As President Clinton noted of the 1996 habeas-corpus reforms, ``it should not take eight or nine years and three trips to the Supreme Court to finalize whether a person in fact was properly convicted or not.'' For the sake of all parties, we should minimize these delays.

The 1996 habeas corpus reforms were supposed to prevent delays in Federal collateral review. Unfortunately, as the Justice Department noted in testimony before the House Crime Subcommittee in March 2003, there still are ``significant gaps [in the habeas corpus statutes] . . . which can result in highly protracted litigation, and some of the reforms that Congress did adopt in 1996 have been substantially undermined in judicial application.''

The Streamlined Procedures Act is designed to fill some of these gaps. First, the SPA imposes reasonable but firm time limits on court of appeals' review of Federal habeas petitions. It requires a court of appeals to decide a habeas appeal within 300 days of the completion of briefing, to rule on a petition for rehearing within 90 days, and to decide a case on rehearing within 120 days before the same panel, or 180 days before an en banc court.

As generous as these time limits are, they would make a real difference in some cases. In Morales v. Woodford, 336 F.3d 1136, 9th Cir. 2003, for example, the Ninth Circuit took 3 years to decide the case after briefing was completed. And after issuing its decision, the court took another 16 months to reject a petition for rehearing. Similarly, in Williams v. Woodford, 306 F.3d 665, 9th Cir. 2002, the court waited 25 months to decide the case--and then waited another 27 months to reject a petition for rehearing, for a total delay of almost 4\1/2\ years after appellate briefing had been completed. This is too long for either defendants or victims to have to wait.

The SPA also bars courts of appeals from rehearing successive- petition applications on their own motion--current law bars petitions for rehearing or certiorari for such applications, but some courts have interpreted this restriction to not preclude rehearing by the court of appeals sua sponte. The SPA also bars Federal courts from tolling the current 1-year deadline on filing habeas claims for reasons other than those authorized by the statute, and clarifies when a State appeal is pending for purposes of tolling the deadline.

In addition, the SPA creates uniform, clear procedures for review of procedurally improper claims. Current judicial caselaw creates a series of different standards for addressing claims in a Federal petition that were not exhausted in state court, that were presented in a late amendment, or that were procedurally defaulted. The SPA sets a uniform standard, allowing procedurally improper claims to go forward only if they present meaningful evidence that the defendant did not commit the crime, with all other improper claims barred.

The SPA also expands and improves the special expedited habeas procedures authorized in chapter 154 of the United States Code. These procedures are available to States that establish a system for providing high-quality legal representation to capital defendants. Chapter 154 sets strict time limits on Federal court action and places limits on claims. Currently, however, the court that decides whether a State is eligible for chapter 154 is the same court that would be subject to its time limits. Unsurprisingly, these courts

have proven resistant to chapter 154. The SPA would place the eligibility decision in the hands of a neutral party--the U.S. Attorney General, with review of his decision in the DC Circuit, which does not hear habeas appeals. The SPA also makes chapter 154's deadlines more practical by limiting the claims that can be raised under its provisions to those presenting meaningful evidence that the defendant did not commit the crime, and by extending the time for a district court to review and rule on a chapter 154 petition from 6 months to 15 months.

The SPA also eliminates duplicative Federal review of minor sentencing errors that already have been judged by State courts to be harmless or not prejudicial. It limits Federal courts to asking only whether the type of sentencing error at issue is one that could not have been harmless.

The SPA also applies the deferential review standard enacted in the 1996 reforms to all pending cases. Remarkably, some current habeas petitions still are not governed by the 1996 reforms. The SPA corrects this oversight, ending the need to apply the pre-1996 legal regime to any cases that still are being litigated today.

And finally, the SPA limits judicial review of State clemency and pardon decisions, guaranteeing that a State won't be sued for formalizing and regularizing its pardon procedures; it limits defendants' ability to ask Federal courts for investigatory funds without allowing prosecutors to be present and rebut defense allegations; and it guarantees a crime victim's right to be notified of, to be present at, and to speak at a criminal defendant's Federal habeas hearing.

