Rural Hospital and Provider Equity (HoPE) Act of 2006

Mr. President, today I am pleased to join with Senator McCain to introduce the Las Cienegas Enhancement Act of 2006. This legislation directs a land exchange between the Bureau of Land Management and the Las Cienegas Conservation, LLC. in southeastern Arizona. The bill is the product of consensus. State and local officials, conservationists, and other stakeholders have worked together to structure an exchange that is fair and in the public interest.

Let me explain the details of the exchange. The land to be transferred out of Federal ownership, approximately 1,280 acres, is referred to as the ``Sahuarita property.'' This property is BLM-managed land south of Tucson near Corona de Tucson. The land is low-lying Sonoran desert and has been identified for disposal by the BLM through its land-use planning process.

The private land to be brought into Federal ownership is approximately 2,392 acres of land referred to as the ``Empirita- Simonson property.'' This property lies north of the Las Cienegas National Conservation Area managed by the BLM. The Empirita-Simonson property lies within the ``Sonoita Valley Acquisition Planning District'' established by Public Law 106-538, which designated the Las Cienegas National Conservation Area. The act directed the Department of the Interior to acquire lands from willing sellers within the planning district for inclusion within the conservation area to further protect the important resource values for which the area was designated.

Although this bill is centered on the land exchange I just described, it also accomplishes two other important objectives: addressing water withdrawals at Ciengas Creek and providing road access to a popular recreation destination, the Whetstone Mountains controlled by the Forest Service.

Let's talk about water. Arizonans understand that protecting our water supply is crucial to the State's future. For this reason, when we can, we look for ways to promote responsible use of our limited water supply. This bill is one of those examples of responsible use. There is a prior claim to a well site on the private land that will be exchanged. That prior claim would allow the developer to withdraw 1,600 acre feet of water a year. Pima County and the community at large are concerned about the future of Ciengas Creek and the entire riparian area if these water withdrawals occur.

To address this concern, the land exchange is conditioned on Las Cienegas Conservation Inc. conveying the well site to Pima County and relinquishing those water rights it controls. The net result is a water savings of 1,050 acre-feet per year. This is a significant benefit to this riparian area.

Overall, this bill allows us to accomplish important environmental and conservation objectives while managing our development. It is a bill with broad support that includes the Governor of Arizona, Pima County, the city of Tucson, and many others. I urge my colleagues to work with me to approve this legislation at the earliest possible date.

Mr. President, I rise today to introduce the Internet SAFETY Act of 2006. The word ``SAFETY'' in the bill's title stands for Stop Adults Facilitating the Exploitation of Youth. It is a fairly descriptive acronym, for the provisions of the Internet SAFETY Act are designed to crack down on the spread of Internet child pornography and related conduct. The act does so by creating new Federal offenses and causes of action targeted at those who produce or knowingly facilitate Internet child pornography, by increasing penalties for child pornography, sex trafficking, and sexual abuse offenses, and by increasing resources available for prosecution and prevention of child sexual-abuse offenses, including authorizing 200 new assistant U.S. attorneys across the country to prosecute child pornography and sexual exploitation crimes.

The need for renewed law-enforcement attention to child pornography is demonstrated in a recent report of the U.S. Justice Department titled ``Project Safe Childhood.'' I will ask to have an extended excerpt from the report printed in the Record at the conclusion of my remarks. As the report notes, ``judging simply by [recent] crime statistics, it is clear that the Internet is helping to fuel an epidemic of child pornography'' in this country. Unfortunately, by providing greater technical ease and increased anonymity in trading images, the Internet has ``taken down barriers that one time served as a deterrent to child pornographers.'' In 2003, an estimated 20,000 images of child pornography were posted on the Internet every week. Between 1998 and 2004, child pornography reports made to the National Center for Missing and Exploited Children increased from 3,267 to 106,119--a thirty-fold increase over a 6-year period. The Justice Department also notes that there has been an escalation in the severity of abuse depicted in child pornography in recent years, ``with the images found today more frequently involving younger children-- including toddlers and even infants--and despicable acts such as penetration of infants.'' The Project Safe Childhood report concludes that ``the nation should be alarmed at the fact that child pornography is being produced,

possessed, and distributed in record numbers.'' As the report notes, child pornography's harm extends beyond that done to the children who are sexually abused to produce such images: ``child pornography [also] plays a central role in child molestations, serving to justify offenders' conduct, assist them in gaining compliance with their victims, and to provide a means to blackmail the children they have molested in order to prevent exposure.''

