Floor Statements

Mr. President, I ask unanimous consent that all pending amendments be laid aside so that the Senator from New Jersey may offer an amendment.

I withdraw the request. I ask unanimous consent that there be 30 minutes equally divided on the Lautenberg amendment and, immediately following that debate, the Senate vote on the Lautenberg amendment.

I yield the floor and withdraw my request.

I know the Senator from New Hampshire would like to go ahead. I will speak for just a minute or 2 before he does.

I very much agree with the Senator. It seems absurd that we have to wait until 2006 before this program goes into effect. I very much understand the concern of the Senator.

Let me say this to all of us who are concerned. Before the conference report comes back, I am going to do my level best by pushing the CBO and CMS, asking a lot of tough questions of these agencies, to see if there is some way we can get this put together earlier. It is my hope we could bring back a conference report that has an earlier date, significantly earlier date. My guess is the private sector could get this done pretty quickly. It would not take a full 2 years to get it done.

I just pledge to my colleagues, this is one Senator who is going to do his level best to try to get an earlier date. The current date just doesn't make sense. We need to ask some tough questions and get some answers.

I yield the floor.

I move to lay that motion on the table.

The motion to lay on the table was agreed to.

Amendment No. 982

Mr. President, I see the Senator from West Virginia is in the Chamber.

Mr. President, I suggest the absence of a quorum.

Mr. President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. President, I ask unanimous consent that the pending amendments be temporarily laid aside so the Senator from West Virginia can offer his amendments.

Mr. President, I suggest the absence of a quorum.

Mr. President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. President, I would like to say a couple of words about one of the two amendments offered by the distinguished Senator from West Virginia regarding the true out-of-pocket expenses, where the employers' contributions to retirees' health care plans be considered in calculating the out-of-pocket expense that would determine when a senior citizen reaches the stop loss provisions of this bill.

This may sound like a fairly arcane point, but it is a very important one.

Let me just describe the provisions of the bill. Under the bill, after a $275 deductible, the provisions of this bill require that employees would receive a contribution from the Government of 50 percent of each prescription he or she filled, up to $4,500 in drug expenses. After that amount, $4,500, then seniors would pay 100 percent of the costs until the beneficiary's spending reached $3,700. This should not be confused with total spending, of which the beneficiary spent $3,700 out of his pocket. It would be $5,812.

Anyway, after the beneficiary spends $3,700 out of pocket, the total stop loss coverage kicks in and the Government picks up 90 percent of the beneficiary's drug spending and the beneficiary, him or herself, pays 10 percent.

The real question is, What about the employers' contributions? Would they count toward the stop loss coverage? Under the underlying bill, all spending must be provided by the beneficiary, not on behalf of the beneficiary. As a consequence, employers' contributions would not count. The CBO estimates up to 37 percent of retiree health coverage would therefore be dropped by employers.

Just to recapitulate, the amendment offered by the Senator from West Virginia basically provides that the stop loss amounts in the underlying bill should be based on out-of-pocket costs, and the employers' contribution towards retiree health benefits could count towards that stop loss computation.

What about this? Frankly, I have a lot of sympathy for the Senator's amendment. That is, as it currently stands, the beneficiary, a senior citizen, would have to spend $3,700 before the stop loss would be calculated. Under the amendment offered by the Senator from West Virginia, that amount would be quite a bit lower.

I mentioned earlier that CBO estimates about 37 percent of retirees who now are covered by health plans under their employer health coverage would no longer receive drug coverage because those employers would drop coverage. Or, to say it differently, CBO estimates that, because the employer's contributions do not now count towards stop loss, about 11 percent of the seniors generally would lose their employer-sponsored health coverage.

As I mentioned, I share my colleague's desire to prevent the loss of employer-sponsored coverage; that is, to the extent possible. We have our work cut out for us because retiree coverage is already on the decline. According to the Kaiser Family Foundation/Hewitt Study, that was released last December, one in five large employers is likely to eliminate retiree health coverage for future retirees in the next 3 years.

That is a lot. That is irrespective of the provisions of this bill with respect to prescription drug coverage. If one out of five large employers in fact does eliminate retiree health coverage for their retirees within the next 3 years, it is going to have a huge impact, clearly, on those retirees, and also on the portion of the health care system that is not paid for by larger companies.

That study also found that nearly 80 percent of large employers are likely to increase the amount paid directly by their employees for health care. That is, most--four-fifths of all employers--are likely to have their employees pay more than they, the employers, are paying. We know about the negotiations between General Electric and its employees not too long ago, where both agreed to shift more of the rising cost of health care to employees. Clearly, we should be doing all we can to ensure that a bad situation does not get worse.

The chairman of the committee, Senator Grassley, and I have been looking for ways to address concern about employer-sponsored coverage. We are looking at ways to make employers' participation in the new Part D benefit more manageable, so employers have flexibility with respect to the offering of these benefits. I, certainly, personally am willing to entertain proposals that would allow more employer coverage, and also help address the out-of-pocket situation the Senator from West Virginia would like to cover with his amendment.

The slight problem we have, as most of us know, is that we are working within the confines of $400 billion over 10 years. If the amendment offered by the Senator from West Virginia were to be agreed to, according to CBO, that would cost approximately $65 billion. That is $65 billion, generally, over the $400 billion that has been set aside for this bill. Senator Grassley and I are working with various groups in and out of the Senate, trying to address the potential loss of employer retiree coverage. It is a great concern of ours. There have been several proposals offered as to how we might deal with that, in addition to the ones contained in the amendment by the Senator from West Virginia. I am hopeful that during the next several days, before the final passage of this bill--hopefully before the weekend--we will be able to significantly address this issue. So far, we do not have it nailed down. But as you might expect, this and a lot of other issues are kind of hovering about as we try to find ways to fit the pieces together so we can get a very good bill passed.

I also remind my colleagues who are slightly concerned about the complexity of this bill--and this bill is somewhat complex--there was an interesting piece in, I think it was today's New York Times; it might have been yesterday's. In any event, it was about the complexity of the bill and how bewildered some people are because of the complexity. I think the article did a good job in explaining why major social policy, almost by definition, is complex; that is, it is a result of compromises.

In this case, the big compromise is between about half of this body, who wants to provide prescription drug benefits under Medicare, and about half of this body, who wants prescription drug benefits to be provided under private competition. It is difficult to put those two pieces together. It is the attempt to put those two pieces together that has caused a lot of the complexity that does exist in this bill.

I might say, however, that Medicare itself is already quite complex. They could come back and say: Why make something complex even more complex? But it has to be weighed against another factor. That is, do we want to provide a prescription drug benefit to seniors or not? The choice at the end of this week is going to be, do we want something that is a little bit complex but provides prescription drug benefits for seniors--and does a good job doing so? Maybe with not as many benefits as

some seniors would like and some Members of this body would like, but still does a pretty good job and is a bit complex. Or, on the other hand, do we want to do nothing? Do we want to let senior citizens today, who do not have prescription drug coverage, remain without coverage? That is basically the question we are going to be facing later on this week.

To ask the question, I think, is to answer it. Namely, we should do a pretty good job, trying to get a pretty good bill passed, even though there is some complexity, even though there are some tradeoffs, rather than have nothing.

I suspect this body is always going to be somewhat split. I do not think one party is going to be totally in control at one time or the other party is going to be totally in control at another time. I think it is the nature of the American body politic that people want to hedge their bets, that they want to have both Democrats and Republicans working together. Certainly, our Founding Fathers set up our Government that way under our Constitution. They absolutely distrusted power. They distrusted it almost absolutely. That is why we have power dispersed by definition. That means in order to get something of consequence passed, there is going to have to be some compromise. In this bill there certainly is a lot of compromising.

A final point contained in that article--and I thought it was a pretty good article--is that when we, in this country, have passed other major social policy--let's say Medicare and Social Security--it has been based somewhat on faith, and we have worked to fix it, to make it even better after it has been passed. But you have to start somewhere. And I think, certainly, we have to start somewhere with respect to prescription drug benefits, and certainly, we should provide prescription drug benefits for seniors.

So I urge my colleagues to keep that in mind as we are working on amendments, which are designed to make this bill better. We can accept some amendments, but some in this body will not accept others. Nevertheless, all of us are generally working together toward the same goal.

In that vein, Mr. President, I ask unanimous consent that the pending amendments be temporarily set aside so the Senator from Hawaii may offer two amendments in sequence.

Mr. President, I ask unanimous consent that all pending amendments be temporarily set aside so the Senator from Arkansas may offer an amendment.

Mr. President, I ask unanimous consent that the pending amendments be set aside so the Senator from New Mexico can offer three amendments in sequence.

Mr. President, I thank the Senator from New Mexico. I think he has a very good point. The current assets test is degrading, unworkable. It is just not good policy. It is also extremely complicated. Currently, assets tests apply to various kinds of benefits--sometimes Medicaid or Medicare, or certain categories of Medicare. It defies logic, it is so complicated. Frankly, if this Senator had his way, we would repeal a lot of the assets tests which have not been updated for a good number of years--since 1987 or 1989. We are talking about $9,000 a year or something like that. On the other hand, we are dealing with $400 billion in this bill. A total repeal of the assets test on drugs only would be--I don't know the cost, but it would be expensive.

