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DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION AND RELATED AGENCIES APPROPRIATIONS ACT, 2000--Continued
(Senate - October 07, 1999)

Text of this article available as: TXT PDF [Pages S12188-S12215] DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION AND RELATED AGENCIES APPROPRIATIONS ACT, 2000--Continued Mr. SPECTER. Mr. President, I ask unanimous consent that we turn to the Senator from---- Mr. REID. Mr. President, will the Senator yield? Mr. SPECTER. Florida for 15 minutes. Mr. REID. Mr. President, will the Senator yield for a brief statement? Mr. SPECTER. Pardon me. I withdraw that because the Senators from New Mexico were here sequenced ahead of Senator Graham. Mr. REID. Mr. President, I appreciate the statements of the chairman of the Judiciary Committee and the statement of the Senator from Pennsylvania on the judicial controversy. I hope we can end all of that this afternoon and get this bill completed because now we have people on our side wanting to come and talk about this matter dealing with Judge White. I hope we can move and get this bill finished before we have further speeches on this judicial controversy. Mr. SPECTER. Mr. President, I ask unanimous consent that the remainder [[Page S12189]] of the time on this bill be directed to the amendment of the Senators from New Mexico, then 15 minutes to Senator Graham of Florida, then 10 minutes to be equally divided between the managers of the bill, and then go to final passage. Mr. REID. Reserving the right to object, if the ranking member of the Judiciary Committee wants to come over and speak on the judicial controversy, I want him to have 15 minutes, the same amount of time the chairman of the Judiciary Committee had. Mr. SPECTER. I incorporate that in the unanimous consent request. Mr. KENNEDY. If I could have 2 minutes. Mr. SPECTER. Two minutes for Senator Kennedy. Mr. INHOFE. Mr. President, reserving the right to object, for what purpose would the Senator be yielding to the Senator from Florida? Are we back on the judicial nominations? Mr. SPECTER. He is speaking on the bill. Mr. INHOFE. Is this on the nomination? Mr. SPECTER. Unless Senator Leahy comes and claims the time which Senator Reid has asked for. Mr. INHOFE. No objection. The PRESIDING OFFICER. Is there objection? Mr. HARKIN. Reserving the right to object. Mr. SPECTER. We added 5 more minutes for Senator Harkin: the managers, 15 minutes; Senator Harkin, 10; myself, 5. Mr. REID. And Senator Kennedy for 2 minutes. Mr. DOMENICI. I ask if Senator Kennedy is on the bill or something else? Mr. KENNEDY. All I want to do, indirectly on the bill, is just to announce that the House of Representatives passed the Patients' Bill of Rights 275-149. This is a hard-won victory for millions of patients and families throughout America, and a well-deserved defeat for HMOs and the Republican extremists in the House who put managed care profits ahead of patients' health. The Senate flunked this test in July, but the House has given us a new chance to do the right thing. The House-Senate conference should adopt the Norwood-Dingell provisions, without the costly and ineffective tax breaks added by House Republicans. Mr. DOMENICI. The Senator did it. Does he still need the 2 minutes? Mr. KENNEDY. No. I don't need the 2 minutes. I thank the Senator very much. Mr. SPECTER. Mr. President, exclude Senator Kennedy from the unanimous consent request. The PRESIDING OFFICER. Without objection, it is so ordered. Mr. SPECTER. Mr. President, I ask that we turn to the Senators from New Mexico. Mr. DOMENICI. Senator Bingaman has the floor. The PRESIDING OFFICER. The Senator from New Mexico. Amendment No. 2272 (Purpose: To require the Secretary of Health and Human Services to conduct a study on the geographic adjustment factors used in determining the amount of payment for physicians' services under the medicare program) Mr. BINGAMAN. Mr. President, I send an amendment to the desk. The PRESIDING OFFICER. The clerk will report. The legislative clerk read as follows: The Senator from New Mexico (Mr. Bingaman), for himself, and Mr. Domenici, proposes an amendment numbered 2272. Mr. BINGAMAN. Mr. President, I ask unanimous consent that reading of the amendment be dispensed with. The PRESIDING OFFICER. Without objection, it is so ordered. The amendment is as follows: At the end of title II, add the following: SEC. 216. STUDY AND REPORT ON THE GEOGRAPHIC ADJUSTMENT FACTORS UNDER THE MEDICARE PROGRAM. (a) Study.--The Secretary of Health and Human Services shall conduct a study on-- (1) the reasons why, and the appropriateness of the fact that, the geographic adjustment factor (determined under paragraph (2) of section 1848(e) (42 U.S.C. 1395w-4(e)) used in determining the amount of payment for physicians' services under the medicare program is less for physicians' services provided in New Mexico than for physicians' services provided in Arizona, Colorado, and Texas; and (2) the effect that the level of the geographic cost-of- practice adjustment factor (determined under paragraph (3) of such section) has on the recruitment and retention of physicians in small rural states, including New Mexico, Iowa, Louisiana, and Arkansas. (b) Report.--Not later than 3 months after the date of enactment of this Act, the Secretary of Health and Human Services shall submit a report to Congress on the study conducted under subsection (a), together with any recommendations for legislation that the Secretary determines to be appropriate as a result of such study. Mr. BINGAMAN. Mr. President, this is an amendment that Senator Domenici and I are offering to direct the Secretary of Health and Human Services to conduct a study of and the appropriateness of the geographic adjustment factor that is used in Medicare reimbursement calculations as it applies particularly to our State of New Mexico. We have a very serious problem in our State today; many of our physicians are leaving the State. The reimbursement that is available under Medicare, and accordingly under many of the health care plans in our State, is less for physicians performing procedures and practicing medicine in our State than it is in all of our surrounding States. We believe this is traceable to this adjustment factor, this geographic adjustment factor. This is a system that was put into place in 1992. It now operates, as I understand it, such that we have 89 geographic fee schedule payment areas in the country. We are not clear on the precise way in which our State has been so severely disadvantaged, but we believe it is a serious problem that needs attention. Our amendment directs that the Secretary conclude this study within 90 days, or 3 months, report back, and make recommendations on how to solve the problem. We believe it is a very good amendment. We recommend that Senators support the amendment. I yield the floor. The PRESIDING OFFICER. The Senator from New Mexico. Mr. DOMENICI. Mr. President, first, I am pleased to say I am a cosponsor of this amendment. I have helped Senator Bingaman with it. This is a good amendment. We aren't asking for any money. We are not asking that any law be changed. We are merely saying that something is not right for our State. The reimbursement--or some aspect of how we are paying doctors under Medicare--is causing us to have much lower fees than the surrounding States, and as a result two things are happening: One, doctors are leaving. In a State such as ours, we can ill afford that. Second, we are being told it is harder and harder to get doctors to come to our State. That was not the case years ago. They loved New Mexico. They came for lots of reasons. But certainly we cannot be an underprivileged State in terms of what we pay our doctors--be a poor State in addition--and expect our citizens to get good health care. We want to know what the real facts are: Why is this the case? Is it the result of the way the geographic evaluation is applied to our State because maybe rural communities aren't getting the right kind of emphasis in that formula? Whatever it is, we want to know. When we know, fellow Senators, we can assure Members, if we find out it is not right and it is not fair, we will be on the floor to talk about some real changes. Until we have that, we ask Members for help in obtaining a study. I yield the floor. Mr. SPECTER. The managers have taken a look at this amendment and are prepared to accept it. It is a good amendment. There is one concern, and that is a jurisdictional concern with respect to the Finance Committee. We have attempted to contact the chairman of the Finance Committee to see if there was any substantial reason we should not accept it. If it went to a vote, it would clearly be adopted. It merely asks for a report for a very good purpose. Therefore, the amendment is accepted. The PRESIDING OFFICER. The question is on agreeing to the amendment. The amendment (No. 2272) was agreed to. Mr. DOMENICI. I move to reconsider the vote. Mr. SPECTER. I move to lay that motion on the table. The motion to lay on the table was agreed to. [[Page S12190]] The PRESIDING OFFICER. The Senator from Florida. Mr. GRAHAM. Mr. President, I am here today, as I was in July, to point out to my colleagues another stealth effort to kill competition within the Medicare program. Title I, section 214, buried in the middle of this long appropriations bill on page 49, carries the following statement: None of the funds provided in this Act or in any other Act making appropriations for fiscal year 2000 may be used to administer or implement in Arizona or in Kansas City, Missouri or in the Kansas City, Kansas area the Medicare Competitive Pricing Demonstration Project operated by the Secretary of Health and Human Services under authority granted in the Balanced Budget Act of 1997. If that statement sounds familiar, it is. Almost the same language was buried in the HMO Patients' Bill of Rights bill as it passed the Senate back in July. It passed then undebated and undiscussed as to its implications--just as we are about to do here tonight. July's action was outrageous. This action is even more so. There is a certain irony here. We have just heard that the House of Representatives passed, by an overwhelming vote, a version of the HMO Patients' Bill of Rights which is very similar to the bipartisan bill offered but not considered in the Senate. Our bipartisan bill was strongly opposed by the HMO industry. Their basic argument is: let's keep government out of our business, let us operate based on a competitive model that will allow the consumer, the beneficiary of the HMO contract, to negotiate without government standards, without government sanctions for failure to deliver on those standards with the HMO industry. They wanted to have laissez-faire free enterprise; Adam Smith roams the land. However, today we are about to pass a provision that says when the HMOs are dealing with their pocketbook and the question of how they will get reimbursed, how much money they are going to get paid from Medicare, they don't want to have a free market of competition; they don't want to have a means by which the taxpayers can be assured what they are paying for the HMO product is what the market says they should be paying. There is a certain amount of irony there which I think underscores the motivations of a significant portion of this industry. There also is a procedural ploy here. If this provision I just quoted were to be offered as an amendment to this bill, it would be ruled out of order under rule XVI in part because it purports not only to control action in this act but in any other act that Congress might consider making in an appropriations bill. But this is not an amendment; this is in the bill itself as it has come out of the Appropriations Committee, and therefore rule XVI does not apply. Normally under the procedures the Congress has followed traditionally, we would be dealing with a House bill because the House traditionally has led in the appropriations process; therefore, we would be amending a House bill. Thus, we could have excised this provision. However, because we are violating tradition and taking up a Senate bill first, we do not have the opportunity to remove it by a point of order. I will state for the record that henceforth, when it is proposed we take up a Senate appropriations bill before a House bill, I am going to stand here and object. This is exactly the kind of procedural abuse we can expect in the future as is happening right now. If that isn't bad enough, this is just plain bad policy. It stifles innovation by eliminating the competitive demonstration which hopefully would have led to a competitive process of compensating HMOs. It forces Medicare to pay more than necessary for some services in certain areas of the country while it denies managed care to other areas of the country. This HMO pricing is not without its own history. The Balanced Budget Act of 1997 included the competitive pricing demonstration program for Medicare. That provision was fought in the committee and fought in the Senate in 1997 by the HMO industry and certain Members of this body, but it prevailed. One by one, the HMO industry has been able to kill or has attempted to kill demonstrations which have been scheduled in many communities across the country. Today it is Arizona and Kansas City. The equation is pretty simple. It does not take rocket science to understand what is happening. Who benefits by continuing a system of paying Medicare HMOs that are not subject to competition? The HMOs benefit. Who loses when the same system is open to competition? The HMOs, because they no longer have the gravy train that exists today. Who gains by competition? Beneficiaries gain, particularly in rural areas which don't have managed care today. It would be the marketplace