Ensuring the Future Physician Workforce Act of 2008

Madam President, our vote today on H.R. 6331 carries real and immediate consequences for people who depend on Medicare. Action on this legislation is mandatory now because, 8 days ago, the temporary fix we passed at the end of last year expired. The cuts are in effect.

Next Tuesday, when the Centers for Medicare and Medicaid Services begins paying claims for services rendered after June 30, 2008, payments will be cut unless we pass this measure.

Because I return home every evening to my State, I interact frequently with Maryland providers. They cannot sustain a nearly 11- percent cut in their Medicare payments; they and many of their colleagues will stop accepting new Medicare patients unless we pass this bill.

The pending cuts are the result of a flawed system that pegs provider reimbursement to the growth of the Nation's GDP. It was created by the 1997 Balanced Budget Act as a way to rein in dramatic growth in Medicare spending on physician services. But this system, known as SGR, has not worked as intended. In fact, every year since 2001, Congress has had to act to prevent the cuts from going into effect. We know that the SGR formula must be repealed.

I have introduced legislation in past years to eliminate SGR and replace it with a system that reimburses based on the actual reasonable costs of providing care. The bill that was passed overwhelmingly by the House, H.R. 6331, provides another temporary fix through December 31, 2009. That is sufficient time for the next Congress, working with a new administration and the provider community, to develop a new mechanism.

But although ``doctor fix'' is the shorthand often used, this bill is far more than that, and our failure to pass it has repercussions far beyond physician offices. Another provision that expired on June 30 is the exceptions process for outpatient rehabilitation services. The 1997 Balanced Budget Act imposed dollar limits of $1,500 on Part B therapy services--one cap for physical and speech-language therapy, and another for occupational therapy. They are adjusted annually for inflation and are now at $1,810. I was a member of the Ways and Means Health Subcommittee at the time. Congress held no hearings on this issue to examine how the caps might affect patient care. The authors of the provision had no policy justification for imposing them, and the dollar amount was arbitrary. These caps were imposed for purely budgetary reasons. They were a crude budget-cutting measure designed to deliver savings--$1.7 billion over 5 years.

This misguided policy ignored clinical needs and it restricted care for the most frail patients--such as those who are recovering from stroke or hip fracture, and those with multiple injuries in a given year.

And because the dollar limits are not adjusted for cost variations across the country, seniors in high cost areas reach their caps even sooner.

The University of Maryland's Shock Trauma Center was the first such unit in the Nation. It is a world-renowned leader in caring for critically injured patients. They see patients with extensive fractures, severe burns, spinal cord and brain injuries, and other debilitating conditions. These patients require lengthy therapy sessions to restore basic functioning. They cannot be rehabilitated for $1,810 a year.

The therapy caps actually went into effect once before, on January 1, 1999, and they had serious consequences for beneficiaries. By April, many patients in skilled nursing facilities had exceeded the limits and were unable to receive necessary care. The administration recognized the danger of this provision, stating:

The limits will reduce the amount of therapy services paid

for by Medicare. The patients most affected are likely to be

those with diagnoses such as stroke and amputation, where the

number of therapy visits needed by a patient may exceed those

that can be reimbursed by Medicare under the statutory

limits.

That year, I joined the now-junior Senator from Nevada, John Ensign, to introduce a bill to repeal the caps. We had significant bipartisan support and at the end of 1999, Congress delayed implementation for 2 years. Since that time, Congress has acted several times to prevent the caps from taking effect.

In 2006, Congress created an exceptions process that would allow beneficiaries needing care above the statutory caps to receive those services. It was the right thing to do. This process has worked well. Medicare is saving money and patients are getting needed care. In February, the Centers for Medicare and Medicaid Services released a study concluding that:

The exception process that allows beneficiaries who need

therapy to get that therapy, even if the cost goes beyond the

cap, has worked to control cost growth. This study reveals

that from Calendar Year 2004 through 2006, although the total

number of therapy users continued to increase by 3.5 percent

the overall expenditures actually decreased by 4.7 percent.

This suggests that the exceptions process in CY 2006 may

have satisfied to some extent the Congressional intent to

assure access to medically necessary services while

controlling the growth in expenditures.

The CMS study shows that the exceptions process works to control costs, yet still assures access for the more than 4.4 million beneficiaries who need additional care. The exceptions process allowed them to get the therapy they need to recover, function optimally, and live more productive lives. It allowed them to learn to cook, clean, and care for themselves after a stroke, to walk correctly and strongly after a hip replacement, and to speak and communicate after cancer surgery. But as of Tuesday, July 1, the process has expired. Section 141 of the bill we are voting on today continues the exceptions process through December 31, 2009.

This provision takes up just two lines of the bill. It is a small provision, but it has a major impact on seniors.

The story of Steve Kinsey and his patients illustrates why we must pass this bill without further delay.

Steve operates Hereford Physical Therapy in Baltimore County. He is anxious to know what the Senate will do this afternoon and so are the seniors he cares for. Steve's practice has about 9,500 patient visits each year, and one-fifth of them are covered by Medicare. He told me about two patients who are waiting for the Senate to act.

The first is a 72-year-old gentleman. He is a wheelchair-bound quadriplegic who needs physical therapy to keep up his strength. He qualified through the exceptions process, and so, although he exceeded the $1,810 cap in March, he has been able to receive therapy 2 days every other week to maintain his level of function.

The second patient is an 83-year-old woman who had a total knee replacement earlier this year. She received 20 visits and was under the cap, until a few weeks later when she fell and fractured her hip.

The cost of her care exceeded the cap 6 weeks ago, but after qualifying through the exceptions process, she has been able to continue treatment.

Because of the actions of a few Senators, as of Tuesday, July 1, these two Medicare beneficiaries can no longer receive care.

On July 1, CMS told providers: (1), that the exceptions process expired on June 30, 2008; (2), not to submit any claims with the code for exceptions because they will be automatically rejected; (3), that providers can check a CMS Web site to determine the amount of services their patients have received so far this year; and; (4), that patients who have reached the caps can go to an outpatient hospital department for care or pay out-of-pocket.