The Senator from New Mexico, in his good-faith effort to try to deal with unnecessary complications--which is bad public policy--is trying to modify a repeal of the assets test to a smaller category. Frankly, it has a lot of appeal. But as the Senator knows very well, probably as well if not better than most Members of this body, that would only go part way toward correcting some of the inequities caused by the assets test. Even if the Senator's amendment to totally repeal the asset test applying to drugs would go into effect, nevertheless, the asset test with respect to the rest of the categories would still apply under Medicare. That is low-income categories that are mandatory.

It is incredibly complex, which is to say I am very sympathetic with the Senator and I am hopeful we get this score back from CBO on the Senator's asset test amendment, that it is one that certainly can work within the $400 billion limit we are operating under. I, for one, believe it should pass. I thank the Senator very much for persistently and very forthrightly, with a lot of good information, bringing this up to be dealt with.

Mr. President, I ask unanimous consent that all pending amendments be temporarily laid aside.

On behalf of Senator Edwards, I send an amendment to the desk with respect to consumer advertising.

Mr. President, I ask unanimous consent that further reading of the amendment be dispensed with.

Mr. President, I ask unanimous consent that the amendment be temporarily laid aside.

Mr. President, I send to the desk an amendment on behalf of Senator Lautenberg with respect to moving the effective date of this legislation 1 year forward.

Mr. President, I ask unanimous consent that further reading of the amendment be dispensed with.

Mr. President, those are two amendments which Senators have offered. That means, as a practical consequence, that they are more likely to be considered than amendments that have not been offered. These are amendments that I will now call CBO and get scores on. It is difficult to get scores from CBO on amendments if they are not pending. If Senators have not told me they are going to offer amendments, I cannot put them on the list. This is a roundabout way of saying to Senators who wish to offer amendments, it behooves them to do it now and get them into the queue. Then I can call CBO and tell them we need a score on this or that amendment. CBO cannot score all amendments that will be potentially filed, because it has limited resources. It can only do it as they become real. I urge Senators to come forward with amendments so we can deal with them.

I suggest the absence of a quorum.

Yes, we do.

Absolutely. How many minutes does the Senator want?

I yield the Senator 2 minutes.

Mr. President, the author of the amendment is not here. I think he was caught a bit off guard when it was announced the vote would be on his amendment at 5:30. I understand he is on his way over here. I think it is only fair he be allowed to speak for a couple or 3 minutes at least on his amendment.

I ask consent the vote on the Bingaman amendment not be at 5:30 but at 5:40, and the remaining 10 minutes be equally divided.

I yield to the Senator from Massachusetts, but inform Senators when the time has expired I am going to suggest the absence of a quorum.

Mr. President, I ask unanimous consent that Senator Bingaman be allowed to speak for 2 minutes.

Mr. President, it is my understanding that under the unanimous consent request, it is in order for the Senator from Washington, Mrs. Murray, to offer an amendment. Accordingly, I ask unanimous consent that all pending amendments be temporarily laid aside so she may offer her amendment.

Mr. President, if I might repeat the request, that all pending amendments be temporarily set aside so the Senator from Washington may offer her amendment.

Mr. President, I ask unanimous consent that the pending amendments be temporarily laid aside so the Senator from Minnesota may offer up to three amendments in succession.

Mr. President, I ask unanimous consent the pending amendments be temporarily set aside.

Mr. President, on behalf of Senator Stabenow, I send an amendment to the desk regarding State rebate agreements.

I ask unanimous consent the reading of the amendment be dispensed with.

Mr. President, I ask unanimous consent all pending amendments be temporarily set aside.

On behalf of Senator Dorgan, I offer an amendment with respect to coverage of cardiovascular screening tests. I send that to the desk.

I ask unanimous consent the reading of the amendment be dispensed with.

Mr. President, I suggest the absence of a quorum.

Mr. President, I move to reconsider the vote and I move to lay that motion on the table.

The motion to lay on the table was agreed to.

Mr. President, who controls time?

Mr. President, the Senate is not in order.

Mr. President, I suggest the absence of a quorum.

Mr. President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. President, I will take a moment to review the schedule under the previous order. Under the previous order, the following Senators are to be recognized to offer the following amendments:

Senator Grassley on rural provisions; Senator Harkin on mammography; Senator Conrad on fallbacks; Senator Kerry on a grant program; Senator Clinton on a study; and Senator Graham has one with respect to premiums.

Republican Senators could offer amendments in an alternating fashion between Democratic amendments. A number of these Senators have chosen to offer amendments at a later time.

Thus, I ask unanimous consent that this order remain the order under which Senators would be recognized to offer amendments, except that the Senator from Florida, Mr. Graham, now be recognized to offer his amendment, and immediately following Senator Graham, the Democratic leader be recognized for whatever amount of time he wishes to speak, and that the pending amendments be temporarily laid aside so the Senator from Florida may offer his amendment.

Mr. President, I suggest the absence of a quorum.

Mr. President, as we did with the Graham amendment, I would now like to allow consideration of the Kerry amendment, and thus I ask unanimous consent that all the terms of the previous order remain in place except that the pending amendments be temporarily set aside, and that the Senator from Massachusetts be recognized to offer his amendment.

Mr. President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. President, we are now awaiting the arrival of Senator Lincoln from Arkansas who has two amendments she wishes to offer. She will be arriving shortly. Until she arrives, I have a few words about a particular provision in the bill. It is called MARCIA, Medicare Appeals Regulatory and Contracting Improvements Act. Last year I joined my colleagues, Senator Grassley, Senator Kerry, and now-Governor Murkowski, in introducing what we called the Medicare Appeals Regulatory and Contracting Improvements Act, otherwise know as MARCIA.

Today this bill is an essential part of our Medicare improvement proposal, the underlying bill. The purpose of the provision is to make Medicare a better business partner to providers, a smarter purchaser of services for our taxpayers, and a more customer-friendly organization for our beneficiaries. MARCIA will strengthen and improve Medicare and will help bring the program's administration into the 21st century.

The provisions provide for regulatory improvements. I have heard from hundreds of doctors, as I know all in this body have, and many providers who complain that the sheer number and complexity of Medicare regulations can drive them crazy and, at times, drive them out of business.

While we cannot make Medicare into a simple program, this bill would make and does take some helpful steps in the right direction.

For one thing, it will require the Secretary on a regular basis to review the thousands of pages of statutes and regulations to see if there are any inconsistencies in Medicare's many requirements.

Just a couple of days ago, the majority leader from Tennessee held up a book which showed the Medicare requirements back, I think it was 1965. It was a fairly thick volume, actually. Then alongside that he also held up a book with the current Medicare regulations, which was a gigantic volume. It is similar to the problems we face in the Tax Code, as we all know.

I am not standing here to say the provisions of this bill are going to make Medicare simple and easy, that we are going to cut the number of pages down to half. But I am saying we are trying to do our very best, and the provisions in this bill should help reduce some of the inconsistencies and the complexities that do now occur in the Medicare regulations. At least we are focusing on that problem and requiring the Secretary to address that, specifically giving that direction.

Second, our legislation would cut down on the CMS practice of using so-called interim final rule authority to impose major new regulations without even giving the public an opportunity to comment. It just stands to reason that the public should have an opportunity to comment on rules because it is more likely if they do, the rules are going to be better rules or, on the other side of the coin, if there is not an opportunity for the public to comment, there is going to be a tendency over time for CMS or any agency to be a little less sensitive to what that is really all about, which is about serving people because, after all, we are all public servants, including CMS personnel. Our real job is to serve the people in the country, and I think this will help move CMS in that direction.

The third provision would make sure that new regulations cannot be applied retroactively. Intuitively, I think it makes sense that it does not apply retroactively. I think these new requirements are just a simple matter of fairness.

The underlying bill, as we are talking about the regulatory provisions, would also make improvements to the Medicare appeals system. In the year 2001, on average it took 441 days to complete an appeal before an administrative law judge. The next level of appeal took almost 2 years. It is true certain provisions in the 2000 law that we passed tried to speed up the appeals process, but unfortunately that law did not provide the resources or the realistic timeframes necessary to make these changes work.

MARCIA, the regulatory provisions, would make some important improvements to get this appeals system back on track so our Medicare beneficiaries and providers can get justice more quickly. Clearly, 441 days for the first level of appeal and 2 years for the second is not right, for a whole host of obvious reasons.

The bill also requires CMS to submit a plan to develop and train a group of dedicated Medicare ALJs, administrative law judges. This plan would ensure that administrative law judges remain truly independent, which I think is a crucial feature of any fair appeals system.

Medicare contractors will also have to bid and compete for contracts under this bill. That is a very significant change from current practice. Essentially, under the current practice, Medicare contractors, especially talking about the intermediaries, are essentially nominated by the intermediaries. They themselves nominate who it is going to be, and there is no limit to how long a contracting period can be. I think it tends to be a little bit too close and there is not enough fresh air to help assure, at least the best we can, that the contractor selection process is one that provides more efficiency and better service to our people.