To many people, the issues addressed by the SPA--petitions for rehearing, State remedies exhaustion, procedural default, chapter 154, AEDPA deference--may seem abstract and remote. For surviving crime victims, however, these matters can be very concrete.

A case recently in the news illustrates the importance of these concerns: that of the man who murdered three member of the Ryen family and Christopher Hughes in Chino Hills, California in June 1983. The killer in that case was an escaped convict from a nearby prison. He has since admitted that he spent 2 days hiding in a vacant house next to the home of the Ryen family. After several unsuccessful telephone calls to friends asking them to give him a ride, the killer took a hatchet and buck knife from the vacant house and set out to find a vehicle. The California Supreme Court describes the rest of what occurred, 53 Cal.3d 771, 794-95:

On Saturday, June 4, 1983, the Ryens and Chris Hughes

attended a barbecue in Los Serranos, a few miles from the

Ryen home in Chino. Chris had received permission to spend

the night with the Ryens. Between 9 and 9:30 p.m., they left

to drive to the Ryen home. Except for Josh [the Ryen's 8-

year-old son], they were never seen alive again.

The next morning, June 5, Chris's mother, Mary Hughes,

became concerned when he did not come home. A number of

telephone calls to the Ryen residence received only busy

signals. [Mary's husband] William went to the Ryen home to

investigate.

William observed the Ryen truck at the home, but not the

family station wagon. Although the Ryens normally did not

lock the house when they were home, it was locked on this

occasion. William walked around the house trying to look

inside. When he reached the sliding glass doors leading to

the master bedroom, he could see inside. William saw the

bodies of his son and Doug and Peggy Ryen on the bedroom

floor. Josh was lying between Peggy and Chris. Only Josh

appeared alive.

William frantically tried to open the sliding door; in his

emotional state, he pushed against the fixed portion of the

doors, not the sliding door. He rushed to the kitchen door,

kicked it in, and entered. As he approached the master

bedroom, he found Jessica on the floor, also apparently dead.

In the bedroom, William touched the body of his son. It was

cold and stiff. William asked Josh who had done it. Josh

appeared stunned; he tried to talk but could only make

unintelligible sounds.

William tried to use a telephone in the house but it did

not work. He drove to a neighbor's house seeking help. The

police arrived shortly. Doug, Peggy, Chris, and Jessica were

dead, the first three in the master bedroom, Jessica in the

hallway leading to that bedroom. Josh was alive but in shock,

suffering from an obvious neck wound. He was flown by

helicopter to Loma Linda University Hospital.

The victims died from numerous chopping and stabbing

injuries. Doug Ryen had at least 37 separate wounds, Peggy

32, Jessica 46, and Chris 25. The chopping wounds were

inflicted by a sharp, heavy object such as a hatchet or axe,

the stabbing wounds by a weapon such as a knife.

The escaped prisoner who committed this crime was caught 2 months later. Again, he admitted that he stayed in the house next door, but denied any involvement in the murders. According to the California Supreme Court, however, the evidence of defendant's guilt was ``overwhelming.'' Not only had the defendant stayed at the vacant house right next door at the time of the murders; the hatchet used in the murders was taken from the vacant house; shoe prints in the Ryen house matched those in the vacant house and were from a type of shoe issued to prisoners; bloody items, including a prison-issue button, were found in the vacant house; prison-issue tobacco was found in the Ryen station wagon, which was recovered in Long Beach; and defendant's blood type and hair matched that found in the Ryen house. Defendant was convicted of the murders and sentenced to death in 1985, and the California Supreme Court upheld the defendant's conviction and sentence in 1991.

