Veterans Outreach Improvement Act of 2009

Mr. President, Senator Sanders and I are introducing the Veterans Outreach Improvement Act which will help to ensure that all of our veterans know about Federal benefits to which they may be entitled by improving outreach programs. I introduced similar legislation in the 108, 109, and 110 Congresses. I am also pleased to note that there is a companion bill in the House, H.R. 32, sponsored by Representative McIntyre. Last year, the House Veterans' Affairs Subcommittee on Disability Assistance and Memorial Affairs approved the bill by a voice vote.

I would like to thank the junior Senator from Hawaii for working with me to improve outreach to veterans. This year, he has introduced an omnibus veterans health care bill, S. 252, which includes a provision creating a grant program for organizations that, among other things, perform outreach to veterans. At my request, this grant program was extended to include State and local agencies that conduct outreach to veterans, consistent with provisions of my outreach bill. I greatly appreciate the Chairman's willingness to consider the key role these agencies play in ensuring that veterans receive the benefits they have more than earned. I would also like to thank Senator Sanders for working with me to expand the scope of this grant program.

Based on Senator Akaka's recommendations, I have made a few changes to my outreach bill this year. He has informed me of the special need to increase outreach to veterans in rural areas. I have modified my outreach bill to reflect this important need.

I was extremely troubled by revelations of gaps in care as servicemembers transition to the VA that emerged as a result of investigations of the Walter Reed Army Medical Center. I appreciate the Department of Defense and Department of Veterans Affairs' attempts to remedy these gaps, but more work remains to be done. It can be extremely difficult for veterans to navigate the VA's health care and benefits systems. This bill will increase congressional oversight of the VA's outreach activities and authorize the Secretary of Veterans Affairs to work with State, local and community-based organizations to perform outreach.

Several years ago, the Wisconsin Department of Veterans Affairs, WDVA, launched a statewide program called ``I Owe You.'' The program encourages veterans to apply, or to re-apply, for benefits that they earned from their service in the U.S. military.

As part of this program, WDVA has sponsored several events around Wisconsin called ``Supermarkets of Veterans Benefits'' at which veterans can begin the process of learning whether they qualify for Federal benefits from the Department of Veterans Affairs, VA. These events, which are based on a similar program in Georgia, supplement the work of Wisconsin's County Veterans Service Officers and veterans service organizations by helping our veterans to reconnect with the VA and to learn more about services and benefits for which they may be eligible. More than 11,000 veterans and their families have attended the supermarkets, which include information booths with representatives from WDVA, VA, and veterans service organizations, as well as a variety of Federal, State, and local agencies. I was proud to have members of my staff speak with veterans and their families at a number of these events. These events have helped veterans and their families to learn about numerous topics, including health care, how to file a disability claim, and preregistration for internment in veterans cemeteries.

The Institute for Government Innovation at Harvard University's Kennedy School of Government recognized the ``I Owe You'' program by naming it a semi-finalist for the 2002 Innovations in American Government Award. The program was also featured in the March/April 2003 issue of Disabled American Veterans Magazine.

In order to help to facilitate consistent implementation of VA's outreach responsibilities around the country, my bill would help to improve outreach activities performed by the VA in three ways. First, it would create separate funding line items for outreach activities within the budgets of

the VA and its agencies, the Veterans Health Administration, the Veterans Benefits Administration, and the National Cemetery Administration to ensure oversight of the VA's outreach activities. Secondly, the bill would create an intra-agency structure to require the Office of the Secretary, the Office of Public Affairs, the VBA, the VHA, and the NCA to coordinate outreach activities. By working more closely together, the VA components would be able to consolidate their efforts, share proven outreach mechanisms, and avoid duplication of effort that could waste scarce funding. Finally, the bill would give the VA grantmaking authority to award funds to State, local and community-based organizations to conduct outreach activities such as the WDVA's ``I Owe You Program.''

I look forward to working with Chairman Akaka and the members of the Senate Veteran Affairs Committee to make the veteran outreach grant program a success. As we continue to deploy members of the Armed Services overseas at a staggering pace, it is essential that we ensure a smooth transition into the VA for all veterans in need of care. It is the least we can do.