that would be establishing what the appropriate reimbursement level should be for an HMO in a currently unserved or underserved rural area--not a formula which underpays what the real cost of providing managed care would be in such an area. And the taxpayers lose because they do not get the benefit of the marketplace as a discipline of what the HMO's compensation should be. It is curious that out of one side of their mouth, they are screaming the current system of reimbursement is putting them out of business and causing them to have to leave hundreds of thousands of former HMO beneficiaries high and dry and also to curtail benefits such as prescription drugs, but at the same time, they are saying out of the left side of their mouth they are doing everything they can to prevent the insertion of competitive bidding as a means of establishing what their HMO contracts are really worth and what they should be paid. They cannot have it both ways. It takes a certain degree of political courage to make this reform happen. Let me give an example. In my own State of Florida, we were part of this demonstration project. We were selected to have a demonstration for Part B services for what are referred to as durable medical equipment. Lakeland, FL, was selected as the place to demonstrate the potential savings for medical equipment such as oxygen supplies and equipment, hospital beds and accessories, surgical dressings, enteral nutrition, and urological supplies. The savings that have been achieved in this project are impressive. They are 18-percent savings for oxygen supplies. I know the Senator from Iowa has stood on this floor and at times has even wrapped himself in medical bandages to demonstrate how much more Medicare was paying than, for instance, the Veterans' Administration for the same items. This competitive bidding process is attempting to bring the forces of the market into Medicare, and an 18-percent savings by competitively bidding oxygen supplies and equipment over the old formula we used to use. There were 30-percent savings for hospital beds and accessories, 13-percent savings for surgical dressings, 31 percent for enteral nutrition products, and 20 percent for urological supplies. It has been estimated if that Lakeland, FL, project were to be applied on a nationwide basis, the savings over 10 years would be in excess of $1 billion. We are not talking about small change. Beneficiaries have saved money from this demonstration, and access and quality have been preserved and protected. I find it troubling we are again today, as we were in July, debating, at the end of a major piece of legislation, a silently, surreptitiously included item which has the effect of sheltering HMOs from the marketplace. We might find some HMOs cannot compete and others will thrive, but that is what the marketplace should determine. That is what competition is all about. I urge my colleagues to examine this provision, to examine the implications of this provision in this kind of legislation and the restraints it imposes upon us, as Members of the Senate, to excise it as inappropriate legislative language on an appropriations bill. I hope our conferees, as they meet with the House, will resist the inclusion of this in the final legislation we might be asked to vote upon when this measure comes back from conference. This disserves the beneficiaries of the Medicare program. It disserves the taxpayers of America. It disserves the standards of public policy development by the Senate. I hope we will not have a further repetition of this stealth attack on the Medicare program. Mr. ASHCROFT. Mr. President, I took great interest in the statement that Senator from Florida (Mr. Graham) made expressing his displeasure that this legislation contains [[Page S12191]] a provision--Section 214--halting implementation of the Medicare Prepaid Competitive Pricing Demonstration Project both in Arizona and in the Kansas City metropolitan area. The Senator from Florida claimed that the inclusion of this provision was accomplished by HMOs. I would like to take this opportunity to point out to him that it was Medicare beneficiaries and doctors who alerted me to their grave concerns that the project would create huge patient disruption in the Kansas City area. In fact, after the Senator from Florida made similar remarks during debate on the Patient's Bill of Rights legislation regarding a similar provision in that bill, the Metropolitan Medical Society of Greater Kansas City wrote him a letter conveying their concerns with the implementation of the demonstration project in Kansas City, and expressing support for congressional efforts to stop the demonstration in their area. I ask unanimous consent that a copy of this letter be inserted in the record at the conclusion of my remarks. The PRESIDING OFFICER. Without objection, it is so ordered. (See exhibit 1.) Mr. ASHCROFT. After hearing from a number of doctors and patients in my State over the past few months, I concluded that Kansas City is an inappropriate location for this project and that it will jeopardize the health care benefits that seniors currently enjoy in the area. I believe that halting this project is necessary to protect the health care of senior citizens and to assure that Medicare beneficiaries continue to have access to excellent health care at prices they can afford. HCFA's project is a clear and present danger to the health and well-being of my constituents. The Balanced Budget Act of 1997 created the Medicare Prepaid Competitive Pricing Demonstration Project to use competitive bidding among Medicare HMOs. Through the appointment of a Competitive Pricing Advisory Committee, HCFA was to select demonstration sites around the nation. Kansas City was one of the selected cities. As I understand it, the intent of the project was to bring greater competition to the Medicare managed care market, to address concerns that Medicare HMO reimbursement rates in some areas are too high, to expand benefits for Medicare HMO enrollees, and to restrain the cost of Medicare to the taxpayers. When considering these factors, it is clear that the Kansas City metropolitan area is not an appropriate choice for this demonstration. First, managed care competition in the Kansas City market is already vigorous, with six managed care companies currently offering Medicare HMOs in the area. Participation in Medicare HMOs is also high: As of July 1 of this year, nearly 23% of Medicare recipients in the Kansas City metropolitan area were in Medicare+Choice plans--approximately 50,000 of 230,000 total beneficiaries. Nationally, only 17% of Medicare recipients are enrolled in such plans. Second, Medicare managed care payments in the Kansas City area are below the national average. According to a recent analysis by the Congressional Research Service of the Library of Congress, 1999 payment rates per Medicare+Choice enrollee in Kansas City are $511, while the national rate is $541. Documents provided to me by HCFA also demonstrate that 75 other cities had a higher adjusted average per capita cost (AAPCC) rate for 1997 than Kansas City. I wonder why Kansas City was chosen for this experiment, when so many other cities have higher payment rates. Third, I am concerned that this demonstration project will not provide expanded benefits to Medicare HMO enrollees, but will instead cause severe disruption of Medicare services. It is important to note that customer dissatisfaction is low in current Medicare managed care plans in the Kansas City area. Only one in twelve seniors disenrolls from Medicare HMOs each year. Currently, 33,000, or 66% of the seniors in Medicare managed care plans in the Kansas City area do not pay any premium. Under the bidding process set up by CPAC for the demonstration, a plan that bids above the enrollment-weighted median--which becomes the reimbursement rate for all plans--will be forced to charge seniors a premium to make up the difference between the plan's bid and the reimbursement rate paid by the government. In essence, the penalty for a high bid will be imposed upon seniors. Under this scenario, it is virtually assured that some seniors who pay no premium today will be required to start paying one. Moreover, seniors who cannot afford to pay a premium would be forced to abandon their regular doctor when it becomes necessary to change plans. Both individual doctors as well as the Metropolitan Medical Society of Greater Kansas City have warned that the demonstration could cause extreme disruption of beneficiaries away from current doctor- patient relationships. I have also heard concerns that both health plans and physicians may withdraw from the Medicare program if reimbursements under the demonstration project prove financially untenable. As a result, Medicare beneficiaries may be left with fewer choices in care. This would be intolerable. I question why we should implement a project that will create more risk and uncertainty for my State's seniors, who are already satisfied with what they have. Finally, I question how the demonstration project would be able to provide us with useful information on how to improve the Medicare program if fee-for-service plans--which are generally the most expensive Medicare option--are not included in the project. In its January 6, 1999 Design Report, the Competitive Pricing Advisory Committee expressed the judgment that the exclusion of fee-for-service might ``limit HCFA's ability (a) to measure the impact of competitive pricing and (b) to generalize demonstration results to the entire Medicare program.'' After studying this issue, I concluded that implementation of the Medicare Managed Care Demonstration Project in the Kansas City metropolitan area should be halted immediately. HCFA must not be allowed to risk the ability of my State's seniors to continue to receive high quality health care at affordable costs. I have been working closely with my Senate colleagues from Missouri and Kansas to protect our Kansas City area seniors from the dangers and uncertainty of a planned federal experiment with their health care arrangements. So, I want to make clear to my colleague from Florida that patients and doctors speaking on behalf of their patients were the ones who approached me and asked for my assistance in stopping the Medicare managed care demonstration project in the Kansas City area. I heard from a number of individual doctors, as well as medical societies in the State, expressing grave concerns about the project. The President of the Metropolitan Medical Society of Greater Kansas City even made the prediction that the unintended risk of the demonstration ``could dictate 100% disruption of beneficiaries away from their current relationships'' with their doctors. Clearly, this is unacceptable. Inclusion, Mr. President, I would like to quote from some of the letters I received from the seniors themselves, voicing their opposition to the Medicare managed care demonstration project coming to their area. Elizabeth Weekley Sutton, of Independence, Missouri, wrote to me: Dear Senator Ashcroft: We need help. My husband, my friends, and I are very concerned and worried that our health care will be very limited by the end of the Competitive Pricing Demonstration that will be starting in January. Of all the HMO's in the U.S., only the entire K.C. area and Maricopa County in Arizona will be conducting this competition for the next 5 years! And here are some excerpts from a letter sent by Edward Smith of Platte City, Missouri: I am totally opposed to the Health Care Financing Administration competitive pricing demonstration project to take place here in the Kansas City area. My health will not permit me to be a guinea pig for a total of five years when the rest of the country will have business as usual. He continues: Instead of the Health Care Financing Administration determining what is best for the beneficiaries I would prefer to do that myself. And finally, Mr. Smith says: If this plan is adopted my HMO could choose to leave the market. Then what is gained? Certainly not my health. Mr. President, we need to listen to the voice of our seniors. We cannot afford to jeopardize their health with a [[Page S12192]] risky experiment that could raise costs, limit choices, and cause doctor-patient disruption. For this reason, I have continued--and will continue--to work to halt this project in its present form in the Kansas City area. Exhibit 1 Metropolitan Medical Society of Greater Kansas City, July 21, 1999. Hon. Bob Graham, U.S. Senate, Washington, DC. Dear Senator Graham: I was concerned to read in the July 16, 1999, Congressional Record your dissatisfaction about the Senate's passage of the moratorium on the Medicare Prepaid Competitive Pricing Demonstration Project in Kansas City and Arizona. On behalf of the more than 2500 physicians of the Metropolitan Medical Society of Greater Kansas City and its affiliated organizations, I want to assure you that doctors strongly support the moratorium that was passed in the Senate Patient Bill of Rights legislation last week. The physicians of Kansas City have expressed serious concerns about the demonstration project since April, and we continue to be concerned. We believe the experiment will bring unacceptable levels of disruption to our Medicare patients and the local health care market. Additionally, I worry that quality care, which is often more expensive, will be less available to Medicare patients. In Kansas City, the opposition to the project is widespread. Our senators acted on behalf of our entire health care community, including patients, doctors, hospitals, and health care plans. The medical community has participated in the discussions about the demonstration with the Health Care Financing Administration (HCFA) and the local Area Advisory Committee for the demonstration project. Despite these discussions, problems with the experiment remain. We support congressional efforts to stop the demonstration project in the Kansas City area. I remain concerned that under-funded HMOs place our most vulnerable Medicare recipients at risk of getting less attention to their health care needs. I expect to hear more cases of catastrophes to Medicare recipients when the care given is too little, too late. You may be aware that Jacksonville, Florida is another potential site for the demonstration. Thank you for your consideration of my concerns. I hope I've helped to clarify the existence of broad based support in Kansas City for the moratorium on the competitive pricing demonstration. Sincerely, Richard Hellman, MD, President-Elect and Chair, National Government Relations Committee. amendment no. 1845 (Purpose: To express the sense of the Senate regarding school infrastructure) The PRESIDING OFFICER (Mr. Smith of Oregon). The Senator from Iowa. Mr. HARKIN. Mr. President, Senator Robb and I have an amendment at the desk. I call it up at this time, No. 1845. The PRESIDING OFFICER. The clerk will report. The legislative clerk read as follows: The Senator from Iowa [Mr. Harkin], for himself, and Mr. Robb, proposes an amendment numbered 1845. Mr. HARKIN. Mr. President, I ask unanimous consent that reading of the amendment be dispensed with. The PRESIDING OFFICER. Without objection, it is so ordered. The amendment is as follows: At the end of title III, add the following: SEC. ____. SENSE OF THE SENATE REGARDING SCHOOL INFRASTRUCTURE. (a) Findings.