The defendant's Federal habeas proceedings began shortly thereafter, and they continue to this day--22 years after the murders. In 2000, the defendant asked the courts for DNA testing of a blood spot in the Ryen house, a t-shirt near the crime scene, and the tobacco found in the car. Despite the overwhelming evidence of his guilt, the courts allowed more testing. All three tests found that the blood and saliva matched defendant, to a degree of certainty of one in 320 billion. Blood on the t-shirt matched both the defendant and one of the victims.

One might have thought that this would end the case. Not so. In February 2004, the en banc Ninth Circuit sua sponte authorized defendant to file a second habeas petition to pursue theories that police had planted this DNA evidence. Since the evidence had been in court custody since 1983, the Ninth Circuit's theory not only required police to plan and execute a vast conspiracy to plant the evidence--it also required them to foresee the future invention of the DNA technology that would make that evidence useful in future habeas proceedings.

The Streamlined Procedures Act would have made a difference in this case. For example, it would have eliminated the need to return to state court to exhaust new claims, reducing the delay in the Federal proceedings by nearly 3 years. It would have applied the 1996 reforms to this case, allowing deferential review of state factual findings and legal analysis. It would have placed time limits on Federal appeals court decisionmaking and grants of rehearing. And it would have prevented the court of appeals from ordering rehearing of the defendant's successive-petition application on its own motion, thereby barring the current round of O.J. Simpson-style conspiracy-theory litigation. The SPA could have brought this case to closure a long time ago.

And this case deserves to be brought to closure. One cannot underestimate the grievous impact that crimes like these have on the families of the victims. Mary Hughes, the mother of 11-year-old Christopher Hughes, who was sleeping over at the Ryen house on the night of the murders, has spoken movingly of the loss of her son:

Christopher Hughes loved his bicycle, swimming and showing

off for his mom and dad.

The 11-year-old's bedroom was filled with swimming trophies

and Star Wars collectibles. He was a handsome kid who was

chased by a lot of fifth-grade girls on the playground during

recess at Our Lady of the Assumption in Claremont.

He wasn't short on friends, either.

Christopher really liked Joshua Ryen, an 8-year-old boy who

lived up the street from him. They would trick-or-treat

together on Halloween, play together, and their parents were

good friends.

On the night of June 4 1983, Christopher asked his parents

if he could spend the night at the Ryen house.

It was a decision that would change the Hughes family

forever.

[Mary Hughes'] son Christopher would have been 32 today.

She sometimes wonders who he would have been, what he

would've looked like, and even during her most solemn

moments, she wonders what life would've been like if Cooper

had never gone to the Ryens' house.

``It never really ever gets better,'' she said. ``Kevin

Cooper robbed him of the chance to be a child, to attend his

first dance, to have a girlfriend, and to one day get married

and

have kids of his own. He robbed me of my child.''

Mary Ann Hughes does have one special memory of her son she

holds close to her heart. A week before his death, she took

him to see the movie ``Return of the Jedi.''

``He was so happy. It was such a great day,'' she said.

``It seems like such a small thing, but it's the best memory

I have of both of us.'' (Sara Carter, ``He Was at the

Beginning of His Life When He Died,'' Inland Valley Daily

Bulletin, February 9, 2004.)

In light of how much the surviving family already has suffered, one might expect that all participants in the criminal proceedings would take great concern and care for the feelings of the family. Unfortunately, that has not been the case. The Ninth Circuit has proved willing to turn the appeals into a three-ring circus, allowing continual pursuit of the most frivolous conspiracy theories. The impact of these now 22 years of trial and appeals on the victims' families has been predictable: they feel that they and the victims have become irrelevant to the entire process. Shortly after the Ninth Circuit authorized an additional round of appeals in this case, a local newspaper described what the families have experienced:

For nearly 20 years, since convicted murderer Kevin Cooper

was sentenced to death for the 1983 slayings of a Chino Hills

family and their young houseguest, families of the victims

have waited silently for the day the hand of justice would

grant them peace.