The Medicare contractors will have to bid now. They are going to have to compete for contracts under this bill--that is new--thereby assuring that the Medicare Program and the taxpayers are getting the best service for the lowest price the market will allow.

In assessing the bids, CMS will have to consider customer service and accuracy. That is required when CMS is now selecting contractors and getting bids from contractors. Again, we are talking generally about the so-called intermediaries who are the ones who deal directly with providers. They deal between the providers and the beneficiaries and the Government.

In assessing the bids, CMS will have to consider customer service and accuracy, as I said, and contractors will also have to provide much more information to providers and to beneficiaries. If the providers raise questions about Medicare claims or policies, contractors will have to answer them in writing. That, too, is new.

The bill also would require the Secretary to standardize the way in which Medicare conducts audits, the way it conducts prepayment and postpayment reviews of provider claims. We often hear of great, almost gross, inconsistencies among different parts of the country, different regions. It makes sense to standardize this a little bit better. I am encouraged that CMS has already taken steps in this direction to make the audit process more fair but to ensure that providers are treated fairly and consistently, I believe the law has to require it.

Finally, I am pleased this bill also contains money for continued strong enforcement against waste, fraud, and abuse in the Medicare Program. I have long believed the Medicare integrity programs must be firm, but they must also be fair. This bill takes important steps to ensure honest dealing with taxpayer money and fair treatment for the professionals who serve our seniors every day.

Essentially, these are provisions that hopefully address a good part of the regulatory complaints, the legitimate

complaints that all of us in this body have been hearing about from doctors and hospitals as they try to do their very best job in providing care, in this case, to seniors. I think these are good, solid provisions.

Turning to another matter, as we did for Senator Graham and Senator Kerry, I would now like to make it possible for the Senator from Arkansas to offer her amendments. I ask unanimous consent that the pending amendments be temporarily set aside and that the Senator from Arkansas be recognized to offer up to three amendments in succession.

Mr. President, I suggest the absence of a quorum.

Mr. President, I ask unanimous consent that the pending amendments be set aside.

Mr. President, on behalf of the Senator from Vermont, I send an amendment to the desk and ask for its immediate consideration.

Mr. President, I ask unanimous consent, again, that all pending amendments be set aside.

Mr. President, I send a second amendment to the desk on behalf of the Senator from Vermont and ask for its immediate consideration.

Mr. President, I ask unanimous consent reading of the amendment be dispensed with.

Mr. President, I suggest the absence of a quorum.

Mr. President, before the Senator critiques the bill, if the Senator from Florida will yield, I very much appreciate his kind remarks. As virtually every Senator knows, this is not the perfect bill. Each Senator would like to change it a little bit. This Senator, in particular, would like to have had more money, frankly. We have $400 billion over 10 years. If we had a little more, maybe we could accommodate many of the provisions to which the Senator is referring. They are good ideas. But I think this legislation is a good first step, a chapter in a very long Medicare book. Chapter 1 was in 1965, when it was first enacted. There will be many more chapters as we work to improve Medicare, so that our senior citizens get the benefits they rightly deserve.

I thank the Senator very much for his working with us. He has given us some great ideas. I think over time, in the next couple to 3 years, we will have another chance. I thank the Senator.

Mr. President, I ask unanimous consent that the pending amendments be temporarily laid aside so the Senator from Florida may proceed to offer up to two amendments.

Mr. President, I ask the Senator from Florida how long he wishes to entertain us and to educate us.

I was expecting a longer speech, frankly. I suggest the Senator speak for, say, 10, 15 minutes or whatever time the Senator wishes to take.

I know the people in Florida very much appreciate the hard work the Senator does. Part of that is on behalf of senior citizens.

I ask unanimous consent that the pending amendments be set aside.

Mr. President, on behalf of the Senator from Iowa, Mr. Harkin, I send an amendment to the desk with respect to approving access to mammography services.

Mr. President, I ask unanimous consent that the pending amendments be temporarily set aside.

On behalf of Senator Harkin, I send a second amendment to the desk restoring certain reimbursements for nursing home services.

Mr. President, I ask unanimous consent that the reading of the amendment be dispensed with.

I ask that all pending amendments be set aside.

On behalf of the Senator from Connecticut, Mr. Dodd, I send an amendment to the desk permitting open enrollment on a drug benefit for 2 years.

Mr. President, I ask that all pending amendments be laid aside temporarily.

I send an amendment on behalf of Senator Dodd expanding low-income protections to 250 percent of poverty.

Mr. President, I ask unanimous consent that the pending amendments be laid aside.

Mr. President, I call up amendment No. 942 on behalf of the Senator from Washington, Ms. Cantwell.

I suggest the absence of a quorum.

Mr. President, I am proud to support Senator Bingaman's legislation to ensure equitable tax treatment for Oldsmobile dealers impacted by General Motors' sudden decision to eliminate the Oldsmobile from its product line. General Motors did agree to partially compensate Oldsmobile dealers for their loss.

Senator Bingaman's bill ensures that like-kind exchange treatment, which defers the gain on the exchange of business or investment property until it is ultimately sold, is also available for motor vehicle dealers who receive payments when the brand of automobile they carry is eliminated by the manufacturer. The proposal allows such reinvested payments to be treated as a like-kind exchange of property if exchanged within 2 years from receipt of the payments, thus deferring the tax consequences. As such, the proposal encourages capital investment by recognizing that a longer period of time is required for dealers to obtain a new franchise or establish a new car sales business.

The manufacturer, not the automobile dealer, makes the unilateral decision to eliminate vehicle brands. Nonetheless, the dealer is the one who invests years of hard work in bringing a particular brand to his or her local community. When a manufacturer decides to eliminate a brand, many family-owned dealerships face a complete loss of business as well as an increased threat to the viability of other brands located in the same facility.

Approximately one-third of the 2,801 Oldsmobile dealers across the country are expected to reinvest the GM payments into another franchise or other retail motor vehicle sales business. Many of the 27 Oldsmobile dealers in Montana have expressed their interest in reinvesting the GM payments they received, if this legislation becomes law. These Montanans have been stripped of a source of income at a time when the economy is not too forgiving.

I urge my colleagues to support this important legislation.

Mr. President, I am proud to support Senator Bingaman's legislation to ensure equitable tax treatment for Oldsmobile dealers impacted by General Motors' sudden decision to eliminate the Oldsmobile from its product line. General Motors did agree to partially compensate Oldsmobile dealers for their loss.

Senator Bingaman's bill ensures that like-kind exchange treatment, which defers the gain on the exchange of business or investment property until it is ultimately sold, is also available for motor vehicle dealers who receive payments when the brand of automobile they carry is eliminated by the manufacturer. The proposal allows such reinvested payments to be treated as a like-kind exchange of property if exchanged within 2 years from receipt of the payments, thus deferring the tax consequences. As such, the proposal encourages capital investment by recognizing that a longer period of time is required for dealers to obtain a new franchise or establish a new car sales business.

The manufacturer, not the automobile dealer, makes the unilateral decision to eliminate vehicle brands. Nonetheless, the dealer is the one who invests years of hard work in bringing a particular brand to his or her local community. When a manufacturer decides to eliminate a brand, many family-owned dealerships face a complete loss of business as well as an increased threat to the viability of other brands located in the same facility.

Approximately one-third of the 2,801 Oldsmobile dealers across the country are expected to reinvest the GM payments into another franchise or other retail motor vehicle sales business. Many of the 27 Oldsmobile dealers in Montana have expressed their interest in reinvesting the GM payments they received, if this legislation becomes law. These Montanans have been stripped of a source of income at a time when the economy is not too forgiving.

I urge my colleagues to support this important legislation.

Madam President, I see the Senator from Missouri in the Chamber. He wants to speak next. For the information of all Senators, I think we are going to get an amendment offered on the floor shortly. But the sponsor of the amendment has only a very short time that he can be in the Chamber. I urge my friend from Missouri to remember that brevity is the soul of not only wit but sometimes persuasion.

Madam President, I apologize to my good friend from Missouri. It turns out that the Senator who is going to offer the amendment is not able to do so at this time.

I thank the Chair. Madam President, I wish to take a few minutes to speak about a feature of this prescription drug bill which I believe is particularly noteworthy, and that is help for low-income seniors.

The subsidies provided for low-income seniors and disabled people are far more generous and much more humanitarian than many of the proposals the Senate has considered in the past. We know that most seniors who signed up for this new drug program will benefit from assistance with their prescription drug costs.

Many seniors today pay thousands of dollars a year for drugs. That is common knowledge, and that is a substantial expense to them. It is to everybody, but particularly seniors and particularly low-income seniors.

For 40 percent of our seniors who make less than $15,000 per year, the prescription drug coverage provided by this bill will be truly lifesaving. That is, 40 percent of our seniors make less than $15,000 a year.

We have all heard stories about poor seniors who eat less so they can pay for their prescription drugs or who take only half the dosage the doctor recommends. I have seen that. I worked at a drugstore one day. I was really quite taken aback by the number of times the elderly would walk up to the pharmacist and quietly ask the pharmacist whether they could cut back on their prescription because they could not pay for it all, and they and the pharmacist would go into a little huddle as to which drugs to take and which ones not to take. I have seen it firsthand. A lot of us have heard a lot about this. We have heard about patients with disabling illnesses who cannot afford the expensive drugs that might slow the progression of a dangerous and unpredictable disease. It is clear, 40 percent of our seniors are making less than $15,000. That has to tell us it is a huge problem we have to address.