--The Senate makes the following findings: (1) The General Accounting Office has performed a comprehensive survey of the Nation's public elementary and secondary school facilities and has found severe levels of disrepair in all areas of the United States. (2) The General Accounting Office has concluded that more than 14,000,000 children attend schools in need of extensive repair or replacement, 7,000,000 children attend schools with life threatening safety code violations, and 12,000,000 children attend schools with leaky roofs. (3) The General Accounting Office has found the problem of crumbling schools transcends demographic and geographic boundaries. At 38 percent of urban schools, 30 percent of rural schools, and 29 percent of suburban schools, at least one building is in need of extensive repair or should be completely replaced. (4) The condition of school facilities has a direct affect on the safety of students and teachers and on the ability of students to learn. Academic research has provided a direct correlation between the condition of school facilities and student achievement. At Georgetown University, researchers have found the test scores of students assigned to schools in poor condition can be expected to fall 10.9 percentage points below the test scores of students in buildings in excellent condition. Similar studies have demonstrated up to a 20 percent improvement in test scores when students were moved from a poor facility to a new facility. (5) The General Accounting Office has found most schools are not prepared to incorporate modern technology in the classroom. Forty-six percent of schools lack adequate electrical wiring to support the full-scale use of technology. More than a third of schools lack the requisite electrical power. Fifty-six percent of schools have insufficient phone lines for modems. (6) The Department of Education has reported that elementary and secondary school enrollment, already at a record high level, will continue to grow over the next 10 years, and that in order to accommodate this growth, the United States will need to build an additional 6,000 schools. (7) The General Accounting Office has determined the cost of bringing schools up to good, overall condition to be $112,000,000,000, not including the cost of modernizing schools to accommodate technology, or the cost of building additional facilities needed to meet record enrollment levels. (8) Schools run by the Bureau of Indian Affairs (BIA) for Native American children are also in dire need of repair and renovation. The General Accounting Office has reported that the cost of total inventory repairs needed for BIA facilities is $754,000,000. The December 1997 report by the Comptroller General of the United States states that, ``Compared with other schools nationally, BIA schools are generally in poorer physical condition, have more unsatisfactory environmental factors, more often lack key facilities requirements for education reform, and are less able to support computer and communications technology.''. (9) State and local financing mechanisms have proven inadequate to meet the challenges facing today's aging school facilities. Large numbers of local educational agencies have difficulties securing financing for school facility improvement. (10) The Federal Government has provided resources for school construction in the past. For example, between 1933 and 1939, the Federal Government assisted in 70 percent of all new school construction. (11) The Federal Government can support elementary and secondary school facilities without interfering in issues of local control, and should help communities leverage additional funds for the improvement of elementary and secondary school facilities. (b) Sense of the Senate.--It is the sense of the Senate that Congress should provide at least $3,700,000,000 in Federal resources to help communities leverage funds to modernize public school facilities. Mr. HARKIN. Mr. President, Senator Robb and I are going to take a few minutes. I know the time is late. I know people want to get to a final vote on this. I want to talk about how good this bill is and to urge people to vote for it. This is a sense-of-the-Senate resolution. I will not go through the whole thing. It basically is a sense-of-the-Senate resolution saying Congress should appropriate at least $3.7 billion in Federal resources to help communities leverage funds to modernize public school facilities, otherwise known as public school construction. What we have in this country is schools that are on the average 40 to 50 years old. We are getting great teachers, new methodologies, new math, new science, new reading programs, and the schools are crumbling down around us. They are getting older every day. Day after day, kids go to schools with leaky ceilings, inadequate heat, inadequate air conditioning for hot summer days and the fall when the school year is extended. They are finding a lot of these buildings still have asbestos in them, and it needs to be taken out. Yet we are shirking our responsibilities to refurbish, renovate, and rebuild the schools in this country. The General Accounting Office estimates 14 million American children attend classes in schools that are unsafe or inadequate. They estimate it will cost $112 billion to upgrade existing public schools to just ``good'' condition. In addition, the GAO reports 46 percent of schools lack adequate electrical wiring to support the full-scale use of technology. We want to get computers in the classrooms, we want to hook them to the Internet, and yet almost 50 percent of the schools in this country are inadequate in their internal wiring so kids cannot hook up with the Internet. The American Society of Civil Engineers reports public schools are in worse condition than any other sector of our national infrastructure. Think about that. According to the American Society of Civil Engineers--they are the ones who build our buildings, build our bridges and roads and highways and streets and sewers and water systems, and our schools--they say our schools are in the worst state of any part of the physical infrastructure of this country. Mr. HARKIN. Mr. President, if the nicest things our kids ever see or go to [[Page S12193]] is shopping malls and sports arenas and movie theaters, and the most run-down places are their schools, what kind of signal are we sending them about the value we place on education and their future? This is a sense-of-the-Senate resolution which simply outlines the terrible situation we have in this country and calls on the Senate and the Congress to respond by providing at least $3.7 billion, a small fraction of what is needed but a step in the right direction--$3.7 billion in Federal resources to modernize our Nation's schools. I yield the floor to my distinguished colleague and cosponsor, Senator Robb. The PRESIDING OFFICER. The Senator from Virginia. Mr. ROBB. Mr. President, I thank my friend and colleague from Iowa. Senator Harkin and I have offered a sense of the Senate amendment relating to school construction, as Senator Harkin has just explained. The amendment is not unlike the amendment Senators Lautenberg, Harkin, and I offered to the Budget Resolution earlier this year. That amendment assumed that given the levels in the budget resolution, Congress would enact ``legislation to allow States and school districts to issue at least $24.8 billion worth of zero-interest bonds to rebuild and modernize our nation's schools, and to provide Federal income tax credits to the purchasers of those bonds in lieu of interest payments.'' The actual cost as it was scored was referred to by the Senator from Iowa. That amendment was accepted and put the entire Senate on record as supporting the concept of providing federal assistance in the area of school construction and renovation. Understanding that Rule 16 prevents us from doing anything of significance at this time with respect to school construction, Senator Harkin and I in just a moment will withdraw our amendment. But every day that passes, this Congress misses an opportunity to help our States and localities fix the leaky roofs, get rid of all the trailers, and install the wiring needed to bring technology to all of our children. These are real problems--problems that our nation's mayors, school boards, and families simply need some help in addressing. While school infrastructure improvement is typically a local responsibility, it is now a national need. Our schools, as the Senator from Iowa has indicated, are over 40 years old, on average; our school- aged population is at record levels; and our States and localities can't keep up, despite their surpluses. Abstract talk about State surpluses provides little solace to our nation's teachers and students who are forced to deal with wholly inadequate conditions. In Alabama, the roof of an elementary school collapsed. Fortunately, it occurred just after the children had left for the day. In Chicago, teachers place cheesecloth over air vents to filter out lead-based paint flecks. In Maine, teachers have to turn out the lights when it rains because their electrical wiring is exposed under their leaky roofs. Mr. President, we are missing an opportunity to help our States and localities with a pressing need. I will continue to work for and press forward on this issue because I think it's an area where the Federal Government can be extremely constructive. When our children are asked about ``Bleak House,'' they should refer to a novel by Dickens and not the place where they go to school. In my own State of Virginia, there are over 3,000 trailers being used to educate students. And there are over $4 billion worth of unbudgeted, unmet needs for our schools. This is a problem that is not going to go away, and it's a problem that our nation's schools need our help to solve. And I regret that Rule 16 precludes us from considering legislation which would reaffirm the commitment that we made earlier this year. I thank the distinguished Senator from Iowa for his continued work on the subject of school construction, and I yield the floor. Amendment No. 1845 Withdrawn The PRESIDING OFFICER. The Senator from Iowa. Mr. HARKIN. Mr. President, I understand this amendment is not acceptable to the other side. It is late in the day. I know people have to get on with other things, and we want to get to a final vote on the bill. I believe strongly in this. It is a sense-of-the-Senate amendment. Also, Senators Kennedy, Reid, Murray, and Johnson are added as cosponsors. In the spirit of moving this bill along and trying to wrap this up as quickly as possible, I ask unanimous consent to withdraw the amendment at this time, but it will be revisited. The PRESIDING OFFICER. The Senator from Pennsylvania. Mr. SPECTER. I thank my distinguished colleague. I am very sympathetic to the purpose of the sense-of-the-Senate amendment. He is correct; there would be objection, and I think it would not be adopted. I thank him for withdrawing the amendment. The PRESIDING OFFICER. The amendment is withdrawn. Amendments Nos. 2273 through 2289, 1852, 1869, and 1882 Mr. SPECTER. Mr. President, I now submit the managers' package which has been cleared on both sides. The PRESIDING OFFICER. The clerk will report. The legislative clerk read as follows: The Senator from Pennsylvania [Mr. Specter] proposes amendments numbered 2273 through 2289, 1852, 1869 and 1882. The amendments are as follows: amendment no. 2273 At the appropriate place in the bill add the following: SEC. . CONFOUNDING BIOLOGICAL AND PHYSIOLOGICAL INFLUENCES ON POLYGRAPHY. (a) Findings.--The Senate finds that-- (1) The use of polygraph tests as a screening tool for federal employees and contractor personnel is increasing. (2) A 1983 study by the Office of Technology Assessment found little scientific evidence to support the validity of polygraph tests in such screening applications. (3) The 1983 study further found that little or no scientific study had been undertaken on the effects of prescription and non-prescription drugs on the validity of polygraph tests, as well as differential responses to polygraph tests according to biological and physiological factors that may vary according to age, gender, or ethnic backgrounds, or other factors relating to natural variability in human populations. (4) A scientific evaluation of these important influences on the potential validity of polygraph tests should be studied by a neutral agency with biomedical and physiological expertise in order to evaluate the further expansion of the use of polygraph tests on federal employees and contractor personnel. (b) Sense of the Senate.