The Internet SAFETY Act does the following things. It creates a new Federal offense, punishable by a maximum of 10 years in prison, for financially facilitating access to child pornography on the Internet. The act also deters Internet facilitation of child pornography by imposing civil penalties for Internet communications providers that fail to report child pornography, criminal penalties for Web site operators who insert words or images into source code with the intent to deceive persons into viewing obscene material on the Internet, and by requiring commercial Web site operators to place warning marks prescribed by the Federal Trade Commission on Web pages that contain sexually explicit material.

The Internet SAFETY Act also punishes the operation of child pornography enterprises. It creates a new Federal offense, punishable by a minimum of 10 years in prison, for the operation of an enterprise that profits from the sexual exploitation of children. The act also imposes mandatory, consecutive 10 year sentences for any child pornography or exploitation offense committed by a registered sex offender. In addition, the act increases penalties for offenses involving child pornography, child prostitution and sex trafficking, child sexual abuse, and sexual assault.

The Internet SAFETY Act also expands the Federal private right of action against child pornographers. It allows a victim, including parents of a minor victim, to seek civil remedies, and also allows a victim to seek remedies as an adult. This provision is inspired by a young girl named Masha who was adopted from Russia by a man who repeatedly molested her, photographed her, and posted pornographic images of her on the Internet. In addition, the act adds the obscenity and child pornography statutes to the RICO predicates and adds electronic mail fraud to the wiretap predicates.

The Internet SAFETY Act also establishes within the Justice Department an Office on Sexual Violence and Crimes Against Children to coordinate sex offender registration and notification programs and grant programs, and to assist State, local, and tribal governments and other entities with sex offender registration or notification and other measures.

Finally, the act authorizes and directs the Attorney General to make grants to States, local governments, Indian tribes, and nonprofit organizations for child sexual abuse prevention programs. In addition, the act authorizes appropriations for 200 additional child exploitation prosecutors in U.S. Attorneys' Offices around the country and 20 additional Internet Crimes Against Children task forces.

I ask unanimous consent that the following passages from the Justice Department's report Project Safe Childhood be printed in the Record.

Mr. President, American families face great challenges in dealing with the rapidly changing global economy. The value of their wages is declining, the cost of living is going up, and many jobs are moving overseas. More and more Americans feel the American dream is slowly slipping out of reach.

We can and must deal more effectively with this problem. We have a responsibility to make the investments that are necessary to our progress--a responsibility to our families, to our economy, to our Nation, and even to our national security.

We can guarantee America's continuing prosperity in the future, but we must work for it. We must sacrifice for it. The rest of the world is playing for keeps. We cannot just tinker at the margins if we expect to continue to be a leader in this rapidly shrinking world.

We must ensure that our citizens can achieve the American dream once again. To do so, our highest priority must be a world class education for every American. We must make the American employee and employer the best educated, best trained, and most capable in the world. We need to strengthen the capacities of every person in the Nation.

This isn't just my opinion. In recent years, study after study has emphasized education as the solution to keeping America competitive in the years to come.

Last year, the Council on Competitiveness urged a focus on lifelong skill development--through elementary, secondary and higher education, and through training and workforce support, as essential to keeping America on the cutting edge of innovation.

A recent National Academy of Sciences report contains these recommendations. Two of the report's four major recommendations state that education is the solution to meeting the global challenge.

The National Association of Manufacturers has also issued a report urging a renewed focus on education and training to keep American businesses competitive.