This bill will give some hope to those folks. The bill is an improvement, as I mentioned, over last year's bill. Last year, that bill gave seniors generous assistance with cost sharing but up to a point. Once the low-income senior hit the so-called benefit gap--that is the donut we are talking about--the bottom fell out of the low- income safety net.

Seniors who could hardly afford food and rent would have to be responsible under that bill for half the cost of their drugs, a cost that most obviously could not be assumed. By some estimates, 30 percent of low-income seniors would fall into this gap.

In the bill before us, low-income seniors remain much better protected in this so-called gap. They pay higher cost sharing in the benefit gap, but their out-of-pocket expense would never go more than 20 percent above the cost of drugs, and for the lowest income seniors who are not eligible for full Medicaid benefits, cost sharing would not go above 10 percent. I think this is a good improvement.

I am also proud the chairman of the committee, Senator Grassley, and I have been able to increase the number of low-income seniors who will benefit from the extra subsidies. Our bill will provide assistance for Medicaid beneficiaries up to 160 percent of the Federal poverty level. An amendment was offered in committee to raise the poverty level to 160 percent. I wish it could go higher, but we are somewhat limited by the $400 billion we are working with in the entire bill. But at least we are up to 160 percent of the Federal poverty level. That means beneficiaries with an annual income of barely over $14,000--that is because they are not within 160 percent, just slightly over--are still struggling to provide for life's basics.

Perhaps one of the most important improvements in this bill is the assistance it provides for low-income seniors without subjecting them to assets tests.

Asset levels for elderly Medicaid beneficiaries and so-called QMBs and SLMBs are very low. Those are categories depending upon the percentage of poverty, so that if an individual has accountable assets of over $4,000, they are not eligible for assistance. A couple with assets over $6,000 is not eligible for assistance. These asset levels, which are based on SSI eligibility standards, have not been adjusted since 1989.

Asset tests exclude millions of poor Americans from Medicaid, and they would have excluded millions of poor seniors from many of last year's prescription drug subsidies. Think of it, an 80-year-old man with $800 a month in income might not be eligible for any assistance if his brother left him, say, a $10,000 car in his will. If he is married and he has paid life insurance premiums his whole life, the policy could prevent him from getting help with prescription drug benefits.

This proposal includes a subsidy category that is based only on income, not on assets. It is not as generous as the asset-tested categories, and I wish we could improve that, but it takes an important step toward covering more needy seniors and allowing them the dignity of keeping a car or a single precious heirloom.

We could do more if we had more money, but we do not have more money. We could eliminate the asset test altogether. We could provide better subsidies in the donut. We could provide more help to people who are still in need but who make $15,000 or $18,000 per year and have high drug costs.

Nevertheless, I am proud of the progress we have made over last year's low-income proposals, and I suspect with each new chapter in this prescription drug/Medicare book, we are going to be able to make improvements along the way.

This bill is a major improvement over current law. It is a major improvement over the low-income provisions in last year's bill. I urge this body to adopt this proposal.

I yield the floor.

Reserving the right to object, I suggest the absence of a quorum.

Reserving the right to object, I wonder if we could get some time to explain the amendments.

The second two votes will be 10-minute votes? I ask consent they be 10-minute votes, not the ordinary 15.

Mr. President, how much time remains on both sides?

Mr. President, I yield 5 minutes to the Senator from Michigan.

Mr. President, it goes without saying we live in a very complicated era. That is especially true with prescription drug pricing, health care costs, new technologies, and new health care technologies. You cannot turn on the evening news without seeing a new technology, some way to help people lead higher quality lives, and you cannot turn on the TV without seeing an ad where essentially a prescription drug is being advertised as a new drug to help make people's lives better.

It is very hard for people to know what to believe. It is also very difficult to know just what the right policy should be in Congress with respect to prescription drug benefits, more particularly what prices people should pay for drugs, and that is why we have deductibles, copays, and catastrophic coverage, and also what price Medicare should pay to the prescription drug companies when seniors are receiving benefits for drugs, and what the subsidy would be.

It is not easy. I commend the Senators who put together this amendment because this amendment says: OK, the brand-name drug companies, the pharmaceuticals have their patent protection, and there is a good reason for patent protection: Because it takes a long time to develop drugs, and it is expensive. But there comes a time when enough is enough, when 17 years--I think that is the number of years of patent protection--is enough.

Over the years, some of the drug companies have been able to prevent competition from working; that is, the generic companies come along to produce basically the same product, since the patent expired, but they are, in effect, denied the ability to sell at the much lower price because pharmaceuticals have multiple 30-month periods of stay. I am not saying this bill is perfect, but it is a great advance in helping beneficiaries and in helping the Federal Government get the best price, get the best buy for the drugs that are on the market that senior citizens are going to utilize and buy, one way or another, and Uncle Sam is going to buy.

I highly compliment the authors of this legislation. We will see how well it works. My guess is it is going to work pretty well. There are many efforts, Mr. President, as you know, around the country; many States are figuring out ways, with volume purchasing, to get lower prices for prescription drugs under the Medicaid program.

We do not want to kill the goose that lays the golden egg. The pharmaceuticals have provided our people with wonderful drugs. There is no getting around that. At the same time, everybody wants to get as much as he or she can for themselves--not everybody but a lot of people do. Certainly, in our competitive capitalistic system which works pretty well, companies are concerned about the bottom line, shareholders, quarterly reports, so they are going to try to make as much money as they can for the shareholders, and that is their responsibility.

In so doing, brand-name companies have taken advantage of the patent, taken advantage of current law. They have found a loophole, and this legislation is designed to close that loophole, so that after 17 years and the patent period has expired, companies can offer generic drugs, lower-priced drugs. That makes the most sense once the patent period has expired. It is going to help. This is a bill which has many different provisions. It is very complicated. We are entering a whole new era of prescription drug benefits and a whole new way to get them out to senior citizens through Medicare, through private plans, through PPOs, through HMOs, and trying to find the right balance between value for beneficiaries--that is stability, so our senior citizens know what they are getting on the one hand and efficiency on the other; that is making sure it is the lowest price possible.

This amendment before us does a pretty good job in striking that balance; that is, efficiency as a lower cost to seniors and the Federal Government because of generics, and also stability because it is done in a way that seniors have a better idea what they are getting.

I commend the Senators, and I yield the floor.

Mr. President, I just want to inform my colleagues that this

is a balanced bill. It has been very difficult to achieve that balance. I fear it is becoming more fragile as the days pass by. I think it would be very unfortunate if this bill fell apart.

I am not saying, by any stretch of the imagination, that the amendment offered by my very good friend from South Dakota is going to tip the balance of the bill, but I am saying--knowing of other amendments that are coming up, and the views that various Senators are taking on the amendments they may offer later on--this balance, this bill which I think we all want to support, is not in jeopardy yet but it is somewhat tenuous.

There are protections in the bill for premiums. A couple quick points: One, under the bill, there are large geographic areas, which will tend to force the premiums to not fluctuate but to be according to insurable principles.

Second, there are very strong consumer protections that are basically the FEHBP protections which provide premiums have to be in line with benefits. That is under FEHBP. We incorporated that in the bill.

There is also a geographic adjustment in the bill. Right now, the Secretary has discretion to make the geographic adjustment. That might be strengthened later on in the proceedings.

I am sympathetic with the purpose of this amendment, but my judgment is, at this time, we should not adopt this amendment because there are sufficient protections in the bill, and I do not want this bill--I do not think any Senator wants this bill--to go south because of other amendments that may be adopted that may cause that to happen.

This is a historic moment. We are on the eve, the cusp of passing prescription drug benefit legislation. We should not take that lightly. I know we don't. I think we want a big vote. Medicare passed by a large margin back in 1965. Many Senators are saying there is a chance this underlying bill could get 60, 70, 80 votes. I say to my colleagues, I think we owe it to ourselves to try to find a way to help pass this legislation by a large margin.

Mr. President, if I understand the drift of things, obviously Senators can reserve, we can work this out. I ask consent that the Senators from New Jersey be given 10 minutes to speak on a very important subject; following that, the Senator from North Dakota be authorized on his amendment to follow the order in the earlier unanimous consent.

Mr. President, I don't see any more speakers who wish to speak on the second-degree amendment. Am I correct in suggesting that the regular order is now to vote on the second-degree amendment?

Mr. President, I think we are ready to vote.

Amendment No. 947

Mr. President, I suggest the absence of a quorum.

Mr. President, first I very much appreciate the kind words by the chairman of the committee. It is wonderful working with the Senator from Iowa. He is a good man.

With respect to the point made by the chairman, I agree. I think it makes sense at this time, since we are still trying to get papers ready, for the Senator from Idaho to proceed.

Mr. President, first, I congratulate the Senator from Michigan. She has worked very hard and, I might add, effectively in helping make this a better bill.

Everyone in this body wants legislation passed that gives good, solid prescription drug benefits to seniors.