Mr. President, I am pleased to reintroduce legislation that would put an end to automatic pay raises for Members of Congress.

As I have noted when I raised this issue in past years, because Congress has the authority to raise its own pay, something that most of our constituents cannot do, it ought to exercise that authority openly, and subject to regular procedures including debate, amendment, and a vote on the record.

Regrettably, current law allows Congress to avoid that open debate and public vote. All that is necessary for Congress to get a pay raise is that nothing be done to stop it. The annual pay raise takes effect unless Congress acts to prevent it.

This stealth system of pay raises began with a change Congress enacted in the Ethics Reform Act of 1989. On occasion, Congress has voted to deny itself the raise, and the traditional vehicle for the pay raise vote is the Treasury or more recently the Financial Services Appropriations bill. But as I have noted before, that vehicle is not always made available to those who want a public debate and vote on the matter. Last year, for example, Congress enacted a consolidated appropriations bill in which all but three appropriations bills were included. The traditional vehicle for the pay raise vote, the Financial Services Appropriations bill, was included in the massive consolidated appropriations bill, along with funding for eight other appropriations bills. Amendments to that consolidated appropriations bill were effectively shut off, thus, in particular, preventing any amendment that would have stopped the automatic pay raise from going into effect three months later in January of 2009. I voted against the consolidated appropriations bill in part because it did not permit an up or down vote on the Member pay raise.

Sadly this is not an uncommon situation. As I have noted in the past, getting a vote on the annual congressional pay raise is a haphazard affair at best, and it should not be that way. The burden should not be on those who seek a public debate and recorded vote on the Member pay raise. On the contrary, Congress should have to act if it decides to award itself a hike in pay. This process of pay raises without accountability must end.

This issue is not a new question. It was something that our Founders considered from the beginning of our Nation. In August of 1789, as part of the package of 12 amendments advocated by James Madison that included what has become our Bill of Rights, the House of Representatives passed an amendment to the Constitution providing that Congress could not raise its pay without an intervening election. On September 9, 1789, the Senate passed that amendment. In late September of 1789, Congress submitted the amendments to the States.

Although the amendment on pay raises languished for 2 centuries, in the 1980s, a campaign began to ratify it. While I was a member of the Wisconsin State Senate, I was proud to help ratify the amendment. Its approval by the Michigan legislature on May 7, 1992, gave it the needed approval by \3/4\ of the States.

The 27th Amendment to the Constitution now states: ``No law, varying the compensation for the services of the senators and representatives, shall take effect, until an election of representatives shall have intervened.''

I honor that limitation. Throughout my 6-year term, I accept only the rate of pay that Senators receive on the date on which I was sworn in as a Senator. And I return to the Treasury any additional income Senators get, whether from a cost-of-living adjustment or a pay raise we vote for ourselves. I don't take a raise until my bosses, the people of Wisconsin, give me one at the ballot box. That is the spirit of the 27th Amendment. At the very least, the stealth pay raises like the one that Congress allowed for 2009 certainly violate the spirit of that amendment.

This practice must end and this bill will end it. Senators and Congressmen should have to vote up-or-down to raise their pay, and my bill would require just that. We owe our constituents nothing less.

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

Mr. President, I am pleased to introduce the Medicare Rural Health Access Improvement Act of 2009.

The purpose of this legislation is to continue ongoing efforts to ensure that Americans in rural areas have access to health care services. Much has been done in the past to improve access to rural providers such as hospitals and doctors. Much more still needs to be done. And it is even more important in light of the economic challenges we face.

I hold town meetings in each of the 99 counties in the great state of Iowa every year. As many know, Iowa is largely a rural state, and a significant concern that I consistently hear during these meetings is the difficulty my constituents experience in accessing health care services. As the former Chairman and currently the Ranking Member of the Finance Committee, it has therefore been a priority for me to improve the availability of health care in rural areas.

