A bill to amend title XVIII of the Social Security Act to permit nurse practitioners and physician assistants to satisfy the documentation requirement under the Medicare program for coverage of certain shoes for individuals with diabetes.

Mr. President, I rise today to introduce the Promoting Access to Diabetic Shoes Act with my colleague from New Hampshire, Senator Shaheen. I want to thank Senator Shaheen for her partnership on so many issues affecting individuals with diabetes. Our bipartisan bill would allow nurse practitioners and physician assistants to prescribe therapeutic shoes under Medicare. This will enable Medicare beneficiaries who have diabetes to more easily access this important preventive care, should they need it.

As cochairs of the Senate Diabetes Caucus, Senator Shaheen and I are focused on advancing policies that will improve the lives of the more than 37 million Americans who live with diabetes. Therapeutic shoes help prevent some of the costly and painful complications related to diabetes, such as foot ulcers, which almost 1.6 million individuals with diabetes have. If they do not receive timely care, these individuals are at risk of serious health complications, such as lower limb amputations. Only 10 percent of qualifying Medicare patients receive the diabetic shoes they need because of difficulties accessing qualifying providers. By reducing barriers to this preventive care, the Promoting Access to Diabetic Shoes Act will enable more individuals with diabetes to receive the medical care they need to avoid some serious complications.

Nurse practitioners and physician assistants in Maine and across the country provide the full range of care to patients with diabetes. Many patients see an NP or a PA as their preferred primary care provider for treating diabetes. When the treating NP or PA determines that the patient may need therapeutic shoes, however, the NP or PA must send the patient first to a physician to make the same determination, and then the physician must send them to a podiatrist to actually fit the shoes. To make matters more complicated, under current law, the certifying physician must take over all treatment of the patients diabetic condition. This process not only forces a patient to change providers but also delays patient access to effective treatment for diabetes.

In rural States such as Maine, patients often have to drive long distances to see a podiatrist or even a physician. One nurse practitioner from Bangor shared with me that the closest podiatrist she is able to send patients to is an hour-long drive away and has a many- months long waitlist. Patients with diabetes simply cannot afford to wait months and months for treatment. The removal of this outdated and unnecessary barrier means NPs and PAs would be authorized to certify the need for therapeutic shoes for patients with diabetes and ensure they get the care they need in a timely fashion.

Finally, passage of this legislation will reduce Medicare spending by removing the unnecessary and duplicative certifying visit requirements. Data demonstrate that NPs and PAs manage the care for patients with diabetes in a cost-effective manner that results in healthcare savings. The estimated total annual cost of an individual patient with diabetes is $17,000. If the patient does not receive treatment in

time, though, and develops a serious complication, the estimated annual individual cost rises to $52,000. Our bill will create savings for Medicare by reducing the long-term costs of care.

Passage of the Promoting Access to Diabetic Shoes Act will make it possible for NPs and PAs to continue providing high-quality care for their Medicare patients with diabetes. It will also reduce Medicare spending by eliminating duplicative services, improve the timeliness of care for patients with diabetes who need therapeutic shoes, and allow the patient to continue receiving care from the provider of their choice. I urge all of my colleagues to join Senator Shaheen and me in supporting the Promoting Access to Diabetic Shoes Act.

Mr. President, I rise today to introduce the Promoting Access to Diabetic Shoes Act with my colleague from New Hampshire, Senator Shaheen. I want to thank Senator Shaheen for her partnership on so many issues affecting individuals with diabetes. Our bipartisan bill would allow nurse practitioners and physician assistants to prescribe therapeutic shoes under Medicare. This will enable Medicare beneficiaries who have diabetes to more easily access this important preventive care, should they need it.

As cochairs of the Senate Diabetes Caucus, Senator Shaheen and I are focused on advancing policies that will improve the lives of the more than 37 million Americans who live with diabetes. Therapeutic shoes help prevent some of the costly and painful complications related to diabetes, such as foot ulcers, which almost 1.6 million individuals with diabetes have. If they do not receive timely care, these individuals are at risk of serious health complications, such as lower limb amputations. Only 10 percent of qualifying Medicare patients receive the diabetic shoes they need because of difficulties accessing qualifying providers. By reducing barriers to this preventive care, the Promoting Access to Diabetic Shoes Act will enable more individuals with diabetes to receive the medical care they need to avoid some serious complications.