The debate is somewhat over delivery; that is, how we set the plan up, who provides the benefits and so on. The bottom line is the same for all of us. We want good, solid prescription drug benefits for seniors.

The Senator from Michigan is probably as well-versed in this subject and more of an advocate for seniors than any other Member of this body, or at least as much as any other Member of this body. I thank her very much for what she has done.

The issue basically is that we have roughly $400 billion to spend over 10 years, and the question is how we best assure that seniors get those benefits. Now, $400 billion over 10 years may sound like a lot of money to some folks but when it is cranked out in terms of deductibles, copays, premiums and benefits, it is really a modest benefit for seniors. It is not a lot of money.

Some other programs give much more generous prescription drug benefits than is called for under this legislation. For example, under TRICARE, that is the military plan, military retirees receive substantially more benefits than are called for under this bill. The same is true for the VA. If the U.S. Government, under this legislation, were to provide the same benefits for seniors generally that the military does under TRICARE, this bill would not be $400 billion, it would be upwards of $800 billion to a trillion dollars, which gives one a sense of the difference.

The VA's benefits are greater. The Federal Employees Health Benefits Plan, FEHBP, provides drug benefits that are greater than called for under this bill.

I mention that so the expectations are not raised too high that this legislation is going to be the be-all and end-all, that it is going to help seniors with all their drug expenditures. It will not, but it is a first step. It is a major advancement in helping seniors get their prescription drug benefits.

There will be many bills later on in the next several years as we address ways to improve our health care delivery system generally, on how we can help improve prescription drug benefits to seniors more specifically, but we are operating under a bit of a constraint and the constraint is $400 billion. That is what we in the Congress agreed to, $400 billion on the Senate side for prescription drug benefits for seniors.

Under that constraint, we have to work very hard to try to achieve some balance. One goal is stability, another is efficiency. What do I mean?

Under stability, we clearly want this program to be as stable as possible so seniors know what they are getting for the premiums they will be paying. This is a voluntary program. Seniors are not

required to sign up. What we want is a stable program. We do not want a program that is changing a lot. That is unsettling to seniors.

We also want to achieve efficiencies. By that I mean lower some costs. The Medicare Program is growing exponentially. We all know that not too many years from now, when the baby boomers start to retire, we are going to face some significant challenges on how we address Medicare payments generally, which certainly will include some prescription drug benefits. We want to try to cut costs, and the idea that a balance is struck between stability and efficiency is essentially one where both private plans and the U.S. Government participate.

I strongly wish we were able to have more dollars to spend so we would have more stability and have a program that more closely resembles the military's TRICARE plan or the Federal Employees Health Benefits Plan or the Veterans' Administration plan, and even some private plans, but we do not. We are taking this steadily, a step at a time.

The Senator from Michigan has a good idea. Her idea is that in the interest of stability, as opposed to efficiency, that any senior would have the right to participate for life in the Government-sponsored plan as opposed to the private sector. We in the Finance Committee have labored mightily to try to find the right balance, and the right balance is not easy to find, I must say. We have Senators from one side of the spectrum and Senators from the other side of the spectrum bending my ear and bending the ear of the chairman. Quite often, our ears are bent so much we wonder if there is any rubber left in them. We have been talked to.

I have been talked to very much by the wonderful Senator from Michigan about her amendment. If I had my druthers, it would be something I would prefer, but we are a bit constrained. I do not know that I can support the amendment for that reason because we are trying to keep a balance.

I do want to highly commend the Senator for the great effort she has undertaken. She has clearly helped advance the ball in many ways. She will continue to advance the ball, there is no doubt in my mind. She is a great Senator for the people of the State of Michigan.

I yield the floor.

Madam President, if I am not mistaken, the pending amendment is the one offered by the Senator from Michigan. I see the Senator from Florida, Senator Graham, who would like to address the Senate.

I move to lay that motion on the table.

The motion to lay on the table was agreed to.

I suggest the absence of a quorum.

Madam President, I ask unanimous consent that the order for the quorum call be rescinded.

Mr. President, we are now on the Enzi amendment. I ask unanimous consent that the Enzi amendment be temporarily set aside so that at 4:20 the Senate can proceed to an amendment offered by the Senator from New Mexico, Mr. Bingaman.

I also ask that there be 30 minutes on that amendment equally divided in the usual form.

Mr. President, I withdraw the second request. So the only request pending, which I think the Chair has ruled on favorably, is that we go to the Bingaman amendment at 4:20.

I thank the Chair.

Mr. President, pending 4:20, when the Senator from New Mexico will offer his amendment, I rise to speak about the rural provisions in the Medicare bill.

This bill has a lot of provisions to help rural America. I am very proud of these provisions. I also wish to compliment the chairman of the committee, Senator Grassley. Over the last year, he and I have jointly co-authored legislation to address the imbalance in Medicare payments that exists between rural and urban areas of our country. For many rural areas of our country, providing health care services is very challenging given Medicare's current payment rates.

In rural America, Medicare often dominates. That is, most hospitals, doctors and other health care providers receive the lion's share of their reimbursements from Medicare. I know that in many communities in Montana, particularly the smallest communities, Medicare accounts for over more than 50 percent of hospitals total reimbursements. This share is also as high in some larger towns, but certainly more the case in smaller towns.

Rural hospitals are often the major employer in their communities. It is what makes the small town tick. If it were not for the rural hospital, the population in those towns would deteriorate. I have seen that happen in a good number of communities in Montana, where the hospital--fewer than 20 beds in many cases--is the major employer in the town.

Once Medicare payments start to decline significantly, as is the case in many areas, that smalltown hospital has to close up, or converts to what is called a critical access facility and is no longer the full service hospital it was. So it is very important that rural America be adequately reimbursed under Medicare.

In addition to Medicare reimbursements, I believe we have also provided assistance to rural areas with respect to our proposed drug benefit. I believe that the drug benefit outlined in this bill will work for rural America. For example, if private drug-only plans do not materialize, our bill provides for a hard and fast fallback, a Government guarantee for rural seniors. This guarantee is important because many rural States have had an unfortunate experience with Medicare+Choice, the program that currently allows private health plans to participate in Medicare. But because there are so few people in rural America, HMOs and other Medicare+Choice plans, have found it too difficult to operate and have withdrawn.

I do not have the figures with me off the top of my head, but there are thousands of people in rural areas who once had access to a Medicare+Choice plan but no longer have that opportunity because the areas are just so sparsely populated for health plans to work. That is a real concern with respect to the prescription drug benefit we are providing in this bill; namely, will private drug plans, in addition to the preferred provider organizations, want to offer prescription drug benefits in rural America or not? It is a big question, and it is an unanswered question.

We hope they do want to come in and participate. We hope private plans that currently do not now exist will, under the provisions of this bill, when it goes into effect in a few years, want to provide prescription drug benefits for seniors. We hope that many plans want to come in and compete with each other to help reduce costs.

There is no great assurance that these private plans will reduce costs. If one looks at the HMOs, they currently are paid at a higher rate than what Medicare pays for beneficaries in the fee-for-service program. Some can make a strong argument that these private plans are going to cost more. The theory is that competition will allow them to bring down costs and provide the same benefits for seniors. So it is an unanswered question. People just do not know the degree to which these private plans are going to work. Therein lies the question: What about those parts of America where private plans do not participate? What about those seniors? How can we assure that they are going to get prescription drug benefits? The bill before us tries to address that.

The bill addresses this question by providing for a guaranteed fallback plan. In those parts of the country where there are not two or more competing private drug plans, government-backed fallback plan is guaranteed. Seniors will be able to get the prescription drug benefits under pharmacy benefit manager (PMB), or similar organization that is not required to bear insurance risk. It will only be required to bear performance risk for the administrative costs of providing the benefit. The fallback plan will not bear insurance risk as required of the private drug plans.

The purpose of the fallback plan is to make sure that rural America-- in fact, any part of America where there are not two private plans--is served fairly by this prescription drug program.

As I mentioned, the bill includes many provisions to address the current imbalance in Medicare reimbursements between urban and rural America. One provision would correct differences in the standardized amount rate for inpatient hospitals. The standardized amount is higher for urban hospitals than for rural hospitals. The provision says that Medicare should pay the same across the board. Clearly, there will be other adjustments that affect different circumstances and different parts of the country, but the standardized amount would be the same rate for both urban and rural hospitals. That is extremely important to many hospitals in rural areas.

Last year's appropriations bill equalized the standardized amount for a 6-month period. This bill makes that permanent. It is a change that the Medicare Payment Advisory Commission, or MedPAC, has recommended that Congress make. This bill this and other MedPAC recommendations to heart by saying, You are the experts, you know better what is going on than anyone else.

This bill contains a couple of other important MedPAC recommendations. For example, it raises the Medicare disproportionate share threshold for rural hospitals. The Medicare DSH program says if you are a hospital and

have a disproportionate number of people under Medicare who are low income, you should receive extra assistance under Medicare. Our bill raises that threshold for rural hospitals a little higher.

The bill also adjusts payments for hospitals with very low patient volume. We know volume is a big component of whether a hospital is able to make ends meet.

The bill extends the rural home health add-on payment at a level of 5 percent. Home health care is extremely important in rural America.