Because the exceptions process was in place for the first 6 months of this year, patients who have already gone beyond the cap--the patients most in need of care--must stop therapy or pay for it themselves. The average charge is about $80 for a 45-minute session. This is wrong.

If we do not reinstate the exceptions process as the bill before us would do, these individuals who need more care will be harmed. They received appropriate therapy under appropriate rules, but that does not matter: On July 1, they were effectively cut off from services that 8 days ago they were deemed eligible for. This is unfair and it is harmful.

Let's not forget that therapy services are also paid under the Medicare fee schedule, so the 10.6 percent cut will also apply to these services as well.

Now, as CMS stated, there is a last resort--to go to the outpatient department of a hospital for additional care. But Steve has learned that the two hospitals near his practice--GBMC and St. Joseph's--are turning away new patients because they don't have the capacity to see them.

Because of the shortage of therapists in Maryland and in other States, hospitals are already overloaded. So, Steve has 10 patients who are waiting at home for him to call and say they can come back in for therapy. They have no where else to go for treatment unless they pay out-of-pocket. They can't afford that.

Outpatient therapy services are paid under Medicare Part B. The people waiting for Steve's call are seniors who worked hard to qualify for Part A coverage and who are paying premiums for Part B. Working Americans--taxpayers--who do not yet qualify for Medicare, are paying to subsidize Part B premiums. The American people as a whole, not only providers and beneficiaries, should be outraged that a minority of the Senate is preventing us from moving forward on this legislation.

The 43 million seniors and persons with disabilities who rely on Medicare deserve a program that meets their health care needs. Our goal should be to ensure that Medicare provides comprehensive, affordable, quality care.

The bill also includes important beneficiary improvements. In 1997, I worked in a bipartisan way to add to the Balanced Budget Act the first- ever package of preventive benefits to the traditional Medicare Program. That was 11 years ago. At that time, the members of the Ways and Means Committee recognized what medical professionals had long known--that prevention saves lives and reduces overall health care costs.

Preventive services such as mammograms and colonoscopies are vital tools in the fight against serious disease. The earlier that breast and colon cancer are detected, the greater the odds of survival. For example, when caught in the first stages, the 5-year survival rate for breast cancer is 98 percent. But if the cancer has spread, the survival rate drops to 26 percent. If colon cancer is detected in its first stage, the survival rate is 90 percent, but only 10 percent if found when it is most advanced.

Seniors are at particular risk for cancer. In fact, the single greatest risk factor for colorectal cancer is being over the age of 50--when more than 90 percent of cases are diagnosed.

Sixty percent of all new cancer diagnoses and 70 percent of all cancer-related deaths are in the 65 and older population. Cancer is the leading cause of death among Americans aged 60 to 79 and the second leading cause of death for those over age 80. So preventing cancer is essential to achieving improved health outcomes for seniors. Screenings are crucial in this fight.

In addition to improving survival rates, early detection can reduce Medicare's costs. Under Chairman Conrad's leadership on the Budget Committee, we have had fruitful debates about the long-term solvency of Medicare. A more aggressive focus on prevention will help produce a healthier Medicare Program.

Medicare will pay on average $300 for a colonoscopy, but if the patient is diagnosed after the colon cancer has metastasized, the costs of I care can exceed $58,000.

There is no question that these vital screenings can produce better and more cost-effective health care.

The 1997 law established place improved coverage for breast cancer screenings, examinations for cervical, prostate, and colorectal cancer, diabetes self-management training services and supplies, and bone mass measurement for osteoporosis. Since then, Congress has added screening for glaucoma, cardiovascular screening blood tests, ultrasound screening for aortic aneurysm, flu shots, and medical nutrition therapy services. In addition, in 2003, a Welcome to Medicare Physical examination was added as a one-time benefit for new Medicare enrollees available during the first 6 months of eligibility.

But we can only save lives and money if seniors actually use these benefits. Unfortunately, the participation rate for the Welcome to Medicare physical and some of the screenings is very low. I have spoken with primary care physicians across my State of Maryland about this. One problem is the requirement to satisfy the annual deductible and co pays for these services.

Most colonoscopies are done in hospital outpatient departments, where their copay is 25 percent or approximately $85. Our seniors have the highest out-of-pocket costs of any age group and they will forgo these services if cost is a barrier.

The other barrier to participation is the limited 6-month eligibility period for the one-time physical examination. By the time most seniors become aware of the benefit, the eligibility period has expired. In many other cases, it can take more than 6 months to schedule an appointment for the physical exam and by that time, the patients are no longer eligible for coverage.

I have introduced legislation to eliminate the copays and deductibles for preventive services and to extend the eligibility for the Welcome to Medicare physical from 6 months to 1 year. My bill would also eliminate the time consuming and inefficient requirement that Congress pass legislation each time a new screening is determined to be effective in detecting and preventing disease in the Medicare population.

It would empower the Secretary of Health and Human Services to add ``additional preventive services'' to the list of covered services. They must meet a three part test: (1) they must be reasonable and necessary for the prevention or early detection of an illness; (2) they must be recommended by the U.S. preventive Services Task Force, and (3) they must be appropriate for the Medicare beneficiary population.

H.R. 6331 incorporates several elements of my bill in the very first section. It will waive the deductible for the physical examination, extend the eligibility period from 6 months to 1 year, and allow the Secretary to expand the list of covered benefits.

This bill will also help low income seniors by raising asset test thresholds in the Medicare savings programs and targeting assistance to the seniors who most need it. It extends and improves assistance programs for seniors with incomes below $14,040 a year, including the QI program, which pays Part B premiums for low-income seniors who don't qualify for Medicaid.

As this Congress continues to make progress toward passing a comprehensive mental health parity bill, this bill provides mental health parity for Medicare beneficiaries, moving their copayments from 50 percent to 20 percent gradually over 6 years. Depression, bipolar disorder, and other mental illnesses are prevalent among seniors, and yet fewer than half receive the treatment they need. This provision will help them get that treatment.