--It is the Sense of the Senate that the Director of the National Institutes of Health should enter into appropriate arrangements with the National Academy of Sciences to conduct a comprehensive study and investigation into the scientific validity of polygraphy as a screening tool for federal and federal contractor personnel, with particular reference to the validity of polygraph tests being proposed for use in proposed rules published at 64 Fed. Reg. 45062 (August 18, 1999). ____ AMENDMENT NO. 2274 (Purpose: To provide funding for a dental sealant demonstration program) At the end of title II, add the following: dental sealant demonstration program Sec. ____. From amounts appropriated under this title for the Health Resources and Services Administration, sufficient funds are available to the Maternal Child Health Bureau for the establishment of a multi-State preventive dentistry demonstration program to improve the oral health of low- income children and increase the access of children to dental sealants through community- and school-based activities. ____ AMENDMENT NO. 2275 (Purpose: To limit the withholding of substance abuse funds from certain States) At the end of title II, add the following: withholding of substance abuse funds Sec. ____. (a) In General.--None of the funds appropriated by this Act may be used to withhold substance abuse funding from a State pursuant to section 1926 of the Public Health Service Act (42 U.S.C. 300x-26) if such State certifies to the Secretary of Health and Human Services that the State will commit additional State funds, in accordance with subsection (b), to ensure compliance with State laws prohibiting the sale of tobacco products to individuals under 18 years of age. (b) Amount of State Funds.--The amount of funds to be committed by a State under subsection (a) shall be equal to one percent of such State's substance abuse block grant allocation for each percentage point by which the State misses the retailer compliance rate goal established by the Secretary of Health and Human Services under section 1926 of such Act, except that the Secretary may agree to a smaller commitment of additional funds by the State. (c) Supplement not Supplant.--Amounts expended by a State pursuant to a certification under subsection (a) shall be used to supplement and not supplant State funds [[Page S12194]] used for tobacco prevention programs and for compliance activities described in such subsection in the fiscal year preceding the fiscal year to which this section applies. (d) The Secretary shall exercise discretion in enforcing the timing of the State expenditure required by the certification described in subsection (a) as late as July 31, 2000. ____ AMENDMENT NO. 2276 (Purpose: To express the sense of the Senate that funding for prostate cancer research should be increased substantially) At the appropriate place add the following: Sec. ____. (a) Findings.--Congress makes the following findings: (1) In 1999, prostate cancer is expected to kill more than 37,000 men in the United States and be diagnosed in over 180,000 new cases. (2) Prostate cancer is the most diagnosed nonskin cancer in the United States. (3) African Americans have the highest incidence of prostate cancer in the world. (4) Considering the devastating impact of the disease among men and their families, prostate cancer research remains underfunded. (5) More resources devoted to clinical and translational research at the National Institutes of Health will be highly determinative of whether rapid advances can be attained in treatment and ultimately a cure for prostate cancer. (6) The Congressionally Directed Department of Defense Prostate Cancer Research Program is making important strides in innovative prostate cancer research, and this Program presented to Congress in April of 1998 a full investment strategy for prostate cancer research at the Department of Defense. (7) The Senate expressed itself unanimously in 1998 that the Federal commitment to biomedical research should be doubled over the next 5 years. (b) Sense of the Senate.--It is the sense of the Senate that-- (1) finding treatment breakthroughs and a cure for prostate cancer should be made a national health priority; (2) significant increases in prostate cancer research funding, commensurate with the impact of the disease, should be made available at the National Institutes of Health and to the Department of Defense Prostate Cancer Research Program; and (3) these agencies should prioritize prostate cancer research that is directed toward innovative clinical and translational research projects in order that treatment breakthroughs can be more rapidly offered to patients. ____ amendment no. 2277 On page 59, line 25, strike ``$1,404,631,000'' and insert ``$1,406,631,000'' in lieu thereof. On page 60, before the period on line 10, insert the following: ``: Provided further, That $2,000,000 shall be for carrying out Part C of Title VIII of the Higher Education Amendments of 1998.'' On page 62, line 23, decrease the figure by $2,000,000. ____ amendment no. 2278 (Purpose: To clarify provisions relating to the United States-Mexico Border Health Commission) At the appropriate place, insert the following: Sec. . The United States-Mexico Border Health Commission Act (22 U.S.C. 290n et seq.) is amended-- (1) by striking section 2 and inserting the following: ``SEC. 2. APPOINTMENT OF MEMBERS OF BORDER HEALTH COMMISSION. ``Not later than 30 days after the date of enactment of this section, the President shall appoint the United States members of the United States-Mexico Border Health Commission, and shall attempt to conclude an agreement with Mexico providing for the establishment of such Commission.''; and (2) in section 3-- (A) in paragraph (1), by striking the semicolon and inserting ``; and''; (B) in paragraph (2)(B), by striking ``; and'' and inserting a period; and (C) by striking paragraph (3). ____ amendment no. 2279 On page 50, line 17, strike ``$459,000,000'' and insert in lieu thereof ``$494,000,000''. ____ amendment no. 2280 On page 66, line 24, strike out all after the colon up to the period on line 18 of page 67. ____ amendment no. 2281 On page 42, before the period on line 8, insert the following: ``: Provided further, That sufficient funds shall be available from the Office on Women's Health to support biological, chemical and botanical studies to assist in the development of the clinical evaluation of phytomedicines in women's health''. ____ amendment no. 2282 (Purpose: To provide for a report on promoting a legal domestic workforce and improving the compensation and working conditions of agricultural workers) On page 19, line 6, insert before the period the following: ``: Provided further, That funds made available under this heading shall be used to report to Congress, pursuant to section 9 of the Act entitled `An Act to create a Department of Labor' approved March 4, 1913 (29 U.S.C. 560), with options that will promote a legal domestic work force in the agricultural sector, and provide for improved compensation, longer and more consistent work periods, improved benefits, improved living conditions and better housing quality, and transportation assistance between agricultural jobs for agricultural workers, and address other issues related to agricultural labor that the Secretary of Labor determines to be necessary''. ____ AMENDMENT NO. 2283 (Purpose: To express the sense of the Senate concerning women's access to obstetric and gynecological services) Beginning on page 1 of the amendment, strike all after the first word and insert the following: ____. SENSE OF THE SENATE ON WOMEN'S ACCESS TO OBSTETRICAND GYNECOLOGICAL SERVICES. (a) Findings.--Congress makes the following findings: (1) In the 1st session of the 106th Congress, 23 bills have been introduced to allow women direct access to their ob-gyn provider for obstetric and gynecologic services covered by their health plans. (2) Direct access to ob-gyn care is a protection that has been established by Executive Order for enrollees in medicare, medicaid, and Federal Employee Health Benefit Programs. (3) American women overwhelmingly support passage of federal legislation requiring health plans to allow women to see their ob-gyn providers without first having to obtain a referral. A 1998 survey by the Kaiser FamilyFoundation and Harvard University found that 82 percent of Americans support passage of a direct access law. (4) While 39 States have acted to promote residents' access to ob- gyn providers, patients in other State- or in Federally-governed health plans are not protected from access restrictions or limitations. (5) In May of 1999 the Commonwealth Fund issued a survey on women's health, determining that 1 of 4 women (23 percent) need to first receive permission from their primary care physician before they can go and see their ob-gyn provider for covered obstetric or gynecologic care. (6) Sixty percent of all office visits to ob-gyn providers are for preventive care. (b) Sense of the Senate.--It is the sense of the Senate that Congress should enact legislation that requires health plans to provide women with direct access to a participating health provider who specializes in obstetrics and gynecological services, and that such direct access should be provided for all obstetric and gynecologic care covered by their health plans, without first having to obtain a referral from a primary care provider or the health plan. Mrs. MURRAY. Mr. President, included in the Manager's amendment is an important provision relating to women's health and access to reproductive health care services. I am pleased to have worked with the managers of this bill to send a strong message on the importance of direct access for women to their OB/GYN. I was disappointed that we were unable to address the rule XVI concerns with the amendment I had originally filed. My original amendment would simply allow women and their OB/GYNs to make important health care decisions without barriers or obstacles erected by insurance company policies. My amendment would have required that health plans give women direct access to their OB/GYN for all gynecological and obstetrical care and would have prohibited insurance companies from standing between a woman and her OB/GYN. However, it has been determined that my amendment would violate rule XVI. As a result of the announcement by the chairman of the Senate Appropriations Committee that he will make a point of order against all amendments that may violate rule XVI, I have modified my amendment. The modification still allows Members of the Senate to be on record in support of women's health or in opposition to removing barriers that hinder access for women to critical reproductive health care services. I am offering a sense-of-the-Senate that puts this question to each Member. I realize that this amendment is not binding, but due to opposition to my original amendment, I have been forced to offer this sense-of-the-Senate. I am disappointed that we could not act to provide this important protection to women, but I do believe this amendment will send an important message that the U.S. Senate does support greater access for women to quality health care benefits. I have offered this amendment due to my frustration and disappointment with managed care reform. I have become frustrated by stalling tactics and empty promises. The managed care reform bill that passed the Senate has [[Page S12195]] been referred to as an empty promise for women. I can assure my colleagues that women are much smarter than they may expect and will not be fooled by empty promises or arguments of procedural discipline. When a woman is denied direct access to the care provided by her OB/ GYN, she will not be interested in a discussion on ERISA or rule XVI. She wants direct access to her OB/GYN. She needs direct access, and she should have direct access. My amendment also reiterates the importance of ensuring that the OB/ GYN remains the coordinating physician. Any test or additional referral would be treated as if made by the primary care physician. This amendment does not call for the designation of an OB/GYN as a primary care physician, it simply says that if the OB/GYN decides additional care is necessary, the patient is not forced to seek approval from a primary care physician, who may not be familiar with her overall health care status. Why is this amendment important? The number one reason most women enter the health care system is to seek gynecological or obstetric care. This is the primary point of entry for women into the health care system. For most women, including myself, we consider our OB/GYN our primary care physician--maybe not as an insurance company defines it-- but, in practice, that's the reality. Does a woman go to her OB/GYN for an ear infection? No. But, does a pregnant woman consult with her OB/GYN prior to taking any antibiotic for the treatment of an ear infection? Yes, most women do. I know the policy endorsed in this amendment has in the past enjoyed bipartisan support. The requirements are similiar to S. 836, legislation introduced by Senator Specter and cosponsored by several Senators both Republican and Democrat. This amendment is similar to language that was adopted during committee consideration in the House of the fiscal year 1999 Labor, HHS appropriations bill. A similar directive is contained in the bipartisan House Patients' Bill of Rights legislation. It has the strong