This bill includes other provisions that not necessarily rural specific. For example, the legislation increases payments to dialysis providers, including those in urban areas, for a 2-year period.

The bill provides desperately needed assistance to urban hospitals that provide a disproportionate share of services to low income individuals. These hospitals are struggling with growing pressures of more uninsured and low income patients. It is not fair for those hospitals that have to bear these costs. They have to provide charity care. In fact, in many respects under the law they are required to. This gives them a bit of a break with these burdens and their nursing shortages

The bill provides much-needed regulatory relief for both rural and urban hospitals. We have heard from doctors and hospitals that say the carriers and fiscal intermediaries are too heavy-handed; they assume physicians and providers are guilty when they question reimbursement, instead of assuming we are innocent. The regulatory relief measures in this bill address this concern. These provisions are significant and go a long way to assure providers spend less time on paperwork burdens and more time with their patients.

Some may say that this bill does not go far enough to relieve these burdens. A lot of doctors and hospitals administrators will say: Gee, why all this Medicare paperwork? We want to spend time with our patients. Nevertheless, the regulatory provisions of this bill will reduce paperwork and unnecessary regulation.

I realize there are a number of provider provisions--with respect to doctors and hospitals and other providers--that are not addressed in this bill. These provisions include payments under the Medicare physician fee schedule, which will be cut in 2004 through 2007 unless further congressional action despite an additional $54 billion in the bill we passed earlier this year. We recognize the need to address these impending cuts in the future. Physician's fees are projected to drop significantly. We cannot address that in this bill. We do not have the money. That is a problem we will have to face in 2004. I alert Senators, that will be expensive. We will have to deal with it.

There are also Senators who want to address what is called IME, or indirect medical education. This is the special payment adjustor under Medicare for teaching hospitals. It is now currently reduced to its lowest level ever. That is, teaching hospitals are receiving less to help train physicians across the country. That is a concern many have. We are going to try to deal with that as best we can as this bill progresses.

Nursing home payments are not addressed. Many Senators have talked about addressing some of the problems facing nursing homes. They, too, experienced a sharp reduction in payments over in 2003. This list of payment provisions is not limited. There are several other provider provisions about which many Senators have raised concerns.

Our ability to deal with these additional issues is limited. Why? Because this is a $400 billion Medicare package. The fact remains, this is a package of relatively sparse drug benefits. Yes, $400 billion sounds like a lot of money, and it is. But $400 billion extended over 10 years, means that we have to carefully consider what the amounts should be for the deductible, copayments, and the premiums. The numbers are OK, but they are not great.

I don't want to oversell this bill or over promise. This legislation is a step in the right direction. This is a good first chapter. It is a start in providing prescription drug benefits for seniors. We only have $400 billion so we have not been able to address these other provisions. We would like to. We would like to find a way to deal with them. But at this time, the dollars are simply not there.

I might add, we will do what we can in future days, weeks, and months to try to address these concerns.

I know the chairman of the committee, Senator Grassley, wants to work with our colleagues to address these provisions and also provide a fair deal for rural, as well as urban, folks in America. We want to address future geographic inequities with respect to the drug benefit. The fact is, rural States are very concerned if we enact this prescription drug benefit, are going to come out on the short end of the stick. More federal money will end up going to go to urban seniors. That will cause a great problem.

At the same time, seniors in urban areas are afraid the money will go to the rural areas, that the urban cities will end up on short end of the stick. The fact is, we do not know how it will work. We just don't know. Senator Snowe offered an amendment in the Finance Committee for a study to address possible geographic inequities in drug spending across the country. She later amended it, made it a little stronger, to say that HHS will have the discretion to address any geographic inequities. There may be an amendment on the floor to require the HHS Secretary to address the inequities.

It is a point about which we are all very sensitive. We are trying to find a way to make this geographic adjustment process work. Geographic adjustment for drug spending has never been tried before. It is uncharted territory. We just don't know. It probably makes sense the Secretary have discretion.

That is a short summary of some of the rural provisions in the bill. I see the Senator from Texas is on the Senate floor. Does the Senator from Texas wish to speak at this point?

I yield the floor.

Mr. President, let me begin by praising the chairman of the Senate Finance Committee, Senator Chuck Grassley, for his fine leadership and cooperative management of this bill. He has been very good. I know the folks in Iowa know that, but I want everybody else tuning in to know it as well. The chairman of the Senate Finance Committee, Chuck Grassley, has done a tremendous job. He deserves a lot of praise for this bill.

On that point, sometimes we fail to recognize just how historic some legislation is. This is truly a historic bill. This is not some garden variety piece of legislation that has come up and will pass in the Senate. This is a major expansion of Medicare--major. It is going to make a huge difference in the lives of many senior citizens in America. I again thank Senator Grassley for his help putting this together.

I also thank many Senators who have helped bring us here today. Senator John Breaux from Louisiana has been tireless in his effort on the Medicare Commission and other efforts to get prescription drug benefits and to try to reform Medicare. His work has been indispensable.

Senator Olympia Snowe from Maine, Senator Hatch from Utah, Senator Jeffords from Vermont, have all contributed mightily to these efforts. It would take me a long time to go through all the efforts they have undertaken if I were to recite chapter and verse all they have done. It has been monumental.

Any discussion for the long struggle for improved health care in America would be absolutely incomplete without the mention of the longstanding effort of the Senator from Massachusetts, Mr. Kennedy. Senator Kennedy is on the floor. He is probably going to speak a little later. Without Senator Kennedy and his efforts, I am not so sure we would be here today, on cusp of passing truly historic legislation.

We are here today to make a meaningful improvement in health care for our seniors. That is why we are here. We are here at last to bring prescription drug coverage to Medicare.

On July 30, the Nation will celebrate the 38th anniversary of the enactment of Medicare. Without exaggeration, Medicare is simply one of the most successful enterprises ever taken by a free people working through their government. Today we are about the business of making it even better.

Medicare took a long time in coming. Following the enactment of Social Security in 1933, progressives called unsuccessfully for a program of national health insurance. President Harry Truman repeatedly advocated national health insurance funded through payroll deductions, but as we know, his plan went nowhere. But the fact remains, retired Americans had a particularly difficult time getting health insurance in the private sector.

In 1951, planners at the Federal Security Agency, recognizing that difficulty, examined extending health insurance to this population. The idea slowly gained popularity in the 1950s.

Senator John Kennedy raised health care as a campaign issue in his successful 1960 Presidential campaign. Taking the reins of the Presidency from his fallen predecessor, President Lyndon Johnson spoke of moving, ``not only toward the rich society and the powerful society, but upward toward the Great Society.''

At the height of legislative action of President Johnson's Great Society in July 1965, Congress enacted Medicare into law in the Health Insurance for the Aged Act. With President Truman at his elbow, President Johnson signed the bill in Independence, MO. President Johnson at that time said, ``No longer will older Americans be denied the healing miracle of modern medicine.''

And President Truman told President Johnson, ``You have made me a very happy man.''

Since then, over the nearly four decades of its life, Medicare has improved the lives of over 100 million Americans. Medicare now provides health insurance coverage to more than 35 million seniors, virtually everyone aged 65 or older, and 6 million disabled enrollees for hospital or related care under the

Hospital Insurance Program. It covers nearly as many for doctors' services, outpatient hospital services, and other medical expenses under the Supplemental Medical Insurance Program.

Medicare has been a success. Health care expenses used to impoverish seniors. In conjunction with Social Security, Medicare has significantly reduced poverty among seniors. Despite progress on poverty among seniors, they are by no means an affluent group. From 2001 data, we can see that nearly two-thirds of Social Security beneficiaries rely on Social Security for most of their income. A third of beneficiaries rely on Social Security for 90 percent or more of their income. In 2001, the median income for all eligible households was $19,000, and one-fifth have incomes under $10,000; thus, vast numbers of America's seniors need Medicare and Social Security to keep out of poverty.

With the nearly universal health insurance coverage and decreasing poverty achieved by Medicare and Social Security, seniors are also living longer. Before Social Security and Medicare, in 1930, for example, a 60-year-old had a life expectancy of 77 years of age. In the year 2000, 70 years later, a 65-year-old-man could expect to live to 81 and a 65-year-old woman could expect to live to 84. Partly because of Medicare, more and more Americans are living into their late eighties and into their nineties.

Medicare has also improved the quality of seniors' lives. It has helped them to combat debilitating illnesses. It has helped them be free from pain. It has helped them to live fuller, better lives.

But the practice of medicine has also progressed since Congress set up the structure of Medicare. Prescription drugs have taken on a much greater role in maintaining health, replacing procedures, as has more prevention. Prescription drugs are just proportionately so much more important today than they were when Medicare was created.

The Congress that created Medicare did not envision that role of prescription drugs. Although former employers and other private insurance plans cover some seniors, about 10 million seniors have no prescription drug coverage at all.

Because seniors are not a wealthy group, for many this reality means a painful choice between filling their prescriptions and buying food.