It will also ensure that a category of drugs called ``benzodiazepines'' are covered by Medicare Part D. When Part D took effect on January 1, 2006, millions

of beneficiaries found that the medicines they took were not covered by the new law. A little-known provision in the bill actually excluded from coverage an entire class of drugs called benzodiazepines. These are anti-anxiety medicines used to manage several conditions, including acute anxiety, seizures, and muscle spasms. The category includes Xanax, Valium, and Ativan. Most are available as generics.

The current-law exclusion has led to health complications for beneficiaries, unnecessary complexity for pharmacists, and additional red tape for the States. Beneficiaries who are not eligible for Medicaid have had to shoulder the entire cost of these drugs or substitute other less effective drugs. In 2005, I first introduced legislation that would add benzodiazepines to the categories of prescription drugs covered by Medicare Part D and Medicare Advantage plans.

This provision is essential for our seniors; without it, dual eligibles would have to rely on continued Medicaid coverage for benzodiazepines. Medicare beneficiaries who are not eligible for Medicaid will have to continue to pay out-of-pocket for them. For those who cannot afford the expense, their doctors would have to use alternative medicines that may be less effective, more toxic, and more addictive. This is a significant improvement for our seniors who are enrolled in Part D and for the fiscal health of our States.

This bill will also help our community pharmacies. I have heard from pharmacies throughout Maryland who cannot receive prompt reimbursement from private plans. This bill requires plans to pay them within 14 days of receiving a clean claim. It also requires plans to update their price lists weekly so that pharmacies have accurate data about what they should be reimbursed.

H.R. 6331 is paid for by small reforms to the Medicare Advantage program, in particular to private fee-for-service plans. The nonpartisan Medicare Payment Advisory Commission, MedPAC, has recommended that we equalize payments between Medicare Advantage and traditional Medicare.

As we discuss the solvency of the Medicare Program, we must take note that private health plans are not saving the Federal Government money. In fact, they are costing us money. I was a member of the Ways and Means Committee when health plans approached us with an offer.

If the Federal Government would pay them 95 percent of what we were spending on the traditional Medicare Program, they would create efficiencies through managed care--efficiencies that they said were lacking in traditional Medicare--that would save the Federal Government billions of dollars each year. They promised to provide enhanced coverage, meaning extra benefits as well as all the services covered by traditional Medicare, for 95 percent of the cost of fee for service. Congress gave them a chance to do just that.

Instead, what we saw across the country was cherry-picking of younger, healthier seniors. Each time Congress indicated that it would roll back their overpayments to a more reasonable level, they responded by pulling out of markets. In Maryland, the number of plans declined over a 3-year period from eight to one, abandoning thousands of seniors. Since 2003, when payments were substantially increased, the number of plans has steadily increased as well, but at too high a cost to beneficiaries, taxpayers, and the future of the Medicare Program.

Right now, these plans are paid up to 19 percent more than the amount that we would pay if these seniors were in fee-for-service Medicare. Over 10 years, we are overpaying them by more than $150 billion.

That is enough money to fund significant valuable improvements in the overall Medicare Program, or to permanently repeal the sustainable growth rate formula. It is time, for the health of the Medicare Program, to pay these plans appropriately. This bill would make small adjustments to these overpayments as well as prohibit the abusive marketing practices, such as cold calling, door-to-door sales, and offering incentives such as free meals, which have led to many seniors being enrolled in private plans without their knowledge or consent.

Mr. President, this is a balanced and responsible bill that addresses immediate reimbursement concerns while setting the foundation for a higher quality, more cost-effective Medicare Program.

The time to act is now. With the support of just one more Senator, we can pass an urgently needed bill and restore the promise of improved access, adequate reimbursement, low-income assistance, and additional needed benefits to the seniors who depend on Medicare. I urge my colleagues to support this legislation,

Medical Home Demonstration

What is the matter now before the Senate?

I ask unanimous consent that there be 1 hour prior to the vote, which is now set for 4 o'clock, that the time be divided, with the last 20 minutes for Senator McConnell and Senator Reid of Nevada; that I have the last 10 minutes; that the other 40 minutes be equally divided and controlled between the chairman of the Finance Committee, Senator Baucus, and the ranking member of the committee, Senator Grassley.

That means there will be 20 minutes for Senator McConnell and me, and there will be 40 minutes remaining, equally divided.

Madam President, reserving the right to object, in the 10 minutes I have before the vote, I will address in some detail why this is such a fallacious idea, and I object.

Madam President, thank you very much.

My distinguished counterpart, the Republican leader, has often said there is a right way and a wrong way to get things done here in the Senate. The right way, he says, is through bipartisanship. I agree with my colleague.

Before the Fourth of July break, we saw such a stunning moment of bipartisanship in the House of Representatives. Democrats and Republicans saw the harm our country could face if Congress did not take action to pass the doctors fix. Members of Congress knew that without bipartisan leadership, doctors would face cuts in the payments they receive, which would cause them to drop patients and even drop out of Medicare completely. Members of the Senate knew that if they sat on their hands, nothing would be done, obviously, but the House of Representatives knew that if they sat on their hands, millions of senior citizens, people with disabilities, Active Duty, retired military, and their families could all face a reduction in the quality of their care. So the Democrats and Republicans in the House of Representatives passed an identical bill that is now before us, the so- called doctors fix--listen to this--by a bipartisan majority of 355 to 59. Every single Democrat voted for the measure. Two-thirds--two- thirds--of the Republicans joined them.

This is bipartisanship at its very best. When the House, by a vote of 359 to 55, votes as they did, this is bipartisanship at its best. In fact, one of the small number of Republicans who voted no felt so badly after the vote took place that he wrote a letter to all the physicians in his district and all the senior citizens in his district and said: I am sorry. I am sorry. I made a mistake. I didn't know it was so important. He said: If I ever have a chance to vote on it again, I will vote with the vast majority of the Members of the House of Representatives.