For those families, the last two decades have seemed like

an eternity.

``I lived through a nightmare,'' said Herbert Ryen, whose

brother Douglas Ryen was among those killed, along with

Douglas' wife Peggy, their 11-year-old daughter Jessica, and

her 10-year-old friend Christopher Hughes.

[O]n the morning of Feb. 9, [2004,] the day of Cooper's

scheduled death by lethal injection, word came down that the

9th U.S. Circuit Court of Appeals had decided to block the

execution.

[T]o the Ryen and Hughes families, the stay just hours

before Cooper's scheduled execution at San Quentin State

Prison was nearly incomprehensible. The indefinite delay has

left them in a sort of emotional limbo, questioning whether

the legal system had abandoned them.

``The bottom line is that this whole issue is not about

Kevin Cooper . . . it is about the death penalty,'' said Mary

Ann Hughes, the mother of Christoper Hughes. ``We're so mad--

mad because we feel as though the courts turned their back on

my son.''

``They (Court of Appeals) are holding us hostage,'' Hughes

said.

For Herbert Ryen and his wife Sue, waiting for justice has

taken an equally destructive toll on their lives. The torment

their family experienced following the murders, and the

subsequent years lost to depression, could never be replaced,

he said from his home in Arizona.

Mary Ann Hughes said the pain her family suffers is only

amplified by the seemingly continuous bombardment of

celebrities campaigning against Cooper's execution. She

wonders who will cry out in anger for the victims.

One former television star and anti-death penalty activist,

Mike Farrell of the popular series MASH, spoke of the case on

a recent news program.

``He claimed that we must feel relieved since the stay of

execution was granted,'' Hughes said. ``How can (Farrell)

have the audacity to say he knows what we are feeling?''

Farrell could not be reached for comment.

Since Christopher's death, the Hughes family has chosen to

remain out of the media spotlight. And until recently, their

efforts were successful, due largely to the support of their

surviving children, family members and a strong network of

close friends, Hughes said.

The court's decision Feb. 9 has re-opened the case, forcing

the families to re-live the nightmare they have fought so

hard to leave behind, they say.

Mary Ann Hughes is left wondering about other families who

have had loved ones taken from them, about the legal battles

they have had to endure in their own quests for justice.

She thinks of the parents of Samantha Runion, the 5-year-

old Orange County girl who was murdered in 2003, and of what

her family could face in the next 20 years.

For Bill Hughes, the anguish is intensified--he will

forever know the pain of walking into the Ryens' home the

morning after the murders, and finding his son, dead and

covered in blood near the Ryens' bedroom door. He was also

the first to discover Joshua Ryen, also drenched in blood,

clinging to life.

``It is a memory he will always have to live with,'' Mary

Ann Hughes said.

Indeed, time has been no friend to the victims' families,

as California's recent appellate court ruling has further

denied them closure, she added.

``What this decision has done to our legal system in

California is unthinkable,'' she said. ``Somewhere along the

line, the courts have got to uphold the law, and we will wait

it out until they do.'' (Sara Carter, ``Families of Murder

Victims Wait for Justice in Cooper Case,'' Inland Valley

Daily Bulletin, February 24, 2004.)

Mary Hughes' story demonstrates why the use of Federal judicial power must be measured and fair it illustrates the heavy cost imposed by judicial excess.

No statement, however, better explains the gross cruelty caused by allowing endless litigation and appeals in a case like this than that given by one of the surviving victims of the 1983 attack. Josh Ryen was 8 years old when he was stabbed in his parents' bedroom and his parents and sister were murdered. He is now 30 years old. On April 22, 2005, he gave a statement pursuant to the recently enacted Crime Victims' Rights Act in the federal habeas corpus hearing for his parents and sister's killer. I will close my remarks by asking unanimous consent that Josh Ryen's statement be printed in the Record.