support of the American College of Obstetricians and Gynecologists and I know I have heard from several OB/GYNs in my own state testifying to the importance of direct access to the full range of care provided, not just routine care. I would also like to point out to my colleagues, that 39 states have similar requirements and that as participants in the Federal Employees Health Benefit Plan, all of us--as Senators--have this same guarantee as well as our family members. If we can guarantee this protection for ourselves and our families, we should do the same for women participating in a manager care plan. I realize that this appropriations bill may not be the best vehicle for offering this amendment. However, I have waited for final action on a Patients' Bill of Rights for too long. I have watched as patient protection bills have been stalled or delayed. Last year we were told that we would finish action on a good Patients' Bill of Rights package prior to adjournment. Well, here we sit--almost 12 months later--with little hope of finishing a good, comprehensive managed care reform bill prior to our scheduled adjournment this year. I also want to remind my colleagues that we have in the past used appropriations bills to address deficiencies in current law or to address an urgent need for action. I believe that addressing an urgent need in women's health care qualifies as a priority that we must address. I realize that the authorizing committee has objected to the original amendment I filed. As a member of the authorizing committee as well, I can understand this objection. But, again I have little choice but to proceed on this appropriations bill. We all know that it was only recently on the fiscal year 1999 supplemental appropriations bill that we authorized a significant change in Medicaid recoupment provisions despite strong objections from the Finance Committee. In last year's omnibus appropriations bill, we authorized a requirement that insurance companies must cover breast reconstruction surgery following a mastectomy. I can assure my colleagues that this provision never went through the authorizing committee. I would also point out that there are several antichoice riders contained in this appropriations bill that represent a major authorization. As these examples show, when we have to address these types issues through appropriations bills--we can do it. We have done it in the past, and we should do it today to meet this need. I urge my colleagues to support this amendment. We all talk about the need to ensure access for women to health care. I applaud Chairman Specter's efforts in this appropriations bill regarding women's health care. Adopting this amendment gives us the opportunity to do something that does ensure greater access for women. This is what women want. This is the chance for Senators to show their commitment to this critical benefit. I would like to quote a statement made by our subcommittee chairman that I believe more eloquently explains why I am urging this amendment. ``I believe it is clear that access to women's health care cuts across the intricacies of the complicated and often divisive managed care debate.'' I could not agree more. We know from the current state requirement and the Federal Employee Health Benefit Program requirement, this provision does not have a significant impact on costs of health care. We also know from experience that it has a positive impact on health care benefits. Since 60 percent of office visits to OB/GYNs are for preventive care, we could make the argument that adoption of this policy would reduce the overall costs of health care. I urge my colleagues to support this amendment and ask that we do more than simply make empty promises

Major Actions:

All articles in Senate section

DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION AND RELATED AGENCIES APPROPRIATIONS ACT, 2000--Continued
(Senate - October 07, 1999)

Text of this article available as: TXT PDF [Pages S12188-S12215] DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION AND RELATED AGENCIES APPROPRIATIONS ACT, 2000--Continued Mr. SPECTER. Mr. President, I ask unanimous consent that we turn to the Senator from---- Mr. REID. Mr. President, will the Senator yield? Mr. SPECTER. Florida for 15 minutes. Mr. REID. Mr. President, will the Senator yield for a brief statement? Mr. SPECTER. Pardon me. I withdraw that because the Senators from New Mexico were here sequenced ahead of Senator Graham. Mr. REID. Mr. President, I appreciate the statements of the chairman of the Judiciary Committee and the statement of the Senator from Pennsylvania on the judicial controversy. I hope we can end all of that this afternoon and get this bill completed because now we have people on our side wanting to come and talk about this matter dealing with Judge White. I hope we can move and get this bill finished before we have further speeches on this judicial controversy. Mr. SPECTER. Mr. President, I ask unanimous consent that the remainder [[Page S12189]] of the time on this bill be directed to the amendment of the Senators from New Mexico, then 15 minutes to Senator Graham of Florida, then 10 minutes to be equally divided between the managers of the bill, and then go to final passage. Mr. REID. Reserving the right to object, if the ranking member of the Judiciary Committee wants to come over and speak on the judicial controversy, I want him to have 15 minutes, the same amount of time the chairman of the Judiciary Committee had. Mr. SPECTER. I incorporate that in the unanimous consent request. Mr. KENNEDY. If I could have 2 minutes. Mr. SPECTER. Two minutes for Senator Kennedy. Mr. INHOFE. Mr. President, reserving the right to object, for what purpose would the Senator be yielding to the Senator from Florida? Are we back on the judicial nominations? Mr. SPECTER. He is speaking on the bill. Mr. INHOFE. Is this on the nomination? Mr. SPECTER. Unless Senator Leahy comes and claims the time which Senator Reid has asked for. Mr. INHOFE. No objection. The PRESIDING OFFICER. Is there objection? Mr. HARKIN. Reserving the right to object. Mr. SPECTER. We added 5 more minutes for Senator Harkin: the managers, 15 minutes; Senator Harkin, 10; myself, 5. Mr. REID. And Senator Kennedy for 2 minutes. Mr. DOMENICI. I ask if Senator Kennedy is on the bill or something else? Mr. KENNEDY. All I want to do, indirectly on the bill, is just to announce that the House of Representatives passed the Patients' Bill of Rights 275-149. This is a hard-won victory for millions of patients and families throughout America, and a well-deserved defeat for HMOs and the Republican extremists in the House who put managed care profits ahead of patients' health. The Senate flunked this test in July, but the House has given us a new chance to do the right thing. The House-Senate conference should adopt the Norwood-Dingell provisions, without the costly and ineffective tax breaks added by House Republicans. Mr. DOMENICI. The Senator did it. Does he still need the 2 minutes? Mr. KENNEDY. No. I don't need the 2 minutes. I thank the Senator very much. Mr. SPECTER. Mr. President, exclude Senator Kennedy from the unanimous consent request. The PRESIDING OFFICER. Without objection, it is so ordered. Mr. SPECTER. Mr. President, I ask that we turn to the Senators from New Mexico. Mr. DOMENICI. Senator Bingaman has the floor. The PRESIDING OFFICER. The Senator from New Mexico. Amendment No. 2272 (Purpose: To require the Secretary of Health and Human Services to conduct a study on the geographic adjustment factors used in determining the amount of payment for physicians' services under the medicare program) Mr. BINGAMAN. Mr. President, I send an amendment to the desk. The PRESIDING OFFICER. The clerk will report. The legislative clerk read as follows: The Senator from New Mexico (Mr. Bingaman), for himself, and Mr. Domenici, proposes an amendment numbered 2272. Mr. BINGAMAN. Mr. President, I ask unanimous consent that reading of the amendment be dispensed with. The PRESIDING OFFICER. Without objection, it is so ordered. The amendment is as follows: At the end of title II, add the following: SEC. 216. STUDY AND REPORT ON THE GEOGRAPHIC ADJUSTMENT FACTORS UNDER THE MEDICARE PROGRAM. (a) Study.--The Secretary of Health and Human Services shall conduct a study on-- (1) the reasons why, and the appropriateness of the fact that, the geographic adjustment factor (determined under paragraph (2) of section 1848(e) (42 U.S.C. 1395w-4(e)) used in determining the amount of payment for physicians' services under the medicare program is less for physicians' services provided in New Mexico than for physicians' services provided in Arizona, Colorado, and Texas; and (2) the effect that the level of the geographic cost-of- practice adjustment factor (determined under paragraph (3) of such section) has on the recruitment and retention of physicians in small rural states, including New Mexico, Iowa, Louisiana, and Arkansas. (b) Report.--Not later than 3 months after the date of enactment of this Act, the Secretary of Health and Human Services shall submit a report to Congress on the study conducted under subsection (a), together with any recommendations for legislation that the Secretary determines to be appropriate as a result of such study. Mr. BINGAMAN. Mr. President, this is an amendment that Senator Domenici and I are offering to direct the Secretary of Health and Human Services to conduct a study of and the appropriateness of the geographic adjustment factor that is used in Medicare reimbursement calculations as it applies particularly to our State of New Mexico. We have a very serious problem in our State today; many of our physicians are leaving the State. The reimbursement that is available under Medicare, and accordingly under many of the health care plans in our State, is less for physicians performing procedures and practicing medicine in our State than it is in all of our surrounding States. We believe this is traceable to this adjustment factor, this geographic adjustment factor. This is a system that was put into place in 1992. It now operates, as I understand it, such that we have 89 geographic fee schedule payment areas in the country. We are not clear on the precise way in which our State has been so severely disadvantaged, but we believe it is a serious problem that needs attention. Our amendment directs that the Secretary conclude this study within 90 days, or 3 months, report back, and make recommendations on how to solve the problem. We believe it is a very good amendment. We recommend that Senators support the amendment. I yield the floor. The PRESIDING OFFICER. The Senator from New Mexico. Mr. DOMENICI. Mr. President, first, I am pleased to say I am a cosponsor of this amendment. I have helped Senator Bingaman with it. This is a good amendment. We aren't asking for any money. We are not asking that any law be changed. We are merely saying that something is not right for our State. The reimbursement--or some aspect of how we are paying doctors under Medicare--is causing us to have much lower fees than the surrounding States, and as a result two things are happening: One, doctors are leaving. In a State such as ours, we can ill afford that. Second, we are being told it is harder and harder to get doctors to come to our State. That was not the case years ago. They loved New Mexico. They came for lots of reasons. But certainly we cannot be an underprivileged State in terms of what we pay our doctors--be a poor State in addition--and expect our citizens to get good health care. We want to know what the real facts are: Why is this the case? Is it the result of the way the geographic evaluation is applied to our State because maybe rural communities aren't getting the right kind of emphasis in that formula? Whatever it is, we want to know. When we know, fellow Senators, we can assure Members, if we find out it is not right and it is not fair, we will be on the floor to talk about some real changes. Until we have that, we ask Members for help in obtaining a study. I yield the floor. Mr. SPECTER. The managers have taken a look at this amendment and are prepared to accept it. It is a good amendment. There is one concern, and that is a jurisdictional concern with respect to the Finance Committee. We have attempted to contact the chairman of the Finance Committee to see if there was any substantial reason we should not accept it. If it went to a vote, it would clearly be adopted. It merely asks for a report for a very good purpose. Therefore, the amendment is accepted. The PRESIDING OFFICER. The question is on agreeing to the amendment. The amendment (No. 2272) was agreed to. Mr. DOMENICI. I move to reconsider the vote. Mr. SPECTER. I move to lay that motion on the table. The motion to lay on the table was agreed to. [[Page S12190]] The PRESIDING OFFICER. The Senator from Florida. Mr. GRAHAM. Mr. President, I am here today, as I was in July, to point out to my colleagues another stealth effort to kill competition within the Medicare program. Title I, section 214, buried in the middle of this long appropriations bill on page 49, carries the following statement: None of the funds provided in this Act or in any other Act making appropriations for fiscal year 2000 may be used to administer or implement in Arizona or in Kansas City, Missouri or in the Kansas City, Kansas area the Medicare Competitive Pricing Demonstration Project operated by the Secretary of Health and Human Services under authority granted in the Balanced Budget Act of 1997. If that statement sounds familiar, it is. Almost the same language was buried in the HMO Patients' Bill of Rights bill as it passed the Senate back in July. It passed then undebated and undiscussed as to its implications--just as we are about to do here tonight. July's action was