In Iowa, as in many rural areas across the country, hospitals are often not only the sole provider of health care in rural areas, but also employers and purchasers in the community. Moreover, the presence of a hospital is essential for purposes of economic development because businesses check to see if a hospital is in the community in which they might set up shop. As you can see, it is vital that these institutions are able to keep their doors open.

In previous legislation, Congress has been able to improve the financial viability of rural hospitals. For instance, the creation and subsequent improvements to the Critical Access Hospital designation have greatly improved the financial health of certain small rural hospitals and ensured that community residents have access to health care.

However, there are still a group of rural hospitals that need help. I am referring to what are known as ``tweener'' hospitals, which are too large to be Critical Access Hospitals, but too small to be financially viable under the Medicare hospital prospective payment systems. These facilities are struggling to stay afloat despite their tireless efforts. Like in many communities in across the country, the staff of tweener hospitals and their community residents take great pride in the quality of care at these facilities. I have heard countless stories of the exemplary work tweener hospitals in Iowa perform not only as providers of essential health care, but also as responsible members of their communities. It is for this reason that many provisions in this bill are intended to improve the financial health of tweener hospitals and ensure that people have access to health care.

Most tweener hospitals are currently designated as Medicare Dependent Hospitals and Sole Community Hospitals under the Medicare program. There are provisions, both temporary and permanent, included in this bill that would improve Medicare payments for both types of hospitals. This includes improvements to the payment methodologies so that inpatient payments to Medicare Dependent Hospitals would better reflect the costs they incur in providing care. Improvements are also proposed in this bill to Medicare hospital outpatient payments for both Medicare Dependent Hospitals and Sole Community Hospitals so they would both share the benefit of hold harmless payments and add-on payments.

Also, a major driver of the financial difficulties that tweener hospitals face is the fact that many have relatively low volumes of inpatient admissions. This bill would improve the existing low-volume add-on payment for hospitals so that more rural facilities with low volumes would receive the assistance they desperately need.

Over the years, many have commented that it is simply unfair for many rural hospitals to receive only a limited amount of Medicare Disproportionate Share Hospital, or DSH, payments while many urban hospitals are not subject to such a cap. This bill would eliminate the cap for DSH payments for those rural hospitals for a two-year period.

There are also other provisions that would continue to help rural hospitals. The rural flexibility program would be extended for an additional year. This essential program provides valuable resources for rural hospitals.

This legislation also seeks to improve incentives for physicians located in rural areas and increase beneficiaries' access to rural health care providers. It includes provisions designed to reduce inequitable disparities in physician payment resulting from the Geographic Practice Cost Indices, or adjusters, known as GPCIs. Medicare payment for physician services varies from one area to another based on the geographic adjustments for a particular area. Geographic adjustments are intended to reflect cost differences in a given area compared to a national average of 1.0 so that an area with costs above the national average would have an index greater than 1.0, and an area below the national average would have an index less than 1.0. There are currently three geographic adjustments: for physician work, practice expense, and malpractice expense.

Unfortunately, the existing geographic adjusters result in significant disparities in physician reimbursement which penalize, rather than equalize, physician payment in Iowa and other rural States. These geographic disparities in payment lead to rural states experiencing significant difficulties in recruiting and retaining physicians and other health care professionals due to their significantly lower reimbursement rates.

These disparities have perverse effects when it comes to realigning Medicare payment to reward quality of care. Let me put that into context. Iowa is widely recognized as providing some of the highest quality health care in the country yet Iowa physicians receive some of the lowest Medicare reimbursement due to these inequitable geographic adjustments. Medicare reimbursement for some procedures is at least 30 percent lower in Iowa than payment for those very procedures in other parts of the country. That is a significant disincentive for Iowa physicians who are providing some of the best quality care in the country, and it is fundamentally unfair. Congress needs to reduce these disparities in payment and focus on rewarding physicians who provide high quality care.

The inequitable geographic payment formulas have also exacerbated the problems that rural areas face in terms of access to health care. Rural America today has far fewer physicians per capita than urban areas. The GPCI formulas are a dismal failure in promoting an adequate supply of physicians in states like Iowa, and more severe physician shortages in rural areas are predicted in the future.