Other industrialized countries are embracing education as the key to competing in this new economy, but America is slipping behind. We rank 28th out of 40 nations in math education. We were 3rd in the world in 1975 in the production of new scientists and engineers, but now we rank 15th. By 2008, 6 million U.S. jobs will go unfilled because our workforce will not be qualified to fill them.

These shortcomings threaten both our economic security and our national security.

The last time America was shocked into realizing we were unacceptably behind in math and science was in 1957, when the Soviet Union launched Sputnik. To meet that crisis, Republican President Eisenhower worked closely with a Democratic Congress to pass the National Defense Education Act. The new law declared a national ``education emergency,'' and we doubled the Federal investment in education virtually overnight.

Today I join with my colleagues, Senator Clinton and Senator Kerry, to introduce a new National Defense Education Act for our own day and generation.

To respond to this major challenge, we must ensure our education standards are internationally competitive, so that our high school graduates can succeed in the new economy. We must make a commitment to all students--regardless of the studies they choose to pursue--that cost will not be a barrier to a college degree. We must strengthen math and science education in this country by making college free for students training to become math or science teachers in high need schools.

Our New National Defense Education Act responds to each of these imperatives. It modernizes our education system and equips Americans with 21st century knowledge and skills.

It provides incentives and resources for schools to develop and implement more rigorous standards in math, science and reading.

The legislation updates the Nation's report card--the National Assessment of Educational Progress--to ensure that it sets a national benchmark which is internationally competitive and is aligned with the demands of the 21st century global economy. It expands our ability to monitor science achievement. It requires the NAEP to measure student preparedness to enter college, the 21st century workforce, or the armed services. It also requires the Secretary of Education to examine the gaps in student performance on State-level assessments and NAEP assessments, and to assist States in understanding those gaps. It provides critical resources to states to create PreK-16 Preparedness Councils to help them with their efforts to improve state standards and ensure that they are aligned with the expectations of colleges, employers, and the Armed Services. It also provides funding to States working in collaboration to establish common standards and assessments.

The New NDEA also directs resources to high need schools, to enable them to invest in math, science, engineering and technology textbooks and laboratories, and give their students equal

access to a curriculum that will provide the skills they need to be successful in the 21st century global economy.

The legislation recognizes the critical role of the National Science Foundation in ensuring our children have access to cutting-edge science and technology programs, by doubling the investment in elementary, secondary, and postsecondary education programs at NSF.

The New NDEA also helps open the doors of college to all by creating the Contract for Educational Opportunity grant program, or ``CEO Grants,'' which guarantee students that if they work hard and are admitted to college, their financial need will be met through additional State and Federal financial aid.

The legislation also offers additional grants to make college tuition free for low- and middle-income students studying science, technology, engineering or math, as well as critical-need foreign languages.

The bill provides larger grants to students studying to become teachers in these fields who agree to work in a high poverty school for at least 4 years. It also provides teachers with tax credits, increased loan forgiveness and additional incentives to continue to teach where they are needed the most. It provides grants to institutions of higher education to develop innovative programs for recruiting and training new teachers, and invests in teacher training programs to support their continuing education.

The bill recognizes that it is increasingly important for students to be exposed to other languages and cultures. In recent years, foreign language needs have significantly increased throughout the public and private sector because of the wider range of security threats, the emergence of new nation states, and the globalization of the U.S. economy. American businesses increasingly need employees experienced in foreign languages and international cultures to manage a culturally diverse workforce.

The New NDEA responds to these needs by providing grants for elementary and secondary critical-need language programs, summer institutes to improve teachers' knowledge and instruction of foreign languages and international content, and study abroad and foreign language study opportunities for high school students, and undergraduate and graduate students.

The New NDEA also continues to invest in our current workforce. The bill builds on existing formula funds for job training with competitive grants to support innovative strategies to meet emerging labor market needs.

From our earliest days as a nation, education has been the engine of the American dream. Our country is home to the greatest universities in the world, and our education system has produced the world's leading teachers, scientists, writers, musicians, and inventors. We cannot let these achievements stall. Slogans are not enough. We have to put first things first, and give children, parents, schools, communities and states the support they need to refuel the amazing engine of education and keep our country great in the years ahead.