If Senate Republicans are looking for bipartisanship, they need to look no further than the bipartisan breakthrough we saw on Medicare in the House of Representatives. Republicans in the Senate should have seen the overwhelming support for this critical legislation from both sides of the aisle in the House and joined the effort here in the Senate.

As I look across this body, I see a number of us who have served in the House of Representatives: the ranking member of the Finance Committee, the Senator from Michigan, the Senator from Illinois, the chairman of the Finance Committee, and others. The House of Representatives is known as a partisan body. We are not. They showed that, for the good of the American people, they could set their partisanship aside and vote, and they did that.

If, in fact, the Republicans here in the Senate had looked and studied what took place in the House of Representatives, this bill would have passed before the break we took before Fourth of July and it would have been sent to the President and we would be spending our time today focusing on other critical priorities for the American people such as gas prices, such as housing, and issues on which Republicans have done a lot of talking but no legislating. Instead, though, Senate Republicans have once again chosen the side of delay and obstruction.

The Republicans may talk about bipartisanship--and when they do, we agree with every word they say--but words alone won't solve the Medicare problem today. Words won't support doctors. Words won't keep senior citizens healthy or veterans or Active military and their families getting proper health care. This critical problem calls not for words but action, and the only action the Republicans have taken on this Medicare issue is delay, delay, delay.

What can the American people conclude, except that the Republicans have chosen the side of the insurance companies--the insurance companies--and the HMOs that are already making untold fortunes. Last year, the so-called Medicare Advantage, they made $15 billion. How did they make it? They made it at the expense of millions of senior citizens who rely on Medicare to stay healthy.

This morning in the Senate, the Republican leader made a very interesting point, and all should listen to the point he made. He said that with more than 300 Members of the House of Representatives having voted in favor of the legislation, the Senate should follow suit and pass it immediately.

He argued that delaying or trying to amend a bill with such strong, bipartisan support from the House would serve no purpose but to delay its implementation. Senator McConnell was talking about the Foreign Intelligence Surveillance Act, FISA. But it appears that the Republican leader and his colleagues on the other side of the aisle want to have a different set of rules for each piece of legislation. On FISA, having an overwhelming 300 votes meant don't delay it and vote for it here. It means something different on Medicare, when even more voted for it.

If the 300-plus vote in the House was good enough on the FISA bill, shouldn't the 355 votes for Medicare be good enough as well? I would hope so.

In their effort to block this critical legislation, the Republicans have now concocted an argument that their opposition lies in their inability to offer amendments.

Think about that. Their opposition lies in the fact that they cannot offer amendments.

If only the majority would allow amendments, they say, this bill would sail through passage. But the facts are clear. The Senate Republican leadership was at the table when the process of the bill was discussed. The Republican leader agreed to the process about which we are now engaged. This process was agreed to unanimously by every single Senator, Democratic and Republican alike. We are here today because of that unanimous consent agreement.

The process--to which, I repeat, all Republicans agreed and all Democrats agreed--was that after a 60-vote margin on a motion to proceed, the bill would go directly to the President. There was ample opportunity to make the case for amendments prior to the unanimous consent agreement.

I have gotten to know Max Baucus, of Montana, very well in my 26 years in the Congress. I don't know of a Senator who has more of a reputation for bipartisanship than the Senator from Montana. He is known as a person who works with Republicans. That is why we, on the Democratic side, so admire him and support his chairmanship of the Finance Committee. But even Max Baucus has had enough. He has had enough. He knows he has tried. He knows this is stalling and that this is obstruction. Even Max Baucus--I believe the most bipartisan Member of the 100 Senators here--said that is enough.

Well, I made it clear a long time ago to Senator Baucus and others that we would have considered any reasonable proposal. But that time has long since passed. If Republicans were serious about passing this legislation and amendments were the only thing standing in the way, that would be one thing. They would have negotiated for amendments long before the 59-vote debacle of 2 weeks ago and certainly long before now.

It could not be clearer that the amendment argument is the latest

thinly veiled excuse for opposing this legislation to provide for doctors, senior citizens, and veterans.

These excuses for voting the wrong way aren't convincing anyone. Doctors, senior citizens, military families who rely on TRICARE, and all Americans see these Republican tactics for what they are. The Republican call for a 31-day extension is another duck and dodge. Let's think a minute. Where are we going to be in 31 days? Do you think there might be conventions going on, where Obama is being nominated and McCain is being nominated? We are out of session. That shows how fallacious and foolish a 31- or 30-day extension is. What would happen when that time runs out? We would be out of session. Well, of course, that would lead to nothing but redtape and confusion for Medicare providers during the next 30 days.

This legislation that is before this body is the very same that passed the House of Representatives, with all the Democrats and two- thirds of the Republicans voting for it, and it is supported not by a bunch of fringe groups. For example, AARP supports this. The physician community, including the American Medical Association, and all the specialist groups, such as the internists, orthopedic surgeons, and brain surgeons, all support this legislation.

The pharmaceutical industry supports it. My friends say this is very bad for seniors as it relates to pharmaceuticals. Why in the world would the pharmaceutical industry support what we are trying to do? Hospitals, the American Hospital Association, patient groups such as the American Heart Association, American Cancer Society, and hundreds and hundreds of other organizations support this.

Who opposes this bill? I will tell you who. Not hundreds of organizations, not AARP, not the American Cancer Society. Only two organizations: the insurance industry, that always has the best interests of the American people in mind. They always look out for us, as you know. Who is the other special interest group that supports doing nothing? The HMOs. How many of you remember that Jack Nicholson movie, when they brought up HMOs and whole theaters booed all over America when that provision came up?

The American people are booing the Republicans today because they have sided with the insurance industry and the HMOs. We have sided with senior citizens and with the veterans and their families. We know President Bush opposes this legislation and he threatened to veto it. Some Republicans said: Why pass a bill now when the President is going to veto it? Think about this. First of all, talk to my colleagues on the other side of the aisle. We have a government that is founded by our Constitution as three separate and equal branches. We have to do the right thing. That is how checks and balances work.