outrageous. This action is even more so. There is a certain irony here. We have just heard that the House of Representatives passed, by an overwhelming vote, a version of the HMO Patients' Bill of Rights which is very similar to the bipartisan bill offered but not considered in the Senate. Our bipartisan bill was strongly opposed by the HMO industry. Their basic argument is: let's keep government out of our business, let us operate based on a competitive model that will allow the consumer, the beneficiary of the HMO contract, to negotiate without government standards, without government sanctions for failure to deliver on those standards with the HMO industry. They wanted to have laissez-faire free enterprise; Adam Smith roams the land. However, today we are about to pass a provision that says when the HMOs are dealing with their pocketbook and the question of how they will get reimbursed, how much money they are going to get paid from Medicare, they don't want to have a free market of competition; they don't want to have a means by which the taxpayers can be assured what they are paying for the HMO product is what the market says they should be paying. There is a certain amount of irony there which I think underscores the motivations of a significant portion of this industry. There also is a procedural ploy here. If this provision I just quoted were to be offered as an amendment to this bill, it would be ruled out of order under rule XVI in part because it purports not only to control action in this act but in any other act that Congress might consider making in an appropriations bill. But this is not an amendment; this is in the bill itself as it has come out of the Appropriations Committee, and therefore rule XVI does not apply. Normally under the procedures the Congress has followed traditionally, we would be dealing with a House bill because the House traditionally has led in the appropriations process; therefore, we would be amending a House bill. Thus, we could have excised this provision. However, because we are violating tradition and taking up a Senate bill first, we do not have the opportunity to remove it by a point of order. I will state for the record that henceforth, when it is proposed we take up a Senate appropriations bill before a House bill, I am going to stand here and object. This is exactly the kind of procedural abuse we can expect in the future as is happening right now. If that isn't bad enough, this is just plain bad policy. It stifles innovation by eliminating the competitive demonstration which hopefully would have led to a competitive process of compensating HMOs. It forces Medicare to pay more than necessary for some services in certain areas of the country while it denies managed care to other areas of the country. This HMO pricing is not without its own history. The Balanced Budget Act of 1997 included the competitive pricing demonstration program for Medicare. That provision was fought in the committee and fought in the Senate in 1997 by the HMO industry and certain Members of this body, but it prevailed. One by one, the HMO industry has been able to kill or has attempted to kill demonstrations which have been scheduled in many communities across the country. Today it is Arizona and Kansas City. The equation is pretty simple. It does not take rocket science to understand what is happening. Who benefits by continuing a system of paying Medicare HMOs that are not subject to competition? The HMOs benefit. Who loses when the same system is open to competition? The HMOs, because they no longer have the gravy train that exists today. Who gains by competition? Beneficiaries gain, particularly in rural areas which don't have managed care today. It would be the marketplace that would be establishing what the appropriate reimbursement level should be for an HMO in a currently unserved or underserved rural area--not a formula which underpays what the real cost of providing managed care would be in such an area. And the taxpayers lose because they do not get the benefit of the marketplace as a discipline of what the HMO's compensation should be. It is curious that out of one side of their mouth, they are screaming the current system of reimbursement is putting them out of business and causing them to have to leave hundreds of thousands of former HMO beneficiaries high and dry and also to curtail benefits such as prescription drugs, but at the same time, they are saying out of the left side of their mouth they are doing everything they can to prevent the insertion of competitive bidding as a means of establishing what their HMO contracts are really worth and what they should be paid. They cannot have it both ways. It takes a certain degree of political courage to make this reform happen. Let me give an example. In my own State of Florida, we were part of this demonstration project. We were selected to have a demonstration for Part B services for what are referred to as durable medical equipment. Lakeland, FL, was selected as the place to demonstrate the potential savings for medical equipment such as oxygen supplies and equipment, hospital beds and accessories, surgical dressings, enteral nutrition, and urological supplies. The savings that have been achieved in this project are impressive. They are 18-percent savings for oxygen supplies. I know the Senator from Iowa has stood on this floor and at times has even wrapped himself in medical bandages to demonstrate how much more Medicare was paying than, for instance, the Veterans' Administration for the same items. This competitive bidding process is attempting to bring the forces of the market into Medicare, and an 18-percent savings by competitively bidding oxygen supplies and equipment over the old formula we used to use. There were 30-percent savings for hospital beds and accessories, 13-percent savings for surgical dressings, 31 percent for enteral nutrition products, and 20 percent for urological supplies. It has been estimated if that Lakeland, FL, project were to be applied on a nationwide basis, the savings over 10 years would be in excess of $1 billion. We are not talking about small change. Beneficiaries have saved money from this demonstration, and access and quality have been preserved and protected. I find it troubling we are again today, as we were in July, debating, at the end of a major piece of legislation, a silently, surreptitiously included item which has the effect of sheltering HMOs from the marketplace. We might find some HMOs cannot compete and others will thrive, but that is what the marketplace should determine. That is what competition is all about. I urge my colleagues to examine this provision, to examine the implications of this provision in this kind of legislation and the restraints it imposes upon us, as Members of the Senate, to excise it as inappropriate legislative language on an appropriations bill. I hope our conferees, as they meet with the House, will resist the inclusion of this in the final legislation we might be asked to vote upon when this measure comes back from conference. This disserves the beneficiaries of the Medicare program. It disserves the taxpayers of America. It disserves the standards of public policy development by the Senate. I hope we will not have a further repetition of this stealth attack on the Medicare program. Mr. ASHCROFT. Mr. President, I took great interest in the statement that Senator from Florida (Mr. Graham) made expressing his displeasure that this legislation contains [[Page S12191]] a provision--Section 214--halting implementation of the Medicare Prepaid Competitive Pricing Demonstration Project both in Arizona and in the Kansas City metropolitan area. The Senator from Florida claimed that the inclusion of this provision was accomplished by HMOs. I would like to take this opportunity to point out to him that it was Medicare beneficiaries and doctors who alerted me to their grave concerns that the project would create huge patient disruption in the Kansas City area. In fact, after the Senator from Florida made similar remarks during debate on the Patient's Bill of Rights legislation regarding a similar provision in that bill, the Metropolitan Medical Society of Greater Kansas City wrote him a letter conveying their concerns with the implementation of the demonstration project in Kansas City, and expressing support for congressional efforts to stop the demonstration in their area. I ask unanimous consent that a copy of this letter be inserted in the record at the conclusion of my remarks. The PRESIDING OFFICER. Without objection, it is so ordered. (See exhibit 1.) Mr. ASHCROFT. After hearing from a number of doctors and patients in my State over the past few months, I concluded that Kansas City is an inappropriate location for this project and that it will jeopardize the health care benefits that seniors currently enjoy in the area. I believe that halting this project is necessary to protect the health care of senior citizens and to assure that Medicare beneficiaries continue to have access to excellent health care at prices they can afford. HCFA's project is a clear and present danger to the health and well-being of my constituents. The Balanced Budget Act of 1997 created the Medicare Prepaid Competitive Pricing Demonstration Project to use competitive bidding among Medicare HMOs. Through the appointment of a Competitive Pricing Advisory Committee, HCFA was to select demonstration sites around the nation. Kansas City was one of the selected cities. As I understand it, the intent of the project was to bring greater competition to the Medicare managed care market, to address concerns that Medicare HMO reimbursement rates in some areas are too high, to expand benefits for Medicare HMO enrollees, and to restrain the cost of Medicare to the taxpayers. When considering these factors, it is clear that the Kansas City metropolitan area is not an appropriate choice for this demonstration. First, managed care competition in the Kansas City market is already vigorous, with six managed care companies currently offering Medicare HMOs in the area. Participation in Medicare HMOs is also high: As of July 1 of this year, nearly 23% of Medicare recipients in the Kansas City metropolitan area were in Medicare+Choice plans--approximately 50,000 of 230,000 total beneficiaries. Nationally, only 17% of Medicare recipients are enrolled in such plans. Second, Medicare managed care payments in the Kansas City area are below the national average. According to a recent analysis by the Congressional Research Service of the Library of Congress, 1999 payment rates per Medicare+Choice enrollee in Kansas City are $511, while the national rate is $541. Documents provided to me by HCFA also demonstrate that 75 other cities had a higher adjusted average per capita cost (AAPCC) rate for 1997 than Kansas City. I wonder why Kansas City was chosen for this experiment, when so many other cities have higher payment rates. Third, I am concerned that this demonstration project will not provide expanded benefits to Medicare HMO enrollees, but will instead cause severe disruption of Medicare services. It is important to note that customer dissatisfaction is low in current Medicare managed care plans in the Kansas City area. Only one in twelve seniors disenrolls from Medicare HMOs each year. Currently, 33,000, or 66% of the seniors in Medicare managed care plans in the Kansas City area do not pay any premium. Under the bidding process set up by CPAC for the demonstration, a plan that bids above the enrollment-weighted median--which becomes the reimbursement rate for all plans--will be forced to charge seniors a premium to make up the difference between the plan's bid and the reimbursement rate paid by the government. In essence, the penalty for a high bid will be imposed upon seniors. Under this scenario, it is virtually assured that some seniors who pay no premium today will be required to start paying one. Moreover, seniors who cannot afford to pay a premium would be forced to abandon their regular doctor when it becomes necessary to change plans. Both individual doctors as well as the Metropolitan Medical Society of Greater Kansas City have warned that the demonstration could cause extreme disruption of beneficiaries away from current doctor- patient relationships. I have also heard concerns that both health plans and physicians may withdraw from the Medicare program if reimbursements under the demonstration project prove financially untenable. As a result, Medicare beneficiaries may be left with fewer choices in care. This would be intolerable. I question why we should implement a project that will create more risk and uncertainty for my State's seniors, who are already satisfied with what they have. Finally, I question how the demonstration project would be able to provide us with useful information on how to improve the Medicare program if fee-for-service plans--which are generally the most expensive Medicare option--are not included in the project. In its January 6, 1999 Design Report, the Competitive Pricing Advisory Committee expressed the judgment that the exclusion of fee-for-service might ``limit HCFA's ability (a) to measure the impact of competitive pricing and (b) to generalize demonstration results to the entire Medicare program.'' After studying this issue, I concluded that implementation of the Medicare Managed Care Demonstration Project in the Kansas City metropolitan area should be halted immediately. HCFA must not be allowed to risk the ability of my State's seniors to continue to receive high quality health care at affordable costs. I have been working closely with my Senate colleagues from Missouri and Kansas to protect our Kansas City area seniors from the dangers and uncertainty of a planned federal experiment with their health care arrangements. So, I