Mr. President, today I rise to introduce the National Language Coordination Act of 2005 which provides a framework for leading and coordination the learning of foreign languages and cultures, with my good friends Senators Cochran and Dodd.

The National Foreign Language Coordination Act would create the position of a National Language Director and a National Foreign Language Coordination Council to develop and oversee the implementation of a foreign language strategy. The proposed Council, chaired by the National Language Director, would identify crucial priorities, increase public awareness of the need for foreign language skills, advocate maximum use of resources, coordinate cross-sector efforts, and monitor the foreign language activities of the Federal Government.

The genesis of this legislation is a report entitled, ``A Call to Action for National Foreign Language Capabilities,'' issued by the National Language Conference held in June 2004 under the auspices of the Department of Defense. This conference was an extraordinary gathering of government, industry, academia, and language association representatives. The mission of this meeting was twofold: to discuss and deliberate initial strategic approaches to meeting the nation's language needs in the 21st century, and to identify actions that could move the United States toward a ``language-competent nation.'' It was hosted by the Office of the Under Secretary of Defense for Personnel and Readiness and by the Center for Advanced Study of Language (CASL) at the University of Maryland at College Park.

I ask unanimous consent that the executive summary of the report, ``A Call to Action for National Foreign Language Capabilities,'' be printed in the Record following my remarks.

I believe the recommendations of this report speak eloquently to the need for this legislation. As Dr. David Chu, Undersecretary of Defense for Personnel and Readiness, notes in his forward to the report, ``improving the nation's foreign language capability requires immediate and long-term engagement.''

The intent of this legislation is to ensure that immediate and long- term engagement.

The establishment of a National Language Director and the creation of a National Foreign Language Coordination Council will ensure that the key recommendations of the Department of Defense sponsored conference will be implemented, which include: developing policies and programs that build the nation's language and cultural understanding capability; engaging federal, state, and local agencies and the private sector in solutions; developing language and cultural competency across public and private sectors; developing language skills in a wide range of critical languages; strengthening our education system, programs, and tools in foreign languages and cultures; and integrating language training into career fields and increase the number of language professionals.

The terrorist attacks of September 11, 2001, showed how much more was needed to improve education in these critical areas. The investigations surrounding the attacks have underscored how important foreign language proficiency is to our national security. The Joint Intelligence Committee inquiry into the terrorist attacks found that prior to September 11, the Intelligence Community was not prepared to handle the challenge of translating the volumes of foreign language counter- terrorism intelligence that had been collected. Agencies within the Intelligence Community experienced backlogs in material awaiting translation and a shortage of language specialists and language- qualified field officers in the most critical terrorism-related languages used by terrorists.

America needs people who understand foreign cultures and who are fluent in locally-spoken languages. The stability and economic vitality of the United States and our national security depend on American citizens who are knowledgeable about the world. We need civil servants, including law enforcement officers, teachers, area experts, diplomats, and business people with the ability to communicate at an advanced level in the languages and understand the cultures of the people with whom they interact.

Experts tell us we should develop long-term relationships with people from every walk of life all across the world, whether or not the languages they speak are considered critical for a particular issue or emergency.

They are right.

As then-Deputy Secretary of Defense Paul Wolfowitz noted at the National Language Conference, ``The greater our ability to communicate with people, the easier the burden on our troops and the greater the likelihood that we can complete our missions and bring our people home safely. Even better, the greater our linguistic skill, the greater the possibility that we can resolve international differences and achieve our objectives without having to use force.''

I am proud of my own State of Hawaii, whose language patterns reflect that we are a mixing pot of varying cultures. According to the 2000 Census, more than 300,000 people or about 27 percent of those five years and older spoke a language other than English at home. This is compared to about 18 percent nationwide. Language education offerings to improve conversational proficiency with formal training in non- English languages are working to keep pace with increased demand. In addition, enrollments in foreign language courses at the University of Hawaii have been markedly increasing--a trend that I am gratified to see happening across the country. But more needs to be done both in Hawaii and the rest of the country.