We should pass this bill because we owe it to senior citizens, veterans, the doctors who are working hard. I remind our Republican friends that the House of Representatives has more than enough votes to override the veto. There is no reason we cannot do the same in the Senate. I also remind our colleagues of what happened to the GI bill of rights, one of the landmark pieces of legislation to pass this country in the last 50 years. When Senator Webb and others introduced that legislation to give something back to our troops in the form of educational opportunities to help them succeed when they return home, President Bush and many Republicans, including John McCain, declared the bill was too generous. The President vowed he was going to veto the bill.

Surely then, some Republicans said that if the President opposes the bill, the Senate has no business debating and passing it. But we did our job. We did what was right for our troops and veterans, and we passed the GI bill overwhelmingly. To his credit, President Bush acquiesced.

I believe that if the Senate Republicans follow the lead of their House counterparts by voting for cloture today and sending the Medicare doctors fix bill to the President's desk with an overwhelming bipartisan majority, President Bush will heed the calls of the House and the Senate, of doctors, of patients, of advocacy groups, and of our troops.

I, personally, support this legislation on behalf of the 320,000 Medicare patients in Nevada and Dr. Edward Kingsley, a cofounder of the Comprehensive Cancer Centers in Las Vegas, who said:

Some physicians are not going to be able to afford [to

continue taking Medicare patients]. . . . That's ultimately

what we all fear--these patients are not going to have access

to the care they need.

I support this legislation also on behalf of the approximately 320,000 Nevadans who are Medicare patients.

I support this on behalf of the almost 9 million service men and women and families enrolled in TRICARE.

I support this legislation on behalf of the 44 million senior citizens and the people with disabilities who rely on Medicare to stay healthy and live their golden years to the fullest. That is what Medicare is about.

Since President Lyndon Baines Johnson signed the Medicare law more than 40 years ago, the Congress and Senate has always worked to improve and maintain it. Congress has never seriously threatened Medicare or the benefits our senior citizens have earned.

Before the July 4 recess, 59 Senators voted to move toward passage of the doctors fix. All Democrats voted yes--every one of us. We were joined by a small group of exemplary Republicans who were willing to stand up to the insurance companies and HMOs and the veto threats of the President.

We needed 60 votes to pass this. We came up one short. Today, we remain one Republican vote away from passing this bill. As I look across the aisle to my Republican friends, the 60th vote is there.

I urge my colleagues to vote for cloture so we can send this legislation to the President with an overwhelming bipartisan vote to reflect overwhelming support for it among the American people.

Madam President, may I inquire, what is the pending business before the Senate?

Madam President, the Prophet Isaiah urged:

Cease to do evil,

learn to do good;

seek justice,

correct oppression;

defend the fatherless,

plead for the widow.

Since 1965, Medicare has been about defending the disabled. Medicare has been about providing for the elderly. From its beginning, Medicare has been about doing good. Before Medicare, old age was very much about widows.

In 1960, a man could expect to live a little more than 66 years, whereas a woman could expect to live past 73. Now, with the help of Medicare providing health care for the elderly, men can expect to live beyond 75 and women can expect to live beyond 80.

Before Medicare, in 1959, more than 35 percent of the elderly lived in poverty. When President Johnson signed the Medicare Act into law, he said of the elderly:

Most of them have low incomes. Most of them are threatened

by illness and medical expenses that they cannot afford.

Thus, before Medicare, the elderly received poorer health care. They endured more pain. They met early death. But then, 43 years later, in July 1965, with my fellow Montanan Mike Mansfield looking on, President Johnson signed the Medicare Program into law. This chart to my left shows the picture of that day.

That day President Johnson said:

No longer will older Americans be denied the healing

miracle of modern medicine. No longer will illness crush and

destroy the savings they have so carefully put away over a

lifetime so they might enjoy dignity in their later years. No

longer will young families see their own hopes eaten away

simply because they are carrying out their deep moral

obligations to their parents.

Further quoting President Johnson:

And no longer will this Nation refuse the hand of justice

to those who have given a lifetime of service and wisdom and

labor to the progress of this country.

Thus, from its beginning, Medicare has been a moral issue. Medicare has been about doing good, about doing what is right. I come to the floor today to speak in defense of Medicare. I come to plead for the widow. I come to fight for the disabled.

Today Medicare is threatened. Health care costs have been growing rapidly. Federal Reserve Chairman Bernanke told the Finance Committee's health care summit:

Health care has long been and continues to be one of the

fastest growing sectors in the economy. Over the past 4

decades, this sector has grown, on average, at a rate of

about 2.5 percentage points faster than the gross domestic

product.

But the fruits of the 1997 law threaten to cut--yes, cut--payments to doctors who treat Medicare beneficiaries unless we act. If we do not act, the law will force cuts in payments to doctors by 10.6 percent. We have to stop that cut.

That cut threatens access to care for America's seniors. Already some providers are declining Medicare patients. My colleagues hear that constantly. Fewer and fewer doctors are taking Medicare; more and more are dropping. Why? Because reimbursement rates are already too low, and unless we act today, those reimbursement rates will be much lower.

Doctors know about these cuts. My colleagues in their home States hear this constantly. I am sure, over the July 4 break, they heard over and over that the doctors are very concerned about Medicare reimbursement. The share of doctors accepting new Medicare patients has been falling. It is falling for those who accept and do not accept Medicare. It is falling for those military personnel in TRICARE who seek services from doctors as well because TRICARE payments are tied to Medicare.

Unless we act, those patients in the TRICARE system, our military service men and women, will also find that their doctors are not treating them either. That trend will accelerate if we do not act. An American Medical Association survey found if the scheduled cuts stay in effect, 60 percent of doctors will have to limit the number of new Medicare patients whom they treat; 60 percent would have to limit, unless we restore these cuts.

These cuts also threaten access to health care for our military men and woman. As I mentioned, TRICARE uses the Medicare formula to pay their doctors. Those cuts could endanger health care for military retirees and even for those on Active Duty.