want to make clear to my colleague from Florida that patients and doctors speaking on behalf of their patients were the ones who approached me and asked for my assistance in stopping the Medicare managed care demonstration project in the Kansas City area. I heard from a number of individual doctors, as well as medical societies in the State, expressing grave concerns about the project. The President of the Metropolitan Medical Society of Greater Kansas City even made the prediction that the unintended risk of the demonstration ``could dictate 100% disruption of beneficiaries away from their current relationships'' with their doctors. Clearly, this is unacceptable. Inclusion, Mr. President, I would like to quote from some of the letters I received from the seniors themselves, voicing their opposition to the Medicare managed care demonstration project coming to their area. Elizabeth Weekley Sutton, of Independence, Missouri, wrote to me: Dear Senator Ashcroft: We need help. My husband, my friends, and I are very concerned and worried that our health care will be very limited by the end of the Competitive Pricing Demonstration that will be starting in January. Of all the HMO's in the U.S., only the entire K.C. area and Maricopa County in Arizona will be conducting this competition for the next 5 years! And here are some excerpts from a letter sent by Edward Smith of Platte City, Missouri: I am totally opposed to the Health Care Financing Administration competitive pricing demonstration project to take place here in the Kansas City area. My health will not permit me to be a guinea pig for a total of five years when the rest of the country will have business as usual. He continues: Instead of the Health Care Financing Administration determining what is best for the beneficiaries I would prefer to do that myself. And finally, Mr. Smith says: If this plan is adopted my HMO could choose to leave the market. Then what is gained? Certainly not my health. Mr. President, we need to listen to the voice of our seniors. We cannot afford to jeopardize their health with a [[Page S12192]] risky experiment that could raise costs, limit choices, and cause doctor-patient disruption. For this reason, I have continued--and will continue--to work to halt this project in its present form in the Kansas City area. Exhibit 1 Metropolitan Medical Society of Greater Kansas City, July 21, 1999. Hon. Bob Graham, U.S. Senate, Washington, DC. Dear Senator Graham: I was concerned to read in the July 16, 1999, Congressional Record your dissatisfaction about the Senate's passage of the moratorium on the Medicare Prepaid Competitive Pricing Demonstration Project in Kansas City and Arizona. On behalf of the more than 2500 physicians of the Metropolitan Medical Society of Greater Kansas City and its affiliated organizations, I want to assure you that doctors strongly support the moratorium that was passed in the Senate Patient Bill of Rights legislation last week. The physicians of Kansas City have expressed serious concerns about the demonstration project since April, and we continue to be concerned. We believe the experiment will bring unacceptable levels of disruption to our Medicare patients and the local health care market. Additionally, I worry that quality care, which is often more expensive, will be less available to Medicare patients. In Kansas City, the opposition to the project is widespread. Our senators acted on behalf of our entire health care community, including patients, doctors, hospitals, and health care plans. The medical community has participated in the discussions about the demonstration with the Health Care Financing Administration (HCFA) and the local Area Advisory Committee for the demonstration project. Despite these discussions, problems with the experiment remain. We support congressional efforts to stop the demonstration project in the Kansas City area. I remain concerned that under-funded HMOs place our most vulnerable Medicare recipients at risk of getting less attention to their health care needs. I expect to hear more cases of catastrophes to Medicare recipients when the care given is too little, too late. You may be aware that Jacksonville, Florida is another potential site for the demonstration. Thank you for your consideration of my concerns. I hope I've helped to clarify the existence of broad based support in Kansas City for the moratorium on the competitive pricing demonstration. Sincerely, Richard Hellman, MD, President-Elect and Chair, National Government Relations Committee. amendment no. 1845 (Purpose: To express the sense of the Senate regarding school infrastructure) The PRESIDING OFFICER (Mr. Smith of Oregon). The Senator from Iowa. Mr. HARKIN. Mr. President, Senator Robb and I have an amendment at the desk. I call it up at this time, No. 1845. The PRESIDING OFFICER. The clerk will report. The legislative clerk read as follows: The Senator from Iowa [Mr. Harkin], for himself, and Mr. Robb, proposes an amendment numbered 1845. Mr. HARKIN. Mr. President, I ask unanimous consent that reading of the amendment be dispensed with. The PRESIDING OFFICER. Without objection, it is so ordered. The amendment is as follows: At the end of title III, add the following: SEC. ____. SENSE OF THE SENATE REGARDING SCHOOL INFRASTRUCTURE. (a) Findings.--The Senate makes the following findings: (1) The General Accounting Office has performed a comprehensive survey of the Nation's public elementary and secondary school facilities and has found severe levels of disrepair in all areas of the United States. (2) The General Accounting Office has concluded that more than 14,000,000 children attend schools in need of extensive repair or replacement, 7,000,000 children attend schools with life threatening safety code violations, and 12,000,000 children attend schools with leaky roofs. (3) The General Accounting Office has found the problem of crumbling schools transcends demographic and geographic boundaries. At 38 percent of urban schools, 30 percent of rural schools, and 29 percent of suburban schools, at least one building is in need of extensive repair or should be completely replaced. (4) The condition of school facilities has a direct affect on the safety of students and teachers and on the ability of students to learn. Academic research has provided a direct correlation between the condition of school facilities and student achievement. At Georgetown University, researchers have found the test scores of students assigned to schools in poor condition can be expected to fall 10.9 percentage points below the test scores of students in buildings in excellent condition. Similar studies have demonstrated up to a 20 percent improvement in test scores when students were moved from a poor facility to a new facility. (5) The General Accounting Office has found most schools are not prepared to incorporate modern technology in the classroom. Forty-six percent of schools lack adequate electrical wiring to support the full-scale use of technology. More than a third of schools lack the requisite electrical power. Fifty-six percent of schools have insufficient phone lines for modems. (6) The Department of Education has reported that elementary and secondary school enrollment, already at a record high level, will continue to grow over the next 10 years, and that in order to accommodate this growth, the United States will need to build an additional 6,000 schools. (7) The General Accounting Office has determined the cost of bringing schools up to good, overall condition to be $112,000,000,000, not including the cost of modernizing schools to accommodate technology, or the cost of building additional facilities needed to meet record enrollment levels. (8) Schools run by the Bureau of Indian Affairs (BIA) for Native American children are also in dire need of repair and renovation. The General Accounting Office has reported that the cost of total inventory repairs needed for BIA facilities is $754,000,000. The December 1997 report by the Comptroller General of the United States states that, ``Compared with other schools nationally, BIA schools are generally in poorer physical condition, have more unsatisfactory environmental factors, more often lack key facilities requirements for education reform, and are less able to support computer and communications technology.''. (9) State and local financing mechanisms have proven inadequate to meet the challenges facing today's aging school facilities. Large numbers of local educational agencies have difficulties securing financing for school facility improvement. (10) The Federal Government has provided resources for school construction in the past. For example, between 1933 and 1939, the Federal Government assisted in 70 percent of all new school construction. (11) The Federal Government can support elementary and secondary school facilities without interfering in issues of local control, and should help communities leverage additional funds for the improvement of elementary and secondary school facilities. (b) Sense of the Senate.--It is the sense of the Senate that Congress should provide at least $3,700,000,000 in Federal resources to help communities leverage funds to modernize public school facilities. Mr. HARKIN. Mr. President, Senator Robb and I are going to take a few minutes. I know the time is late. I know people want to get to a final vote on this. I want to talk about how good this bill is and to urge people to vote for it. This is a sense-of-the-Senate resolution. I will not go through the whole thing. It basically is a sense-of-the-Senate resolution saying Congress should appropriate at least $3.7 billion in Federal resources to help communities leverage funds to modernize public school facilities, otherwise known as public school construction. What we have in this country is schools that are on the average 40 to 50 years old. We are getting great teachers, new methodologies, new math, new science, new reading programs, and the schools are crumbling down around us. They are getting older every day. Day after day, kids go to schools with leaky ceilings, inadequate heat, inadequate air conditioning for hot summer days and the fall when the school year is extended. They are finding a lot of these buildings still have asbestos in them, and it needs to be taken out. Yet we are shirking our responsibilities to refurbish, renovate, and rebuild the schools in this country. The General Accounting Office estimates 14 million American children attend classes in schools that are unsafe or inadequate. They estimate it will cost $112 billion to upgrade existing public schools to just ``good'' condition. In addition, the GAO reports 46 percent of schools lack adequate electrical wiring to support the full-scale use of technology. We want to get computers in the classrooms, we want to hook them to the Internet, and yet almost 50 percent of the schools in this country are inadequate in their internal wiring so kids cannot hook up with the Internet. The American Society of Civil Engineers reports public schools are in worse condition than any other sector of our national infrastructure. Think about that. According to the American Society of Civil Engineers--they are the ones who build our buildings, build our bridges and roads and highways and streets and sewers and water systems, and our schools--they say our schools are in the worst state of any part of the physical infrastructure of this country. Mr. HARKIN. Mr. President, if the nicest things our kids ever see or go to [[Page S12193]] is shopping malls and sports arenas and movie theaters, and the most run-down places are their schools, what kind of signal are we sending them about the value we place on education and their future? This is a sense-of-the-Senate resolution which simply outlines the terrible situation we have in this country and calls on the Senate and the Congress to respond by providing at least $3.7 billion, a small fraction of what is needed but a step in the right direction--$3.7 billion in Federal resources to modernize our Nation's schools. I yield the floor to my distinguished colleague and cosponsor, Senator Robb. The PRESIDING OFFICER. The Senator from Virginia. Mr. ROBB. Mr. President, I thank my friend and colleague from Iowa. Senator Harkin and I have offered a sense of the Senate amendment relating to school construction, as Senator Harkin has just explained. The amendment is not unlike the amendment Senators Lautenberg, Harkin, and I offered to the Budget Resolution earlier this year. That amendment assumed that given the levels in the budget resolution, Congress would enact ``legislation to allow States and school districts to issue at least $24.8 billion worth of zero-interest bonds to rebuild and modernize our nation's schools, and to provide Federal income tax credits to the purchasers of those bonds in lieu of interest payments.'' The actual cost as it was scored was referred to by the Senator from Iowa. That amendment was accepted and put the entire Senate on record as supporting the concept of providing federal assistance in the area of school construction and renovation. Understanding that Rule 16 prevents us from doing anything of significance at this time with respect to school construction, Senator Harkin and I in just a moment will withdraw our amendment. But every day that passes, this Congress misses an opportunity to help our States and localities fix the leaky roofs, get rid of all the trailers, and install the wiring needed to bring technology to all of our children. These are real problems--problems that our nation's mayors, school boards, and families simply need some help in addressing. While school infrastructure improvement is typically a local responsibility, it is now a national need. Our schools, as the Senator from Iowa has indicated, are over 40 years