I visited a community health center and talked to an internist--a doctor--the administrator of that health center. She told me she had to cut back on her medicine. She has to give up some of her medicine. Why? In order to pay for the medicines for her mother. Just think of it. A doctor who has to cut back on medicines for herself because they are so expensive and because her mother can't afford them. The doctor is sacrificing her health care to make sure her mother has prescription drug benefits. That is not an isolated incident. It is happening over and over again in America, and it is wrong.

Seniors should not have to choose among necessities in order to maintain their health. We can do something about that today.

To maintain Medicare's success, we must expand it to address the health care delivery structure that we have today. The bill that we bring to the floor would take a substantial step in that direction.

This bill would make available Medicare prescription drug insurance universally to all seniors. It maintains the important principle of universalism that has held together the remarkable social compact of Medicare and Social Security.

This bill would ensure that 44 percent of Medicare beneficiaries-- those with the lowest incomes--would have truly affordable prescription drug coverage with minimal out-of-pocket costs. For these lower-income seniors with incomes up to 160 percent of the poverty level, co- payments would never exceed 20 percent of the cost of drugs.

Just think of that--never more than 20 percent.

This bill would make it so that an elderly retired couple in Great Falls, MT with an income of $16,000 a year, would be able to buy their prescription drugs without ever having to pay more than 10 percent of the cost of the drugs.

This bill would thus ensure that those who have been least able to receive what President Johnson called ``the healing miracle of modern medicine'' would now be able to do so. Millions of people would have a better quality of life. Lives would be saved.

This bill would create a strong government fallback. Seniors would have access to at least two private plans for a prescription drug benefit or the government would provide a standard fallback plan. If there is no true competition, then traditional Medicare would provide a fallback.

Now some have raised fears that the competition that this bill seeks to foster would lead to the privatization of Medicare. This is not so. The Department of Health and Human Services would continue to oversee these plans. The plans would operate within tightly-controlled limits. This bill includes strong consumer protections.

This bill does not tilt the playing field. This bill does not make private plans a better deal than traditional Medicare.

But those of us who believe in traditional Medicare should not fear the entry of private options. For either they will work and make things better for beneficiaries, or traditional Medicare will still be there. It is another opportunity. Either private plans will deliver the efficiencies that their advocates on the other side of the aisle promise for them--in which case the beneficiaries who choose them will get more value for their contributions--or traditional Medicare will still be there.

Others have found fault with the costs that this bill would ask beneficiaries to pay. Some have focused on what they call a break-even point--of a little more than a thousands dollars in drug spending-- below which higher-income beneficiaries would spend more on the plan than they would receive in benefits. Yes, from a third to half of beneficiaries might spend more in a given year than they receive in benefits. But that means that from half to two-thirds will get more in benefits than they spend.

But it should not be surprising that some will pay more in premiums than they receive in benefits. That is the nature of insurance. We pay for insurance to protect against the risk of something that we hope will not happen. Most of us would be thankful if we do not encounter the ailments that require us to use our health insurance. Many would count that a blessing.

But this bill would provide a substantial subsidy for the health insurance need of Medicare beneficiaries. That is the nature of the cost of this bill. We as a society are choosing to make this insurance available at a substantial subsidy to all seniors.

For millions of Americans who are less fortunate, who have lower incomes and health needs, this bill will make a dramatic difference. For the 44 percent of Medicare beneficiaries with lower incomes, this plan would provide very affordable benefits. And remember that this lower-income population includes precisely the group most likely to be doing without prescription drug coverage today.

I acknowledge that some may have legitimate concerns with this bill. I note, in particular, that I and other drafters of the bill have become struck by CBO's high estimate of the percentage of beneficiaries whose former employers would drop their coverage, if Medicare started providing it. I would also like to find a way to make it so that seniors who were in a fallback plan could stay with that plan longer. I, for one, will look for opportunities during this process to address these concerns and improve the bill.

But this bill would create a $400 billion expansion of a major entitlement program. Yes, we could have done more with more money. But this is a historic opportunity to make a fundamental change for the better, for millions of Americans.

In so doing, this bill would finally do something that the overwhelming majority of industrialized nations have already done; that is, provide prescription drug benefits to their seniors.

Medicare took a long in coming. But it came quickly when it did. Sometimes, the time is simply ripe.

The Health Insurance for the Aged took several decades to come to the Senate floor in 1965. But when the Senate took it up in 1965, it finished its debate in 4 days--July 6 through July 9 of 1965--and passed the bill with 68 votes.

Starting today, we will spend 2 weeks on this debate. And we should. And I look forward to a full and open airing of the issues.

But in the end, I also look forward to passage of this new benefit, with substantial support from both sides of the aisle.

The time was ripe in the summer of 1965, when Congress enacted the Health Insurance for the Aged Act and created Medicare. I believe that the time is ripe again, today.

The time is ripe for a new chapter in the successful story of Medicare. And we begin that chapter today.

I yield the floor.

Mr. President, I rise today to echo the condemnations of the military rulers of Burma that my colleagues have so forcefully offered.

Burma should by all rights be a prosperous country. It has over 50 million people, abundant natural resources, and a population hungry for democracy.

Instead, it is an international outcast, ruled by a few military men who finance their country through drug trafficking and forced labor.

Perhaps most egregious is the failure of the military rulers to recognize the results of a free and fair election in which the Burmese people overwhelmingly chose Aung San Suu Kyi as their leader. Rather than sitting at the head of a democratic Burmese Government, she is sitting in a Burmese jail, a prisoner of the military rulers.

The existence of a democratically elected government-in-waiting makes Burma unique, but that is not all that makes Burma unique.

Suu Kyi has consistently supported sanctions against the military rulers of Burma, and 3 years ago, the International Labor Organization, for the first time in its 82-year history, urged the world to impose sanctions against those rulers.

The bill we consider today will send a strong message to the illegitimate military regime in Burma that their recent actions in attacking Suu Kyi and her followers and imprisoning Suu Kyi are intolerable. A unanimous passage would send that signal loud and clear.

These sanctions would be most effective if the whole world joined us. Unilateral sanctions can send a strong message, but they are rarely effective. In fact, they can even end up unintentionally adding further misery to an already oppressed people while leaving their rulers unscathed.

Multilateral sanctions, on the other hand, can have a dramatic effect. I know that others are considering sanctions, including the European Union. I applaud their attention to this issue and urge them to act as we have acted.

I also urge the administration to work with our allies, particularly those in the region, to create a united front of sanctions against the military rulers of Burma. We must work toward multilateral support.

Importantly, this bill ensures that Burma will never fade from congressional minds. We will not simply impose sanctions now and then forget all about Burma.

Every year, we will vote on renewing sanctions. Every year, we will be talking about Burma and how best we can work to aid those working for democratic change in that country.

The military rulers of Burma should know that their crimes against Suu Kyi, her followers, and the Burmese people will be neither forgiven nor forgotten.

I appreciate the leadership of Senators McConnell and Feinstein on this issue. They deserve our thanks for consistently bringing the important issue of human suffering in Burma to the attention of this body.

I would also like to thank Senator Grassley. He and I worked hard to make changes to this bill that, in my view, make it better.

I urge my colleagues to pass this bill unanimously today, and I urge the House of Representatives and the President to act soon to pass this bill into law. Let's send the strongest signal possible to the illegitimate regime in Burma.

Mr. President, reserving the right to object, this is obviously a very important matter, and we should address this in a very careful and appropriate way. I might say to Senators, this matter has not been referred to the Senate Finance Committee. The committee has jurisdiction on it. Rather, it is coming straight to the floor with a request that there be no amendments, which I think is a little bit bizarre.

I might also point out that in other sanctions areas, for example, China, we had a long, deep, involved debate a few years ago and agreed to how we should address sanctions, particularly trade sanctions against China.

I might also inform Senators, I have been in consultation with the chairman of the Finance Committee who agrees with me that it would be inappropriate to proceed at this time, certainly in the manner suggested by the Senator from Kentucky.

I might ask the Senator if he will agree to modify his request in a way I think is much more appropriate, particularly even stronger than the resolution suggested by the Senator. And that would be for similar, as was the case with China MFN, annual extensions or annual sanctions, but that the President would suggest that the sanctions be continued and that would be the case unless there is a motion of disapproval passed by both Houses of Congress. I believe the executive branch should be part of this. This is not just a legislative branch issue. When it comes to sanctions, clearly the executive branch should play a very important role.

I might ask the Senator if he would agree to modify his request in the nature of an annual request. If the President wants to continue, he certainly could make an annual request, and that would be subject to disapproval by both Houses of Congress.

Is the Senator agreeable to make that change?

Mr. President, is it correct that the order provides for 30 minutes equally divided?

I yield 10 minutes to the Senator from Arkansas. I might add, she is the prime mover of this bill. She is the one who made that happen. We are deeply indebted to her.

Mr. President, how much time remains on each side?

Mr. President, I rise to support the bill offered by my good friend, the senior Senator from Arkansas, Mrs. Lincoln, and my good friend from Maine, Senator Snowe. Their legislation ensures that our military and low- and middle-income parents will receive a check from the child tax credit.

The legislation repairs the damage done by the majority in the tax bill conference. Senator Lincoln was successful in getting this provision included in the $350 billion tax bill that passed the Finance Committee and the Senate. But the provision was specifically stripped out before passage of the final version of the $350 billion tax bill.