I urge my colleagues to join us in making this strong new commitment to securing our Nation's future by supporting the New National Defense Education Act.

Mr. President, I ask unanimous consent that the text of the New National Defense Education Act be printed in the Record.

Mr. President, I am pleased to rise today to introduce the Rural Hospital and Provider Equity, R-HoPE, Act of 2006 with Senator Conrad, Senator Harkin, Senator Roberts, and fellow Senate Rural Health Caucus members Senators Collins, Dayton, Salazar, Burns, Domenici, Dorgan, Thune, Johnson, Ben Nelson, and Murkowski. As always, it is important to note that rural health care legislation has a long history of bipartisan collaboration and cooperation.

The 108th Congress reaped unparalleled successes in terms of rural health care legislation. When Congress enacted the Medicare Modernization Act, MMA, it included a comprehensive health care package specifically tailored with rural communities, hospitals, and providers in mind. This was the largest rural provider payment package ever considered by Congress.

As Republican cochairman of the Senate Rural Health Caucus, I was proud to help lead the effort to put rural providers on a level playing field with their urban neighbors. We enacted commonsense Medicare payment equity provisions critical to maintaining access to quality health care in isolated and underserved areas. Rural America achieved a significant victory, and we have much to celebrate. However, our mission is not complete. Several of the MMA's rural health provisions have expired, or are set to expire this year. That is why I have introduced the Rural Hospital and Provider Equity Act--to finish the work we started 3 years ago.

This legislation not only reauthorizes expiring rural MMA provisions but also takes additional steps to address inequities in the Medicare payment system that continually place rural providers at a disadvantage. My bill recognizes the unique needs of rural hospitals and levels the playing field between rural and urban providers.

Rural hospitals are more dependent on Medicare payments as part of their total revenue. In fact, Medicare accounts for almost 70 percent of total revenue for small, rural hospitals. Rural hospitals have lower patient volumes, but must compete nationally to recruit providers due to the nursing--and other health professional--workforce shortages. Additional burdens are placed on rural hospitals and providers because of higher uninsured and underinsured rates in rural America. Also, seniors living in rural areas tend to be poorer and have more chronic conditions than their urban and suburban counterparts.

First, the Rural Hospital and Provider Equity Act recognizes the special circumstances rural hospitals face and addresses these issues by equalizing Medicare disproportionate share hospital, DSH, payments. These add-on payments help hospitals cover the costs of serving a high proportion of low-income and uninsured patients. Current law allows urban facilities to receive unlimited add-ons corresponding with the amount of patients served. However, small or rural hospital add-on payments are capped at 12 percent. This measure eliminates the rural hospital cap, bringing their payments in line with the benefits urban facilities receive.

Second, the bill recognizes that low-volume hospitals have a higher cost per case which results in negative operating margins. To alleviate this problem, we established a low-volume inpatient payment adjustment for hospitals that have less than 2000 annual discharges per year and are located more than 15 miles from another hospital. This provision will improve payments for approximately one-third of all rural hospitals.

In addition to these Medicare payment reforms, this legislation strengthens the over 3,000 rural health clinics that serve many rural Americans. Under current law, rural health clinics receive an all- inclusive payment rate that is capped at approximately $63. This payment has not been adjusted--except for inflation--since 1988. To recognize the rising costs of health care, this bill raises the rural health clinic cap to $82, making it comparable to the rate Community Health Centers receive. By caring for folks in underserved areas, rural health clinics and community health centers are a key component of the rural health care delivery system. As not every small town can sustain a hospital, we need to ensure these types of facilities are paid adequately and are provided enough flexibility to meet the health care needs of the communities they serve.

Home health care agencies are another critical element of the continuum of care in rural areas. These providers face unique circumstances in the distances they are required to travel to provide services. The current Medicare payment system does not make adequate adjustments to reflect the reality of rural and frontier health care. This bill recognizes the situation these providers face by ensuring their Medicare payments cover their costs to provide Medicare services.