I am a passionate believer in beginning these programs at the earliest age possible. Americans need to be open to the world; we need to be able to see the world through the eyes of others if we are going to understand how to resolve the complex problems we face.

The need to hear and understand one another is timeless and essential.

An ongoing commitment to developing language and cultural expertise

helps prevent a crisis from occurring and provides diplomatic and language resources when needed. We cannot afford to seek out foreign language skills after an event like 9/11 occurs. The failures of communication and understanding have already done their damage. We must provide an ongoing commitment to language education and encourage knowledge of foreign languages and cultures.

The answer is simple. If we are committed to maintaining these relationships and creating a language proficient citizenry, we must have leadership. The National Foreign Language Coordination Act will provide this leadership and ensure that we are aware and involved in the world around us.

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

I urge my colleagues to support this important legislation.

Mr. President, I rise today to introduce the Preserving Patient Access to Physicians Act of 2005. This bill updates Medicare physician reimbursement for 2006 and 2007 according to the recommendations of the Medicare Payment Advisory Committee (MedPAC). There would be a 2.7 percent increase to the physician payment schedule for 2006 and using the Medicare Economic Index update for the price of inputs, a 2.6 percent increase in 2007.

If the schedule is left alone, the consequences for physicians will be a negative. Instead of the 1.5 percent payment increase for 2004 and 2005 which I helped author in the Medicare Modernization Act, there would be a 4.3 percent decrease.

The sustainable growth rate (SGR) formula used to calculate physician payment depends on a number of factors: the number of Medicare fee-for- service beneficiaries, the volume and type of services provided, the price of services rendered, changes in regulations and laws. The formula also incorporates other factors such as prescription-drug prices and the gross domestic product. The SGR was intended to control expenditures by basing a given year's physician payment rate on the previous year's performance. Instead, it creates an arbitrary deficiency that continues to force Congress to intervene.

There is a debate going on, her CMS has the authority to alter the SGR formula by removing drugs. Setting that aside, though, the fact of the matter is that without Congress stepping in to provide for a physician payment update, it probably will not occur. My Senate colleagues and I have talked for many years about ensuring adequate physician payment because current and past administrations have failed to modify the formula. This formula is not doing what it was intended to do. Therefore, I believe we need to scrap it and start again. My bill is a starting point and proposes amounts for an update, but I would really like to see us go all the way back to the drawing board and answer the fundamental question of how to pay physicians appropriately for their services.

I want doctors to be able to continue to assist our nation's seniors, but it is unfair to expect them to practice and to have their reimbursement decrease. Practice expenses, the costs of medical technology, wages for administrative and clinical staff, and medical liability premiums are all increasing while physicians are on track to receive a payment decrease. They cannot afford to continue practicing medicine while receiving reimbursements that do not allow them to even break even. Many are retiring early or threatening to limit the number of Medicare patients they treat.

The service of physicians all across the country is vital to our seniors. Almost half a million doctors provide treatment to the 42 million people under the Medicare program. Physicians are often the gateway for access to other medical services and treatments. Not being able to consult a physician results in delayed referrals, delayed treatment and delayed care. In sum, the quality of health care continues to erode and our system does not operate efficiently.

Should the scheduled physician reimbursement cuts take effect, the result will be a $710 million decrease in payments to doctors in Arizona over 2006 through 2010. I have heard from virtually every physician with whom I have spoken about the constraints that inadequate payments are placing on their practice of medicine. While many work for hospitals and health systems, in the rural areas, a large number are solo practitioners or in small practices. For these physicians, poor payment hits their practice especially hard.

If Medicare rates for doctors are inadequate, many other health care payors will also lack for adequate reimbursement. Other payors such as Medicaid and private insurers often base their payments on Medicare rates. While this bill only addresses Medicare physician payment, the problem of access to services will be compounded if physicians receive reimbursement from other payors that is below the appropriate levels.