I do not think that is well understood, that TRICARE is tied to Medicare. If we cut Medicare, we cut TRICARE. That means about 9 million American service men and women, Active Duty and retirees, the doctors who service them will no longer provide that service; a 60- percent reduction.

The Military Officers Association of America reports that declining participation of providers due to low reimbursements is already one of the most serious health care problems facing military families.

Real and threatened cuts in the level of Medicare reimbursements have caused many providers to stop accepting new TRICARE patients.

Since 1965, there have been those few who did not think that Medicare was good. There have been those who have sought to call it evil. In the 1960s, there were those on the fringe who called it socialized medicine. In 1995, there were those who said it was going to wither on the vine, those who wanted to do away with Medicare. But the truth is, from the start Medicare has had broad,

very broad, bipartisan, very bipartisan, support. The original Medicare Act passed the House of Representatives with a vote of 307 to 16. It passed the Senate by a vote of 70 to 24. That broad support was evident again on June 24 of this year before the break. That day the House of Representatives passed the Medicare Improvements for Patients and Providers Act. That bill would stop those cuts in doctors' payments. The House passed that bill with an overwhelming vote of 355 to 59; 355 House Members voted for it. That is better than a 6-to-1 margin. Even among Republican Members of the House, more than twice as many voted for it than against it.

On June 26, the Senate fell one vote short of invoking cloture on the motion to proceed to that bill. But today the Senate will reconsider that vote, and we should. The Senate should take up and pass this Medicare bill. The Senate should pass this Medicare bill because there is no alternative. If we fail to enact this bill, millions of America's seniors will be worse off. We cannot let that happen. This bill can prevent that. The House-passed bill is very similar to the Baucus-Snowe bill the Senate considered earlier in June, but the House made three noteworthy changes. First the House-passed bill includes legislation to delay the competitive acquisition program for durable medical equipment. Congress needs to ensure that these savings do not harm beneficiary access to care. We need to take a closer look at competitive bidding before it goes forward. Passage of this Medicare bill would allow that. The House-passed bill also does not include cuts in funding for oxygen supplies and equipment, and it does not include cuts in funding for powered wheelchairs. Those who support these reforms make a good case. But ultimately, the cuts could not be included as part of this must-pass legislation.

This bill is a balanced package. It is a compromise. It makes modest changes. When the House passed its children's health bill last year, the House made major changes to the Medicare Advantage Program. Last year's House CHIP bill would have significantly restructured the program. This House Medicare bill, however, would not do that. This bill includes a reduction in the double payment for medical education costs to private plans in Medicare, and this bill would protect seniors from unscrupulous marketing practices by private health plans. This bill would require so-called private fee-for-service plans to form provider networks. It would make sure that there are doctors behind those plans. Currently, those private fee-for-service plans do not have to do that. By fiat, they deem it to be the case. But it is not accurate. This bill would make sure there will be doctors behind those plans.

This bill does not include deep cuts due to the Medicare Advantage Program. Some suggest it does. It does not at all. It does not cut private fee-for-service plan payments at all. I wish to go further on Medicare Advantage. I think we should do more. But this is not the time, and this is not the legislation on which to do so. This, however, is the time to avert the pending cut in payments to doctors. That payment cut would devastate access to care for America's seniors. We cannot let that happen.

For Medicare beneficiaries, this Medicare bill would expand access to services. We all talk about greater access to preventive services. It would eliminate the discriminatory copayment rates for seniors with mental illnesses. We all talk about that. We want mental health parity. We do it in this Medicare legislation. And it will provide additional needed help for low-income seniors. We all talk about that need too.

This Medicare bill would take important steps to shore up our health care system in rural areas. It includes provisions from the Craig Thomas Rural Hospital and Provider Equity Act. Let's do this for Craig Thomas.

This bill also includes important relief for ambulance providers, community health centers, and primary care physicians. Primary care doctors represent the backbone of our health system. We all hear from home that primary care doctors are especially vulnerable and we give additional help to them. This Medicare bill would make important improvements in pharmacy payments. It would make payments under the Part D drug benefit fairer and more timely to those who dispense drugs to our Nation's senior citizens. We have all heard that pharmacists need this help because they are in a disadvantageous position in dispensing Part D drugs.

This bill would save money by providing a single bundled payment for all the services related to treating end-stage renal disease, and that will help reduce costs. For the first time, dialysis facilities would receive a permanent, market-based update to their payments each year, giving them a little bit of predictability. This would ensure that Medicare payments keep up with costs.

The bill would expand emergency health care for veterans in rural areas. It would increase payments for doctors who work in rural areas. It would stop the payment cut to providers. It would give them a decent increase in reimbursement. All of this would help to ensure that seniors and military families would be able to keep seeing the doctors they need to see.

On July 30, 1965, President Truman watched President Johnson sign the Medicare Act. That is what is shown in this photograph to my left. President Truman at that point said:

Mr. President, I am glad to have lived this long and to

witness today the signing of the Medicare bill, which puts

this Nation right where it needs to be, to be right.

Yes, from its beginning, Medicare has been a moral issue. Medicare has been about doing good. So let us defend the elderly. Let us defend the disabled. Let us provide for our military families, and let us enact this important Medicare bill.

I know others are waiting to speak on the other side of the aisle. In a moment I will yield the floor, but before doing so, I yield half of the time remaining under my control to Senator Schumer and half of the time to Senator Durbin for their use when they are recognized.

Madam President, reserving the right to object, I have looked at the Senator's bill, and I must say that any objective observer would know that this is not a serious effort. It is a big warm kiss on doctors to show to them that they love doctors when, in fact, this is going nowhere. It is a $380 billion bill unpaid for. It is not a serious effort whatsoever. I regret the Senator from Texas has the audacity to bring this up.

I object.