Let me give you some examples of who does not benefit from the tax bill that was signed into law by President Bush last week.

First, a 24-year-old single mom with one child. She works hard every day to put food on the table, buy clothes for her daughter, and ensure adequate childcare for her daughter while she is at work.

She makes $15,000 a year. She pays $1,150 per year in payroll taxes. She pays $1,150 in Federal taxes yet gets zero benefit from the recently enacted tax bill. She will not see any check this summer.

Taxes are taxes. I would like to see someone tell her that her payroll taxes are less of a burden to her than an equal amount of income taxes paid by Bill gates.

Senators Lincoln and Snowe fixed that problem. The fix means $225 in her pocket this summer.

She sees a big chunk of her paycheck every week getting paid to the Government. She also pays a lot of other taxes--including sales taxes, excise taxes, and property taxes. She deserves equal treatment.

My second example illustrates the impact for military families. The Department of Defense has estimated that there are approximately 192,000 military families who earn between $10,000 and $25,000. And most of those 192,000 military families will not receive any tax relief from the $350 billion tax bill.

To make matters worse, the families of military personnel who are stationed in combat zones are really left out of the big tax cut.

In my second example, a Marine gunnery sergeant with 8 years service is stationed in Afghanistan for the last 6 months of 2002, and in Iraq from January through March of 2003. She has two children.

She receives an annual salary of $32,015 and hazardous duty pay of $150 per month. Because the income earned by our military while they are stationed in a combat zone is not included in taxable income, only $24,000 of her income is subject to tax. Under the bill that was passed last week, the check she gets this summer will only be $150.

I am pleased that at least she will see something. But if the Lincoln child tax credit had been preserved in the $350 billion tax bill, this Marine gunnery sergeant and her family would receive a check for $800 this summer just like the President has promised to other middle-income families. Unless we fix the problem, she will not see a dime of this.

The Lincoln/Snowe legislation ensures that we count a soldier's combat zone compensation for purposes of the child tax credit, even though that income is excluded for purposes of the income tax.

These examples illustrate just how unfair the tax bill was.

The big tax bill was not fair to working Americans or our military personnel. Clearly, the benefits were skewed heavily to the elites of this country.

One of the beauties of America is that we work to treat people equally. But the $350 billion tax bill did not come close to treating all Americans equally. Simply put, it was not fair.

Instead, the choice was made to lower the tax for dividend and capital gain income, rather than extend the child tax credit to hard- working, low-income taxpayers.

The bill that returned from conference--the one that was signed into law--also stripped out other provisions to provide tax relief to those serving our country in the armed services--those serving in Iraq, in Afghanistan, and all across the globe.

It is disturbing that we can pass this tax bill with all these benefits for the elite of our country. But the conferees specifically stripped out a provision that would exempt $6,000 of death benefit payments from income for our military families.

And, they specifically stripped out the child tax credit provision that put money into the hands of our military and lower and middle- income families.

There is no way around it. The big tax bill was simply unfair.

Senators Lincoln and Snowe are giving us the chance to right one of the wrongs--without increasing the deficit. Enactment of their legislation ensures that 12 million children are helped.

Without their legislation, the families of 8 million children will see absolutely no benefit from the increased child credit that was signed into law last week. These families will not receive any check this summer.

And, millions more families will see a check much smaller than the $400 promised.

In Montana, 54,000 kids--fully one-quarter of the children in Montana--will not benefit from the $350 billion tax bill. But the Lincoln/Snowe legislation would get a check out--this summer--to the working parents of thousands of Montana children.

Their legislation gets the child tax credit to millions of parents-- without saddling their children with huge Government deficits--and without robbing the Social Security trust fund. They fix a $3.5 billion problem, and pay for it.

Unfortunately, some in the Republican leadership considered using this as an opportunity to spend another $130 billion in tax cuts. That was their idea of a ``fix.''

Moreover, they did not intend to pay for these extra tax cuts. Instead they wanted our children and grandchildren and our Nation's seniors to shoulder more of the burden.

In the past couple of days, we have been able to reach an agreement to correct the wrong created with the passage of the recent tax bill. I strongly support the Lincoln/Snowe child tax credit legislation. I urge my colleagues to stand united to get this legislation enacted into law this week. These families should not be asked to wait any longer.

They deserve to get their check this summer--just like all of the parents who were taken care of under the $350 billion tax bill.

This is the right thing to do. This is the fair thing to do. This is the moral thing to do.

Again, I thank the Senator from Arkansas, Mrs. Lincoln. She has done a terrific job highlighting this issue and the need for this child tax credit provision.

Second, Senator Snowe, as I have mentioned several times, has been tremendous in championing this cause. And I might say, with regard to the 2001 tax bill, she deserves the lion's share of the credit for the child tax credit provisions that are in that bill.

The chairman of the committee, Senator Grassley, has been, as usual, just his terrific self in working with the various Senators to try to find an accommodation that makes sense.

I also thank Senator Warner who focused on the impact of this bill on military families. In that respect, the bill will permit thousands of military families, especially those serving in combat zones, to benefit from the child credit. Without this provision in this pending measure, those military families would not get the benefit of the credit.

Finally--I know time is of the essence here--it is imperative that the House act on this matter within 2 weeks so that the checks can get to the millions of families covered by this bill. Otherwise, two sets of checks would have to be sent out, and I think that would be the height of inefficiency and a waste on the part of Uncle Sam. That would be the consequence of the failure of the other body to act within 2 weeks. So I call on the House to act.

I see the Senator from Virginia, the chairman of the Armed Services Committee. I yield the rest of any time I have to him.

I beg your pardon.

Mr. President, I yield back the remainder of my time.

Mr. President, I ask for the yeas and nays.

Mr. President, I am pleased to join my colleague, Senator Santorum, and my other Senate colleagues in introducing legislation to permanently extend and improve upon the Work Opportunity and the Welfare-to-Work tax credits. During this year's debate on the Jobs and Growth Tax Reconciliation Act, I voted to extend these tax credits were not included in the final conference agreement, but I continue to strongly support the passage of legislation this year to make these credits permanent and make several reforms in the programs to improve their effectiveness.

Over the past seven years, the Work Opportunity Tax Credit, WOTC, and the Welfare-to-Work, W-t-W, tax credit have helped over 2.2 million public assistance dependent individuals enter the workforce. Both of these important programs are scheduled to expire on December 31, 2003. These hiring tax incentives have clearly demonstrated their effectiveness in helping to level the job selection playing field for low-skilled individuals by providing employers with additional resources to help recruit, select, train and retain individuals with significant barriers to work. Many vulnerable individuals still need a boost in finding employment, and this is particularly critical during periods of high unemployment. The weak economy and rising unemployment give employers many more hiring options because of the larger pool of experienced laid-off workers. Without an extension of these programs, the task of transitioning from welfare-to-work will become even harder for individuals reaching their welfare eligibility ceiling this year.

Because of the costs involved in setting up and administering a WOTC/ W-t-W program, employers have established massive outreach programs to maximize the number of eligible persons in their hiring pool. The States, in turn, have steadily improved the programs through improved administration. WOTC has become an example of a true public-private partnership design to assist the most needy. Without the additional resources provided by these hiring tax incentives, few employers would actively seek out this hard-to-employ population.

WOTC provides employers with a graduated tax credit equal to 25- percent of the first $6,000 in wages for eligible individuals working between 120 hours and 399 hours and a 40-percent tax credit on the first $6,000 in wages for those working over 400 hours. The W-t-W tax credit is geared toward long term welfare recipients and provides a 35- percent tax credit on the first $10,000 in wages during the first year of employment and a 50-percent credit on the first $10,000 for those who stay on the job a second year.

In my own State of Montana many businesses take advantage of this program, including large multinational firms and smaller family-owned businesses. Those who truly benefit from the WOTC/W-t-W program, however, are low-income families, under the Food Stamp Program and the Aid to Families with Dependent Children, AFDC, and Temporary Assistance for Needy Families, TANF, program, and also low income U.S. Veterans. In Montana, more than 1,000 people were certified as eligible under the WOTC program during the past 18 months, October 2001 through March 2003, including 476 Food Stamp recipients, 475 AFDC/TANF recipients, and 52 U.S. veterans.

The bill we are introducing provides for a permanent program extension of the two credits. After seven years of experience with WOTC and W-t-W, we know that employers do respond to these important hiring tax incentives. Permanent extension would provide these programs with greater stability, thereby encouraging more employers to participate, make investments in expanding outreach to identify potential workers from the targeted groups, and avoid the wasteful disruption of termination and renewal. A permanent extension would also encourage the state job services to invest the resources needed to make the certification process more efficient and employer-friendly.

The bill also includes a proposal to simplify the programs by combining them into one credit and making the rules for computing the combined credits simpler. This would be accomplished by creating a new welfare-to-work target group under WOTC. The minimum employment periods and credit rates for the first year of employment under present work opportunity tax credit would apply to W-t-W employees. THe maximum amount of eligible wages would continue to be $10,000 for W-t-W employees. In addition, the second year 50-percent credit under W-t-W would continue to be available for W-t-W employees under the modified