The legislation I am introducing today makes changes in the GPCI formulas for work and practice expense to reverse this trend. It recognizes the equality of physician work in all geographic areas and establishes a national value of 1.0 for the physician work adjustment. It establishes a practice expense floor of 1.0 floor and revises the calculation of the practice expense formula to reduce payment differences and more accurately compensate physicians in rural areas for

their true practice costs. These changes are needed to help rural states recruit and retain more physicians so that beneficiaries will continue to have access to needed health care.

Last year Congress enacted a number of other provisions to improve Medicare payment for health care professionals and providers in rural areas that will expire at the end of 2009. This bill extends the existing payment arrangements which allow independent laboratories to bill Medicare directly for certain physician pathology services through 2010. It extends and improves the rural ambulance payments enacted in the Medicare Improvements for Providers and Patients Act of 2008 by increasing payments from three to five percent and extending them an additional year, through 2010. The bill also includes several new provisions to improve beneficiary access to health care services. It permanently increases the payment limits for rural health clinics. It also allows physician assistants to order post-hospital extended care services and to serve hospice patients.

Finally, the bill would protect rural areas from being adversely affected by the new Medicare competitive bidding program for durable medical equipment. It would ensure that home medical equipment suppliers who provide equipment and services in rural areas and small metropolitan statistical areas, MSAs, with a population of 600,000 or less can continue to serve the Medicare program by exempting these areas from competitive bidding. We must ensure that rural areas continue to have medical equipment suppliers available to serve beneficiaries in these areas.

As you can see, we still have much to do when it comes to ensuring access to health care in rural America. I look forward to working with my colleagues on this important matter.

Mr. President, the legislation I am introducing today, entitled the Community Health Workers Act of 2009, will help improve access to health education and outreach services to women and children in medically underserved areas, including the U.S. border region along New Mexico.

Lack of access to adequate health care and health education is a significant problem on the southern New Mexico border. While the problem of access is in part due to a lack of insurance, it is also attributable to non-financial barriers such as a shortage of physicians, hospitals, and other health professionals; inadequate transportation; a lack of bilingual health information and health providers; and a culturally insensitive system of care.

This legislation would help overcome these impediments by providing $15 million in grants annually for a 3 year period to State, local, and tribal organizations, including community health centers and public health departments, for the purpose of hiring community health workers to provide health education, outreach, and referrals to women and families who otherwise would have little or no contact with health care services.

Factors such as poverty, language, and cultural differences impede access to health care in medically underserved populations; hence, community health workers are in a unique position to improve health outcomes and quality of care for groups that have traditionally lacked access to adequate services. They often serve as ``community specialists'' and are members of the communities in which they work. As such they can effectively serve hard-to-reach populations.

In a shining example of how community health workers serve their communities, a group of so-called ``Promotoras'', community health workers, in Dona Ana County were quickly mobilized during a recent flood emergency in rural New Mexico. These community health workers assisted in the disaster recovery efforts by partnering with the Federal Emergency Management Agency, FEMA, to find, inform and register flood victims for Federal disaster assistance. Their personal networks and knowledge of the local culture, language, needs, assets, and barriers greatly enhanced FEMA's community outreach efforts. The Promotoras of Dona Ana County demonstrate the important role community health workers could play in communities across the Nation, including increasing the effectiveness of new initiatives in homeland security and emergency preparedness, and in implementing risk communication strategies.

The positive benefits of the community health worker model also have been documented in research studies. Research has shown that community health workers have been effective in increasing the utilization of health preventive services such as cancer screenings and medical follow up for elevated blood pressure and improving enrollment in publicly funded health insurance programs. In the case of uninsured children, a study by Dr. Glenn Flores, ``Community-Based Case Management in Insuring Uninsured Latino Children,'' published in the December 2005 issue of Pediatrics found that uninsured children who received community-based case management were eight times more likely to obtain health insurance coverage than other children involved in the study because case workers were employed to address typical barriers to access, including insufficient knowledge about application processes and eligibility criteria, language barriers and family mobility issues, among others. This study confirms that community health workers could be highly effective in reducing the numbers of uninsured children, especially those who are at greatest risk for being uninsured. Preliminary investigation of a community health workers project in New Mexico similarly suggests that community health workers could be useful in improving enrollment in Medicaid and the State Children's Health Insurance Program.