Mr. President, a report by the Energy Information Administration released this week confirms that we have made real, measurable progress in our efforts to reduce our dependence upon foreign oil. The best estimating group in the world, the Energy Information Administration of America, made this determination. I know the occupant of the chair will be interested, because what we have done in the past 3 years with the passage of three major pieces of energy legislation is, for the first time in modern history, we have reduced the amount of consumption of crude oil from overseas to America by Americans here at home. In other words, during the next 30 years, we will finally get to the point where, instead of that importation going up, it will begin to reverse itself and start coming down.

Now, the bad news for Americans is you can't do that overnight, but we have done it with the passage of the CAFE standards, meaning smaller cars in the future for everyone, and with the passage of two or three other big bills, we have made a lasting impact on how much we use of this dread imported product that we call crude oil.

Over the last several years, as I indicated, Congress has passed three major pieces of legislation: the Energy Policy Act of 2005, the Gulf of Mexico Energy Security Act, and the Energy Independence and Security Act. We put these together, and the estimates are that as a result of this action I just spoke about, more than 2 million barrels of oil per day will be saved by America by 2030. In addition, our action will lead to--and get this--5.3 billion fewer metric tons of energy-related carbon dioxide emissions by that time--the equivalent of 71,500 megawatt coal-burning electric plants. Imagine that. By reducing that amount of oil consumed, we will reduce the amount of carbon dioxide by 5.3 billion fewer metric tons used.

Nevertheless, our work is not nearly done. I have been encouraged by the growth of clean energy technologies, but I have come to believe that in the long run, we will fall far short of the amount of financial resources necessary to move these projects along at a fast enough pace. Consider that nearly half of our current electric generation fleet is over 30 years old. Nearly a third of our overall generation comes from coal-fired plants, the majority of which are not equipped with emission control technology. Yet investor-owner utilities are not large enough to carry several multibillion dollar projects, and competitive electricity markets don't have an effective mechanism to encourage investment in larger, expensive new capacity. I come to the floor to propose at least a partial solution to this challenge.

Today I am introducing legislation to establish a clean energy investment bank. This bank will be a government corporation, modeled after the Export-Import Bank, designed to promote investment in domestic energy projects. I am pleased to have a number of cosponsors, including Senators Landrieu, Murkowski, Martinez, Bunning, Craig, Alexander, and Dole. I haven't worked very hard because I haven't had time, but I think I can get many more Senators to be cosponsors as well.

According to some analysis, over $350 billion will be needed over the next 15 years to meet our increased demands for energy. Not only do we face the challenge of needing to get more power on line, we also are trying to do it in a way that results in less pollution. By investing in clean energy technology, we will reap enormous benefits when it comes to energy, economic, environmental, and national security.

Investors have shown a willingness to support clean energy technology. A United Nations report recently revealed that investment in sustainable energy has nearly doubled since 2005. Additionally, private sector research and development has risen to over $16 billion. Yet the growth we have seen primarily comes from equity investment and venture capital, not long-term debt financing.

The clean energy industry faces unique challenges. Unlike traditional fossil fuel energy projects, which are able to more easily secure long- term debt financing, clean energy markets have a greater level of risk both economically and technically. That is why the certainty provided by Federal Government support would be beneficial. Our goal moving forward should be greater increases for all types of clean energy generation projects through secure financing.

Right now, we are lacking an institution able to undertake this kind of activity and fill this gap. The clean energy investment bank that will be created by the legislation which I introduce today has a real chance of filling that gap.

The bank will engage in investment activities to encourage long term debt

financing of clean energy projects. It will take responsibility for management of the Department of Energy's title 17 loan guarantee program, and have the authority to offer loans, insurance products, and take positions in commercially viable projects.

The clean energy investment bank will be a governmental corporation, with a bipartisan board of directors that will have significant autonomy in choosing the projects they believe are most worthy.

In this legislation, we do not seek to tell the bank exactly which specific types of projects to support. Our requirement is that the projects provide clean energy and that the bank considers a reasonable diversity of projects, technologies, and energy sectors. We give flexibility to the bank's board of directors and management so that they can provide support for the latest technologies, some of which may not even be under consideration right now.

The sole mission of the clean energy investment bank will be to advance the deployment of clean energy technologies. The bank will be staffed with investment professionals who will make informed decisions on loans, loan guarantees, and other investments.

Initially, we anticipate that the clean energy investment bank will be given a similar level of financial support as the Export-Import Bank. The Export-Import Bank assists financing the export of U.S. goods and services to international markets. By enabling companies in our country to turn exports into sales overseas, the bank helps create jobs and ensures a level playing field.

Export-Import provides a worthy and useful service to our economy and to growing economies overseas. Last year, Congress provided $68 million to the bank to subsidize its costs, and another $78 million for administrative expenses. But we must ask ourselves: shouldn't domestic energy diversification receive at least as much support as U.S. companies investing overseas?

The bank will be financed in part through the appropriations process, but in greater measure through a revolving fund. The goal would be for the bank to be self-funding through its investment of activity as soon as possible.

Congress will soon be embarking on a debate about climate change. It is simply a reality that much of that discussion will largely fall on partisan lines. Senators have diverse views about global climate change and the proposed solutions to handle it.

The clean energy investment bank, however, is something that we all can support. It gives us a chance to make real progress in a bipartisan way on our shared goals of increasing energy production and reducing greenhouse gas emissions. Despite the odds, we have demonstrated that when we work together to find common ground on energy, we can succeed and pass legislation that will help make America stronger. In times of economic uncertainty, we need pro-growth strategies that incentivize large private investment, not complex regulatory structures that increase the cost of energy. The clean energy investment bank is such a pro-growth proposal that stands tall on its own.

I look forward to working with my colleagues on both sides of the aisle on this bill, and I hope the Senate will adopt it. We have made great strides in recent years to diversify our energy supply, but we should not rest on our laurels. This bill will help us keep up the momentum and shift America away from foreign oil and toward cleaner, home-grown technologies.

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

Madam President, I rise to oppose cloture on the motion to proceed to H.R. 6331, the Medicare Improvements for Patients and Providers Act.