The cost of addressing the physician payment update is not cheap. Estimates on the cost of this bill are between $25 billion to $35 billion over five years. I await an official score from the Congressional Budget Office. But I point out, that doing nothing to solve this problem may cost us more: more money, more health and access problems, and more physicians leaving the profession. Although this legislation provides for a two year update, we must develop a long range mechanism to pay physicians appropriately.

I am grateful for the support of this legislation by my colleague, Senator

Stabenow of Michigan, and encourage my other colleagues to support the Preserving Patient Access to Physicians Act of 2005.

I ask unanimous consent that a letter of support be printed in the Record.

Today I am introducing legislation to address an important statement on what it means to be a citizen of the United States: the Oath of Allegiance, to which all new citizens swear in court when they are naturalized.

In the last session of Congress, I introduced legislation to enshrine the Oath of Allegiance in law. I was joined in that effort by 34 colleagues, including the Senator from New York, Mr.

Schumer, as the lead cosponsor. That legislation was introduced, in part, in response to reports that the Bureau of Citizenship and Immigration Services, or BCIS, an agency of the Department of Homeland Security, may have been planning to change the Oath of Allegiance that immigrants take to become a citizen of this nation. Other Senators and I felt the proposed language, as reported in the press, would have weakened the Oath.

Today, I introduce a bill that puts forward a compromise that I hope everyone can support. I am again grateful to be joined in this effort by the senior Senator from New York. This bill introduces a modified Oath of Allegiance that is just as strong as the current one, but that uses more modem language.

I was surprise to learn that Congress has never voted on the content of this Oath. We have left it to Federal regulators. That's not how we treat other symbols of our Nation or other statements on what it means to be an American.

For example, the American Flag, with its 50 stars--one for each State--and 13 stripes for the original colonies, cannot be altered by Federal regulation. The only way a star gets added is when Congress acts to admit a new state. And we've never changed the 13 stripes since the flag was first adopted in 1777.

The Pledge of Alliance, which we repeat each morning in the United States Senate, can't be altered by Federal regulation. The Pledge is a statement of some of the values of the American Creed: ``one nation, under God, indivisible, with liberty and justice for all.'' What if a Federal agency decided we should take out justice, just saying ``with liberty for all''? It can't happen: because the Pledge can only be altered by Act of Congress, as it last was in 1954 when the phrase ``under God'' was added.

The National Motto ``In God We Trust,'' which appears on all our coins and dollar bills, can't be altered by Federal regulation. It is a fundamental statement of the religious character of the American people--even though we don't permit and don't want the establishment of state religion. The Treasury Department can't decide to leave the motto off the next dollar bill it prints because the motto was adopted by Congress--at first in 1864 to be printed on the 2-cent piece, an later as the official National Motto in 1956.

Our National Anthem, the Star Spangled Banner, can't be changed by Federal regulation. It, too, is a statement of our values, declaring our country ``the land of the free and the home of the brave.'' If a government agency decided it preferred America the Beautiful, or the Battle Hymn of the Republic, or God Bless America, all of which are great songs, the agency would have to ask Congress to act. Why? Because the Star Spangled Banner was named our National Anthem by law in 1931.

Likewise, the Oath of Allegiance should not be altered lightly--by a government agency, without public comment, and without approval from Congress. Of the five symbols and statements I've described--the Flag, the Anthem, the Pledge, the Motto, and the Oath, only the Oath of Allegiance is legally binding on those who take it. New citizens must take it, and they must sign it.

On September 11, 2003, when I spoke about my legislation, I said:

To be clear, I have no objection to others proposing

modifications to the Oath of Allegiance that we use today. .

. . perhaps ways can be found to make it even stronger.

Still, let's make sure any changes have the support of the

people as represented by Congress. The Oath of Allegiance is

a statement of the commitments required of new citizens.