According to a 2003 Institute of Medicine, IOM, report entitled, ``Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,'' community health workers offer promise as a community- based resource to increase racial and ethnic minorities' access to health care and to serve as a liaison between healthcare providers and the communities they serve.

Although the community health worker model is valued in the New Mexico border region as well as other parts of the country that encounter challenges of meeting the health care needs of medically underserved populations, these programs often have difficulty securing adequate financial resources to maintain and expand upon their services. As a result, many of these programs are significantly limited in their ability to meet the ongoing and emerging health demands of their communities.

The IOM report also noted that ``programs to support the use of community health workers . . . especially among medically underserved and racial and ethnic minority populations, should be expanded, evaluated, and replicated.''

I am introducing this legislation to increase resources for a model that has shown significant promise for increasing access to quality health care and health education for families in medically underserved communities.

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

Mr. President, Senator Sanders and I are introducing the Veterans Outreach Improvement Act which will help to ensure that all of our veterans know about Federal benefits to which they may be entitled by improving outreach programs. I introduced similar legislation in the 108, 109, and 110 Congresses. I am also pleased to note that there is a companion bill in the House, H.R. 32, sponsored by Representative McIntyre. Last year, the House Veterans' Affairs Subcommittee on Disability Assistance and Memorial Affairs approved the bill by a voice vote.

I would like to thank the junior Senator from Hawaii for working with me to improve outreach to veterans. This year, he has introduced an omnibus veterans health care bill, S. 252, which includes a provision creating a grant program for organizations that, among other things, perform outreach to veterans. At my request, this grant program was extended to include State and local agencies that conduct outreach to veterans, consistent with provisions of my outreach bill. I greatly appreciate the Chairman's willingness to consider the key role these agencies play in ensuring that veterans receive the benefits they have more than earned. I would also like to thank Senator Sanders for working with me to expand the scope of this grant program.

Based on Senator Akaka's recommendations, I have made a few changes to my outreach bill this year. He has informed me of the special need to increase outreach to veterans in rural areas. I have modified my outreach bill to reflect this important need.

I was extremely troubled by revelations of gaps in care as servicemembers transition to the VA that emerged as a result of investigations of the Walter Reed Army Medical Center. I appreciate the Department of Defense and Department of Veterans Affairs' attempts to remedy these gaps, but more work remains to be done. It can be extremely difficult for veterans to navigate the VA's health care and benefits systems. This bill will increase congressional oversight of the VA's outreach activities and authorize the Secretary of Veterans Affairs to work with State, local and community-based organizations to perform outreach.

Several years ago, the Wisconsin Department of Veterans Affairs, WDVA, launched a statewide program called ``I Owe You.'' The program encourages veterans to apply, or to re-apply, for benefits that they earned from their service in the U.S. military.

As part of this program, WDVA has sponsored several events around Wisconsin called ``Supermarkets of Veterans Benefits'' at which veterans can begin the process of learning whether they qualify for Federal benefits from the Department of Veterans Affairs, VA. These events, which are based on a similar program in Georgia, supplement the work of Wisconsin's County Veterans Service Officers and veterans service organizations by helping our veterans to reconnect with the VA and to learn more about services and benefits for which they may be eligible. More than 11,000 veterans and their families have attended the supermarkets, which include information booths with representatives from WDVA, VA, and veterans service organizations, as well as a variety of Federal, State, and local agencies. I was proud to have members of my staff speak with veterans and their families at a number of these events. These events have helped veterans and their families to learn about numerous topics, including health care, how to file a disability claim, and preregistration for internment in veterans cemeteries.

The Institute for Government Innovation at Harvard University's Kennedy School of Government recognized the ``I Owe You'' program by naming it a semi-finalist for the 2002 Innovations in American Government Award. The program was also featured in the March/April 2003 issue of Disabled American Veterans Magazine.