Nurse practitioners and physician assistants in Maine and across the country provide the full range of care to patients with diabetes. Many patients see an NP or a PA as their preferred primary care provider for treating diabetes. When the treating NP or PA determines that the patient may need therapeutic shoes, however, the NP or PA must send the patient first to a physician to make the same determination, and then the physician must send them to a podiatrist to actually fit the shoes. To make matters more complicated, under current law, the certifying physician must take over all treatment of the patients diabetic condition. This process not only forces a patient to change providers but also delays patient access to effective treatment for diabetes.

In rural States such as Maine, patients often have to drive long distances to see a podiatrist or even a physician. One nurse practitioner from Bangor shared with me that the closest podiatrist she is able to send patients to is an hour-long drive away and has a many- months long waitlist. Patients with diabetes simply cannot afford to wait months and months for treatment. The removal of this outdated and unnecessary barrier means NPs and PAs would be authorized to certify the need for therapeutic shoes for patients with diabetes and ensure they get the care they need in a timely fashion.

Finally, passage of this legislation will reduce Medicare spending by removing the unnecessary and duplicative certifying visit requirements. Data demonstrate that NPs and PAs manage the care for patients with diabetes in a cost-effective manner that results in healthcare savings. The estimated total annual cost of an individual patient with diabetes is $17,000. If the patient does not receive treatment in

time, though, and develops a serious complication, the estimated annual individual cost rises to $52,000. Our bill will create savings for Medicare by reducing the long-term costs of care.

Passage of the Promoting Access to Diabetic Shoes Act will make it possible for NPs and PAs to continue providing high-quality care for their Medicare patients with diabetes. It will also reduce Medicare spending by eliminating duplicative services, improve the timeliness of care for patients with diabetes who need therapeutic shoes, and allow the patient to continue receiving care from the provider of their choice. I urge all of my colleagues to join Senator Shaheen and me in supporting the Promoting Access to Diabetic Shoes Act.

Mr. President, now on the Qatar plane and the Middle East, last week, Donald Trump concluded a visit to the Middle East that was a smashing success for his own bottom line but a dubious outcome for America's economic and security interest.

First, on the Qatari plane, last week, Donald Trump confirmed that he would accept a $400 million luxury Boeing 747 plane offered by Qatar to use as Air Force One--the largest bribe to an American President in modern history.

So, today, I am introducing the Presidential Airlift Security Act, prohibiting the use of any foreign plane to be utilized as Air Force One. Senate Republicans who say they are troubled by this Qatari gift should join me in supporting this very commonsense legislation.

It should not take an act of Congress to stop the President of the United States from accepting the largest foreign bribe in modern history, but we are dealing with a President who has shown he is perfectly willing to sell out the American people and the Presidency to fill his own pockets.

Specifically, my legislation would prohibit even a single taxpayer dollar from being used by the Department of Defense to procure, modify, or retrofit any foreign aircraft to be used in transporting a U.S. President.

For one, overhauling a foreign luxury plane to serve as Air Force One would cost billions of taxpayer dollars. The refurbishing alone would cost more than the value of the plane itself, and it would take years. It is a senseless waste of taxpayer resources.

Using a foreign plane as Air Force One would also bring unimaginable national security risks. National security experts, from one end of the country to the other, agree: No matter how many modifications are made or how much is spent or how intensely it is retrofitted, there will never be 100 percent confidence that the plane is secure.

This is not a gamble anyone should be willing to take. It makes no practical sense for Donald Trump to accept this luxury gift when other alternatives in the works are less risky and less costly for taxpayers.

This gift reeks of corruption and naked self-enrichment. It reeks of corruption and naked self-enrichment, and Republicans should stand up and support our bill, defend national security, and protect Americans.

In the meantime, I will continue my hold on all political Department of Justice nominees until we get more answers about this clearly unethical deal.

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