Current citizens, through their elected representatives,

ought to have a say as to what those commitments are. That's

a lesson in democracy. A legally binding statement on

American citizenship ought to reflect American values,

including democracy.

It is in that spirit that I offer this compromise language that prescribes an updated but very strong Oath of Allegiance. This is the right way to go forward in considering any changes, and, I hope, will allow us to finally enshrine this statement of what it means to be an American in law.

Mr. President, I am very pleased to introduce the ``Preserving Patient Access to Physicians Act'' with my friend and colleague from Arizona, Senator Kyl. This legislation is critical to ensuring that our Nation's 42 million Medicare beneficiaries continue to have access to high quality physician care.

The Medicare program is one of the most successful Federal programs of all time. It has lifted countless seniors out of poverty, and it has ensured access to necessary, affordable, quality medical care for our most vulnerable citizens for the last 40 years.

However, that success is threatened because the Medicare physician payment formula is fundamentally flawed. At a time when the doctors who treat our seniors are facing increasing practice costs, they are looking at a payment cut of 4.3 percent in 2006 for the Medicare services they provide that simply doesn't make sense.

And the cuts don't stop in 2006: if Congress doesn't act, physicians will be hit with devastating cuts totaling 22 percent over the next 5 years. Those cuts represent over $44 billion dollars nationwide, and a staggering $126 billion over the next 10 years.

Currently, over 20,000 MDs and DOs in Michigan treat over 1.4 million Medicare-eligible Michiganians with very high quality care. But if the doctors in my State receive their scheduled cut of $109 million next year, and over $5 billion over the next ten years, it's not hard to imagine that they may be forced to limit the number of Medicare patients they serve.

Numbers in the billions are indeed staggering--but the critical need for this legislation is even better demonstrated by getting down to the specifics: a Detroit physician currently is reimbursed $56.88 for an office visit. But while we all know medical inflation will continue to increase, under current law, that same physician will receive only $41.86 in 2011 for that same visit. And while an orthopedic surgeon in Detroit is now reimbursed $1,813.10 for performing a knee arthroplasty--a knee repair necessary to ensure full mobility--she is scheduled to receive $478.66 less for performing that same procedure in 2011! The examples go on and on: a cardiologist inserting a stent in a Medicare patient to prevent heart problems receives $873.85 today. The same surgeon inserting a stent in 2011 will be reimbursed only $643.15.

The ``Preserving Patient Access to Physicians Act of 2005'' provides physicians with a minimum update in 2006 and 2007. Specifically, the legislation overrides the Sustainable Growth Rate (SGR) formula in these years: the update to the single conversion factor in 2006 would be 2.7 percent, and a formula based on input prices and a productivity adjustment is used for 2007--the likely update for 2007 will be 2.6 percent.

Kevin Kelly, Executive Director of the Michigan State Medical Society, tells me that the minimum updates provided in this legislation are essential to both physicians and patients in Michigan in terms of assuring access to Medicare services.

And Robert Stomel, D.O., President of the Michigan Osteopathic Association, said that introduction of this legislation ``is an important step in efforts to protect the availability and access to physician services for millions of Medicare beneficiaries.'' Dr. Stomel went on to say, ``This bipartisan legislation represents a continued recognition that physician payment under Medicare must keep pace with the increasing cost of providing care.''

Yet I know that this is just the beginning. We cannot continue to use stop-gap measures but must replace the SGR with a payment system that actually makes sense and reflects the costs of providing physician care to Medicare beneficiaries.

Through the bipartisan partnership Senator Kyl and I have begun today, we can--and must--fix the physician payment formula and continue to provide access to high-quality Medicare services for all of our seniors and people with disabilities.

I ask unanimous consent to have printed in the record letters of support from the American Medical Association and the American Osteopathic Association.

I urge my Colleagues to join us in this effort, and I thank the Chair.