As you all may know, there are approximately 1,165 hospitals nationwide that have converted to critical access hospital, CAH, status. This program was created in the Balanced Budget Act of 1997 to ensure folks in small, rural communities would have access to 24-hour emergency services as well as some hospital care in their hometowns. Fifty-two percent of my State's hospitals have downsized to Critical Access Hospital status. The measure I have introduced contains several provisions to strengthen this important rural hospital program.

The Rural Hospital and Provider Equity Act will also ensure rural areas can maintain access to important emergency medical services, EMS. Rural EMS providers are primarily volunteers who have difficulty recruiting, retaining, and educating EMS personnel. Rural EMS providers also have less capital to buy and upgrade essential, lifesaving equipment. The legislation will assist ambulance providers in collecting payments for transporting patients to the hospital after answering a 911 call regardless of the final diagnosis. This is a commonsense approach and ensures that all aspects of emergency care are operating under the same definition of emergency.

It is important for the Federal Government to remember that one payment system does not fit all. Rural providers care for patients under much different circumstances than their urban counterparts. This legislation is designed to ensure rural hospitals, rural health clinics, rural ambulance providers, rural home health agencies, rural mental health providers, rural physicians, and other critical allied health clinicians are paid accurately and fairly. I strongly encourage all my colleagues with an interest in rural health to cosponsor this legislation.

Finally, I want to thank the American Hospital Association, the National Rural Health Association, the Federation of American Hospitals, the National Association of Rural Health Clinics, the National Association for Home Care, the American Academy of

Nurse Practitioners, the American Ambulance Association, and the Association of Marriage and Family Therapists, for their work and support in this effort.

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

Mr. President, I am pleased to rise today to introduce the Rural Hospital and Provider Equity, R-HoPE, Act of 2006 with Senator Conrad, Senator Harkin, Senator Roberts, and fellow Senate Rural Health Caucus members Senators Collins, Dayton, Salazar, Burns, Domenici, Dorgan, Thune, Johnson, Ben Nelson, and Murkowski. As always, it is important to note that rural health care legislation has a long history of bipartisan collaboration and cooperation.

The 108th Congress reaped unparalleled successes in terms of rural health care legislation. When Congress enacted the Medicare Modernization Act, MMA, it included a comprehensive health care package specifically tailored with rural communities, hospitals, and providers in mind. This was the largest rural provider payment package ever considered by Congress.

As Republican cochairman of the Senate Rural Health Caucus, I was proud to help lead the effort to put rural providers on a level playing field with their urban neighbors. We enacted commonsense Medicare payment equity provisions critical to maintaining access to quality health care in isolated and underserved areas. Rural America achieved a significant victory, and we have much to celebrate. However, our mission is not complete. Several of the MMA's rural health provisions have expired, or are set to expire this year. That is why I have introduced the Rural Hospital and Provider Equity Act--to finish the work we started 3 years ago.

This legislation not only reauthorizes expiring rural MMA provisions but also takes additional steps to address inequities in the Medicare payment system that continually place rural providers at a disadvantage. My bill recognizes the unique needs of rural hospitals and levels the playing field between rural and urban providers.

Rural hospitals are more dependent on Medicare payments as part of their total revenue. In fact, Medicare accounts for almost 70 percent of total revenue for small, rural hospitals. Rural hospitals have lower patient volumes, but must compete nationally to recruit providers due to the nursing--and other health professional--workforce shortages. Additional burdens are placed on rural hospitals and providers because of higher uninsured and underinsured rates in rural America. Also, seniors living in rural areas tend to be poorer and have more chronic conditions than their urban and suburban counterparts.

First, the Rural Hospital and Provider Equity Act recognizes the special circumstances rural hospitals face and addresses these issues by equalizing Medicare disproportionate share hospital, DSH, payments. These add-on payments help hospitals cover the costs of serving a high proportion of low-income and uninsured patients. Current law allows urban facilities to receive unlimited add-ons corresponding with the amount of patients served. However, small or rural hospital add-on payments are capped at 12 percent. This measure eliminates the rural hospital cap, bringing their payments in line with the benefits urban facilities receive.