In order to help to facilitate consistent implementation of VA's outreach responsibilities around the country, my bill would help to improve outreach activities performed by the VA in three ways. First, it would create separate funding line items for outreach activities within the budgets of

the VA and its agencies, the Veterans Health Administration, the Veterans Benefits Administration, and the National Cemetery Administration to ensure oversight of the VA's outreach activities. Secondly, the bill would create an intra-agency structure to require the Office of the Secretary, the Office of Public Affairs, the VBA, the VHA, and the NCA to coordinate outreach activities. By working more closely together, the VA components would be able to consolidate their efforts, share proven outreach mechanisms, and avoid duplication of effort that could waste scarce funding. Finally, the bill would give the VA grantmaking authority to award funds to State, local and community-based organizations to conduct outreach activities such as the WDVA's ``I Owe You Program.''

I look forward to working with Chairman Akaka and the members of the Senate Veteran Affairs Committee to make the veteran outreach grant program a success. As we continue to deploy members of the Armed Services overseas at a staggering pace, it is essential that we ensure a smooth transition into the VA for all veterans in need of care. It is the least we can do.

Mr. President, today I am pleased to introduce the White Mountain Apache Tribe Water Rights Quantification Act of 2009. The legislation would authorize and confirm the tribe's water settlement and authorize funding for a key drinking water project on the tribe's reservation in northern Arizona--the Miner Flat Dam and Reservoir. The legislation is the product of nearly 3 years of negotiation and the tremendous work of the settlement parties.

On behalf of the tribe, the United States filed substantial claims to water in the Gila River and Little Colorado River General Stream adjudications in Arizona. The settlement of these claims would, among other things, resolve the tribe's claims to water by allocating to it a total annual water right of 52,000 acre-feet per year through a combination of surface water and Central Arizona Project water sources. Without a settlement, resolution of the tribe's claims would take many years, entail great expense, prolong uncertainty concerning the availability of water supplies, and seriously impair the long-term economic well-being of all of the parties to the settlement.

Late last year, the representatives of the non-federal water settlement parties indicated that a settlement was nearly finalized. The parties' representatives expressed their written support for the settlement and indicated that they will be submitting the settlement to their respective governing bodies for review and action. A number of the parties, including the White Mountain Apache Tribe, have already formally approved the settlement.

A major factor driving the settlement is the drinking water needs of the White Mountain Apache Tribe. Currently, a relatively small well field serves the drinking water needs of the majority of the residents on the tribe's reservation, but production from the wells has declined significantly over the last few years. As a result, the tribe has experienced summer drinking water shortages. The tribe is planning to construct a relatively small diversion project on the North Fork of the White River on its reservation this year. It indicates that when the project is completed it will replace most of the lost production from the existing well field, but will not produce enough water to meet the demand of the tribe's growing population. The Miner Flat Project would provide a longterm solution for the tribe's drinking water shortages.

A significant percentage of the water and funding for the White Mountain Apache settlement has already been set aside in legislation I sponsored, the Arizona Water Settlements Act. The Arizona Water Settlements Act, which became law in 2004, settled expensive and lengthy litigation concerning the Gila River Indian Community's rights to Gila River water and other water supplies, and the claims of the Tohono O'odham Nation for damages from groundwater pumping in southern Arizona. It also set aside 67,300 acre-feet of Central Arizona Project, CAP, water per year to resolve Indian water claims in Arizona and established a $250 million fund for future Arizona Indian water settlements.

Under the White Mountain Apache Tribe's settlement legislation, a portion of the CAP water set aside in the Arizona Water Settlements Act will be used to settle the White Mountain Apache Tribe's claims and a portion of the $250 million will be used to construct the Miner Flat Project. While a potential scoring issue exists relating to the use of these funds, I am confident that these issues will be resolved as the legislation progresses.

In sum, not only would the legislation I have introduced today provide certainty to water users in the State of Arizona regarding their future water supplies, it would provide the tribe with a long- term reliable source of drinking water. Therefore, I urge my colleagues to support this legislation.

Mr. President, I ask unanimous consent that the text of the bill and letters of support be printed int he Record.