I am beginning to feel like the character from the movie ``Groundhog Day'' who wakes up every morning to the same day. Here we are again, having the same debate about the same Medicare bill that will not be signed into law.

I believe that our time would be better spent working on a bill to restore physician payments instead of having a partisan vote just to make some political points. It would be better to work in a bipartisan way. We could do it in 10 minutes, if we just sit down and do it. I know the distinguished chairman and ranking member could do it.

But it is obvious that some in this body would rather have a political battle and put Medicare beneficiaries and their doctors at risk.

In the last month, I stood on the Senate floor, not once, but twice emphasizing that I want to work on a bipartisan Medicare bill that will be signed into law. In fact, we had a bipartisan agreement in the Senate.

Unfortunately, Senate Democrats are still not permitting a vote on a compromise measure or even the Republican alternative.

The bipartisan compromise bill would have passed overwhelmingly, and this issue would be behind us.

And, quite frankly, H.R. 6331, essentially, the Baucus Medicare bill, contains many provisions that both sides strongly support.

It is troubling that only the Democrat Medicare bill is being given a vote on the Senate floor, especially when there is a Republican alternative that restores physician payments as well, especially since I believe Senators Baucus and Grassley would have worked it out long before now without all the hoopla and politicization.

In addition, when the Democrat Medicare bill failed to get cloture a few weeks ago, the minority leader asked for unanimous consent to pass a 31 day extension of the December Medicare law. The purpose of this extension was to prevent the Medicare physician cuts from going into effect until we were able to work out our differences.

But Senator Reid objected to this unanimous consent request for political reasons and told the Senate that

he wanted the Republicans who voted against cloture to feel the heat when they went home for the Fourth of July recess. I was a little shocked at that.

Fortunately, the Centers for Medicare and Medicaid Services, CMS, is delaying the Medicare reduction for physicians for 10 business days to give us more time. Unfortunately, we do not agree on one key issue--the Medicare Advantage Program. This program was created in the Medicare Modernization Act of 2003. I was on the conference committee and spent months working on Medicare Advantage.

Today, Medicare Advantage provides beneficiaries with many health care choices in addition to traditional Medicare.

Medicare Advantage plans are very similar to private health plans offered to those under 65 years of age. One out of five people in Medicare are on Medicare Advantage, and they love the program.

The Democrat Medicare bill includes reforms to the Medicare Advantage Program that are unacceptable to both the White House and many of us who support the Medicare Advantage Program.

Those of us who support Medicare Advantage feel that the provision in the Democrat Medicare bill will limit plan choices currently offered to beneficiaries.

Beneficiaries participating in the Medicare Advantage Program are happy with their health care coverage.

Every month, I receive hundreds of letters from my constituents telling me how much they like their Medicare Advantage plans.

Medicare Advantage is working across the country.

On the other hand, the Medicare+Choice program, which was the precursor to the Medicare Advantage Program, did not work very well, especially in rural areas.

That was because the Federal Government did not pay plans enough money to operate in rural areas.

The Utah Medicare+Choice plans left our State because plans could not function and they were losing money.

At that point, Utah Medicare beneficiaries only had one choice-- traditional Medicare. And once we start disassembling the Medicare Advantage Program, as some in this body want to do, I believe that health care choices for beneficiaries will diminish. Through the Medicare Modernization Act, we finally figured out how to provide choice to Medicare beneficiaries in both rural and urban areas and how to pay plans appropriately.

But my friends on the other side cannot leave a good thing alone and insist on making changes to a program that works well today and that 90 percent of beneficiaries in Medicare Advantage are satisfied with.

The Democrat Medicare bill, if signed into law, will no longer allow private fee-for-service plans to deem.

Deeming allows beneficiaries in private fee-for-service plans to see any Medicare provider.

Deeming has been important to those living in rural areas where it is difficult for network-based plans to persuade providers to contract with them. It is also helpful to employer groups which provide retiree health coverage to those living in rural areas across the country.

The elimination of deeming could take away health care coverage choices for Medicare beneficiaries living in rural States.

In addition, the elimination of deeming could cause some retirees to lose their health benefits because the retirement plan cannot establish networks in all 50 States.

According to America's Health Insurance Plans, known as AHIP, 21,000 Utah beneficiaries may be dropped from their current Medicare Advantage private fee-for-service plans if the provision to eliminate deeming becomes law.

In fact, AHIP believes that 1.7 million seniors across the country could lose their existing health coverage if H.R. 6331 becomes law.

A few weeks ago, I mentioned that one Utah employer has said that the elimination of deeming will force the company to stop offering health care coverage to almost 12,000 retirees, and that is probably the tip of the iceberg.

I fear that the impact of this provision could be devastating, especially to beneficiaries living in rural States.

We truly do not know the full effect of this policy and how it will affect Medicare beneficiaries across the country.

Therefore, I simply cannot support this policy and it is the main reason that I am going to vote against cloture.

Do not be fooled--the bill we are considering today will not be signed into law.

The President has said he will veto the bill and there will not be enough votes to override his veto. I suppose some on the other side think they have a great political advantage if he vetoes the bill and we can't override it. They can use that against Republicans.

This motion must be defeated for the third time. We should not have had to go to three votes.

Hopefully, my colleagues on the other side of the aisle will want to work with us on a bill that can be signed into law because it would be bipartisan.

We must move forward so Medicare beneficiaries will no longer worry about their doctors dropping out of the Medicare Program.

We must move forward so physicians participating in the Medicare Program will not be cut by 10.6 percent. I don't think anybody in this body believes that we will allow that cut to occur; certainly, I will not.

We must move forward because the American people are getting tired of a do-nothing Congress where Members are not able to work out their differences.

Why don't we put all our differences aside? We could solve this in 10 minutes without making it a political fiasco which is what it has become. I think in the end everybody would be better off. Certainly, seniors who are on Medicare Advantage would continue to be better off than they would be if this very partisan bill passes through this body and is vetoed by the President and that veto is sustained.

I yield the floor.