Second, the bill recognizes that low-volume hospitals have a higher cost per case which results in negative operating margins. To alleviate this problem, we established a low-volume inpatient payment adjustment for hospitals that have less than 2000 annual discharges per year and are located more than 15 miles from another hospital. This provision will improve payments for approximately one-third of all rural hospitals.

In addition to these Medicare payment reforms, this legislation strengthens the over 3,000 rural health clinics that serve many rural Americans. Under current law, rural health clinics receive an all- inclusive payment rate that is capped at approximately $63. This payment has not been adjusted--except for inflation--since 1988. To recognize the rising costs of health care, this bill raises the rural health clinic cap to $82, making it comparable to the rate Community Health Centers receive. By caring for folks in underserved areas, rural health clinics and community health centers are a key component of the rural health care delivery system. As not every small town can sustain a hospital, we need to ensure these types of facilities are paid adequately and are provided enough flexibility to meet the health care needs of the communities they serve.

Home health care agencies are another critical element of the continuum of care in rural areas. These providers face unique circumstances in the distances they are required to travel to provide services. The current Medicare payment system does not make adequate adjustments to reflect the reality of rural and frontier health care. This bill recognizes the situation these providers face by ensuring their Medicare payments cover their costs to provide Medicare services.

As you all may know, there are approximately 1,165 hospitals nationwide that have converted to critical access hospital, CAH, status. This program was created in the Balanced Budget Act of 1997 to ensure folks in small, rural communities would have access to 24-hour emergency services as well as some hospital care in their hometowns. Fifty-two percent of my State's hospitals have downsized to Critical Access Hospital status. The measure I have introduced contains several provisions to strengthen this important rural hospital program.

The Rural Hospital and Provider Equity Act will also ensure rural areas can maintain access to important emergency medical services, EMS. Rural EMS providers are primarily volunteers who have difficulty recruiting, retaining, and educating EMS personnel. Rural EMS providers also have less capital to buy and upgrade essential, lifesaving equipment. The legislation will assist ambulance providers in collecting payments for transporting patients to the hospital after answering a 911 call regardless of the final diagnosis. This is a commonsense approach and ensures that all aspects of emergency care are operating under the same definition of emergency.

It is important for the Federal Government to remember that one payment system does not fit all. Rural providers care for patients under much different circumstances than their urban counterparts. This legislation is designed to ensure rural hospitals, rural health clinics, rural ambulance providers, rural home health agencies, rural mental health providers, rural physicians, and other critical allied health clinicians are paid accurately and fairly. I strongly encourage all my colleagues with an interest in rural health to cosponsor this legislation.

Finally, I want to thank the American Hospital Association, the National Rural Health Association, the Federation of American Hospitals, the National Association of Rural Health Clinics, the National Association for Home Care, the American Academy of

Nurse Practitioners, the American Ambulance Association, and the Association of Marriage and Family Therapists, for their work and support in this effort.

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

Mr. President, today I am pleased to join Senator Thomas in introducing the Rural Hospital and Provider Equity Act, or R-HoPE. This

proposal will help shore up health care in rural areas and give rural Americans hope that health care will be available when they need it.

R-HoPE is the next step in addressing the inequities that exist in Medicare reimbursement and ensuring access to health services, like ambulance, mental health and home health care, in rural communities. The proposal has strong bipartisan support. In fact we're pleased to have over 12 cosponsors today from both sides of the aisle.

Our proposal also has broad support among provider groups including the National Rural Health Association, the American Hospital Association, the American Ambulance Association, Federation of American Hospitals, the National Association of Rural Health Clinics, National Association for Home Care and Hospice, and the American Academy of Nurse Practitioners.

As my colleagues know, prior to the Medicare Modernization Act, Medicare was shortchanging rural providers. Our reimbursement was significantly less than our urban counterparts. For example, Mercy Hospital in Devil's Lake North Dakota received half as much reimbursement for treating pneumonia as Mercy Hospital in New York City did. While I will be the first to admit that health care can be more expensive in urban areas, it certainly isn't twice the cost. And for that matter, rural hospitals don't get a ``rural discount'' when they go to buy supplies or new technology. It costs rural hospitals even more to purchase technology and supplies because they can't achieve the economies of scale that larger, more urban hospitals can.

The MMA recognized this disparity in reimbursement and took steps to close the gap. We secured over $25 billion for rural health care, but most of the changes were only temporary. Even with the MMA funding, many rural hospitals and providers continue to experience negative margins. In 2003, before the MMA passed, rural hospitals had overall Medicare margins of negative 5.4 percent--compared to negative 0.9 percent for urban providers. In its March 2006 report, the Medicare Payment Advisory Commission projected that rural hospitals would experience negative 4.5-percent margins this year. Facilities cannot continue to provide high quality services if they lose over 4 percent on every Medicare patient.

R-HoPE will help continue the progress made by the MMA and add new provisions that will protect access to rural health care.

First, it will help ensure that everyone who chooses to live in a rural community has a hospital nearby. For example, the proposal recognizes that rural facilities can't achieve the same economies of scale as large hospitals by giving extra payments to hospitals with fewer than 2,000 patients a year. R-HoPE also reinstates provisions that protect rural hospitals against losses under the current outpatient payment system. Next, the bill extends an MMA provision that has helped rural hospitals to better meet their labor costs by improving their ``wage index'' calculation. In addition, the proposal would close the gap in payments hospitals receive for serving low- income patients by giving the same level of special ``disproportionate share payments'' that urban areas enjoy. Lastly, the bill establishes a new loan program to help rural hospitals repair crumbling buildings.

Second, R-HoPE would guarantee that rural Americans can see a doctor when they are sick. As is the case with most rural States, much of North Dakota is designated as a health professional shortage area, HPSA. Recruiting doctors to these areas is very difficult, and the Medicare program recognized that extra payments are needed when it established the 10-percent physician scarcity payment for doctors who serve Medicare patients in HPSAs. R-HoPE would extend these vital bonus payments. Our proposal also extends a provision from the MMA that erases geographic inequities in physician payments.

Third, our bill would guarantee that when there is an emergency in a rural area, an ambulance is there to respond. Many rural ambulance services are closing because of low Medicare reimbursement. These services are often staffed by volunteers; few first responders are paid. R-HoPE would protect rural ambulance services by improving how Medicare pays EMS providers in rural areas. The bill also extends a 2- percent bonus payment for rural ambulance services and takes steps to reduce the number of wrongful denials of payment by Medicare contractors.

Fourth, R-HoPE helps to bolster a vital rural health care safety net provider, rural health clinics. Our bill would help preserve this important source of health care by increasing the all-inclusive payment from $63 to $82. In addition, our bill encourages rural health clinics to collaborate with community health centers to provide care in rural areas.

Fifth, R-HoPE takes a number of steps to protect the availability of home and mental health in rural areas by increasing the number of providers who are allowed to order and provide these vital services. It also extends the rural add-on payment for home health services provided in rural areas and creates a pilot project to use home monitoring technology to provide home health services.

This bill also removes barriers to telehealth. Specifically, the bill would address problems that arise when telehealth services are provided across State lines and payment is denied because the practitioner isn't licensed in the State where the patient resides.

Finally, the bill we are introducing includes two small changes to the critical access hospital, CAH, program that will put these facilities on a much sounder financial footing. These provisions would ensure CAHs could afford to provide quality ambulance care and receive fair reimbursement for lab services provided outside the hospital.

Rural America is the backbone of this country. We must not turn our backs on rural Americans and their health care needs. They have a right to the same quality health care enjoyed by other Americans. And that right is being threatened by low Medicare reimbursement and limited access to providers. R-HoPE truly gives hope to those living in rural communities by erasing the inequities in current law that impede access to care.

I want to thank my Senate colleagues who have joined in this effort, as well as the organizations who worked with us, for their cooperation in developing this important health care proposal. It is my hope that this legislation will help strengthen our rural health care system and preserve it for generations to come.