old, on average; our school- aged population is at record levels; and our States and localities can't keep up, despite their surpluses. Abstract talk about State surpluses provides little solace to our nation's teachers and students who are forced to deal with wholly inadequate conditions. In Alabama, the roof of an elementary school collapsed. Fortunately, it occurred just after the children had left for the day. In Chicago, teachers place cheesecloth over air vents to filter out lead-based paint flecks. In Maine, teachers have to turn out the lights when it rains because their electrical wiring is exposed under their leaky roofs. Mr. President, we are missing an opportunity to help our States and localities with a pressing need. I will continue to work for and press forward on this issue because I think it's an area where the Federal Government can be extremely constructive. When our children are asked about ``Bleak House,'' they should refer to a novel by Dickens and not the place where they go to school. In my own State of Virginia, there are over 3,000 trailers being used to educate students. And there are over $4 billion worth of unbudgeted, unmet needs for our schools. This is a problem that is not going to go away, and it's a problem that our nation's schools need our help to solve. And I regret that Rule 16 precludes us from considering legislation which would reaffirm the commitment that we made earlier this year. I thank the distinguished Senator from Iowa for his continued work on the subject of school construction, and I yield the floor. Amendment No. 1845 Withdrawn The PRESIDING OFFICER. The Senator from Iowa. Mr. HARKIN. Mr. President, I understand this amendment is not acceptable to the other side. It is late in the day. I know people have to get on with other things, and we want to get to a final vote on the bill. I believe strongly in this. It is a sense-of-the-Senate amendment. Also, Senators Kennedy, Reid, Murray, and Johnson are added as cosponsors. In the spirit of moving this bill along and trying to wrap this up as quickly as possible, I ask unanimous consent to withdraw the amendment at this time, but it will be revisited. The PRESIDING OFFICER. The Senator from Pennsylvania. Mr. SPECTER. I thank my distinguished colleague. I am very sympathetic to the purpose of the sense-of-the-Senate amendment. He is correct; there would be objection, and I think it would not be adopted. I thank him for withdrawing the amendment. The PRESIDING OFFICER. The amendment is withdrawn. Amendments Nos. 2273 through 2289, 1852, 1869, and 1882 Mr. SPECTER. Mr. President, I now submit the managers' package which has been cleared on both sides. The PRESIDING OFFICER. The clerk will report. The legislative clerk read as follows: The Senator from Pennsylvania [Mr. Specter] proposes amendments numbered 2273 through 2289, 1852, 1869 and 1882. The amendments are as follows: amendment no. 2273 At the appropriate place in the bill add the following: SEC. . CONFOUNDING BIOLOGICAL AND PHYSIOLOGICAL INFLUENCES ON POLYGRAPHY. (a) Findings.--The Senate finds that-- (1) The use of polygraph tests as a screening tool for federal employees and contractor personnel is increasing. (2) A 1983 study by the Office of Technology Assessment found little scientific evidence to support the validity of polygraph tests in such screening applications. (3) The 1983 study further found that little or no scientific study had been undertaken on the effects of prescription and non-prescription drugs on the validity of polygraph tests, as well as differential responses to polygraph tests according to biological and physiological factors that may vary according to age, gender, or ethnic backgrounds, or other factors relating to natural variability in human populations. (4) A scientific evaluation of these important influences on the potential validity of polygraph tests should be studied by a neutral agency with biomedical and physiological expertise in order to evaluate the further expansion of the use of polygraph tests on federal employees and contractor personnel. (b) Sense of the Senate.--It is the Sense of the Senate that the Director of the National Institutes of Health should enter into appropriate arrangements with the National Academy of Sciences to conduct a comprehensive study and investigation into the scientific validity of polygraphy as a screening tool for federal and federal contractor personnel, with particular reference to the validity of polygraph tests being proposed for use in proposed rules published at 64 Fed. Reg. 45062 (August 18, 1999). ____ AMENDMENT NO. 2274 (Purpose: To provide funding for a dental sealant demonstration program) At the end of title II, add the following: dental sealant demonstration program Sec. ____. From amounts appropriated under this title for the Health Resources and Services Administration, sufficient funds are available to the Maternal Child Health Bureau for the establishment of a multi-State preventive dentistry demonstration program to improve the oral health of low- income children and increase the access of children to dental sealants through community- and school-based activities. ____ AMENDMENT NO. 2275 (Purpose: To limit the withholding of substance abuse funds from certain States) At the end of title II, add the following: withholding of substance abuse funds Sec. ____. (a) In General.--None of the funds appropriated by this Act may be used to withhold substance abuse funding from a State pursuant to section 1926 of the Public Health Service Act (42 U.S.C. 300x-26) if such State certifies to the Secretary of Health and Human Services that the State will commit additional State funds, in accordance with subsection (b), to ensure compliance with State laws prohibiting the sale of tobacco products to individuals under 18 years of age. (b) Amount of State Funds.--The amount of funds to be committed by a State under subsection (a) shall be equal to one percent of such State's substance abuse block grant allocation for each percentage point by which the State misses the retailer compliance rate goal established by the Secretary of Health and Human Services under section 1926 of such Act, except that the Secretary may agree to a smaller commitment of additional funds by the State. (c) Supplement not Supplant.--Amounts expended by a State pursuant to a certification under subsection (a) shall be used to supplement and not supplant State funds [[Page S12194]] used for tobacco prevention programs and for compliance activities described in such subsection in the fiscal year preceding the fiscal year to which this section applies. (d) The Secretary shall exercise discretion in enforcing the timing of the State expenditure required by the certification described in subsection (a) as late as July 31, 2000. ____ AMENDMENT NO. 2276 (Purpose: To express the sense of the Senate that funding for prostate cancer research should be increased substantially) At the appropriate place add the following: Sec. ____. (a) Findings.--Congress makes the following findings: (1) In 1999, prostate cancer is expected to kill more than 37,000 men in the United States and be diagnosed in over 180,000 new cases. (2) Prostate cancer is the most diagnosed nonskin cancer in the United States. (3) African Americans have the highest incidence of prostate cancer in the world. (4) Considering the devastating impact of the disease among men and their families, prostate cancer research remains underfunded. (5) More resources devoted to clinical and translational research at the National Institutes of Health will be highly determinative of whether rapid advances can be attained in treatment and ultimately a cure for prostate cancer. (6) The Congressionally Directed Department of Defense Prostate Cancer Research Program is making important strides in innovative prostate cancer research, and this Program presented to Congress in April of 1998 a full investment strategy for prostate cancer research at the Department of Defense. (7) The Senate expressed itself unanimously in 1998 that the Federal commitment to biomedical research should be doubled over the next 5 years. (b) Sense of the Senate.--It is the sense of the Senate that-- (1) finding treatment breakthroughs and a cure for prostate cancer should be made a national health priority; (2) significant increases in prostate cancer research funding, commensurate with the impact of the disease, should be made available at the National Institutes of Health and to the Department of Defense Prostate Cancer Research Program; and (3) these agencies should prioritize prostate cancer research that is directed toward innovative clinical and translational research projects in order that treatment breakthroughs can be more rapidly offered to patients. ____ amendment no. 2277 On page 59, line 25, strike ``$1,404,631,000'' and insert ``$1,406,631,000'' in lieu thereof. On page 60, before the period on line 10, insert the following: ``: Provided further, That $2,000,000 shall be for carrying out Part C of Title VIII of the Higher Education Amendments of 1998.'' On page 62, line 23, decrease the figure by $2,000,000. ____ amendment no. 2278 (Purpose: To clarify provisions relating to the United States-Mexico Border Health Commission) At the appropriate place, insert the following: Sec. . The United States-Mexico Border Health Commission Act (22 U.S.C. 290n et seq.) is amended-- (1) by striking section 2 and inserting the following: ``SEC. 2. APPOINTMENT OF MEMBERS OF BORDER HEALTH COMMISSION. ``Not later than 30 days after the date of enactment of this section, the President shall appoint the United States members of the United States-Mexico Border Health Commission, and shall attempt to conclude an agreement with Mexico providing for the establishment of such Commission.''; and (2) in section 3-- (A) in paragraph (1), by striking the semicolon and inserting ``; and''; (B) in paragraph (2)(B), by striking ``; and'' and inserting a period; and (C) by striking paragraph (3). ____ amendment no. 2279 On page 50, line 17, strike ``$459,000,000'' and insert in lieu thereof ``$494,000,000''. ____ amendment no. 2280 On page 66, line 24, strike out all after the colon up to the period on line 18 of page 67. ____ amendment no. 2281 On page 42, before the period on line 8, insert the following: ``: Provided further, That sufficient funds shall be available from the Office on Women's Health to support biological, chemical and botanical studies to assist in the development of the clinical evaluation of phytomedicines in women's health''. ____ amendment no. 2282 (Purpose: To provide for a report on promoting a legal domestic workforce and improving the compensation and working conditions of agricultural workers) On page 19, line 6, insert before the period the following: ``: Provided further, That funds made available under this heading shall be used to report to Congress, pursuant to section 9 of the Act entitled `An Act to create a Department of Labor' approved March 4, 1913 (29 U.S.C. 560), with options that will promote a legal domestic work force in the agricultural sector, and provide for improved compensation, longer and more consistent work periods, improved benefits, improved living conditions and better housing quality, and transportation assistance between agricultural jobs for agricultural workers, and address other issues related to agricultural labor that the Secretary of Labor determines to be necessary''. ____ AMENDMENT NO. 2283 (Purpose: To express the sense of the Senate concerning women's access to obstetric and gynecological services) Beginning on page 1 of the amendment, strike all after the first word and insert the following: ____. SENSE OF THE SENATE ON WOMEN'S ACCESS TO OBSTETRICAND GYNECOLOGICAL SERVICES. (a) Findings.--Congress makes the following findings: (1) In the 1st session of the 106th Congress, 23 bills have been introduced to allow women direct access to their ob-gyn provider for obstetric and gynecologic services covered by their health plans. (2) Direct access to ob-gyn care is a protection that has been established by Executive Order for enrollees in medicare, medicaid, and Federal Employee Health Benefit Programs. (3) American women overwhelmingly support passage of federal legislation requiring health plans to allow women to see their ob-gyn providers without first having to obtain a referral. A 1998 survey by the Kaiser FamilyFoundation and Harvard University found that 82 percent of Americans support passage of a direct access law. (4) While 39 States have acted to promote residents' access to ob- gyn providers, patients in other State- or in Federally-governed health plans are not protected from access restrictions or limitations. (5) In May of 1999 the Commonwealth Fund issued a survey on women's health, determining that 1 of 4 women (23 percent) need to first receive permission from their primary care physician before they can go and see their ob-gyn provider for covered obstetric or gynecologic care. (6) Sixty percent of all office visits to ob-gyn providers are for preventive care. (b) Sense of the Senate.--It is the sense of the Senate that Congress should enact legislation that requires health plans to provide women with direct access to a participating health provider who specializes in obstetrics and gynecological services, and that such direct access should be provided for all obstetric and gynecologic care covered by their health plans, without first having to obtain a referral from a primary care provider or the health plan. Mrs. MURRAY. Mr. President, included in the Manager's amendment is an important provision relating to women's health and access to reproductive health care services. I am pleased to have worked with the managers of this bill to send a strong message on the importance of direct access for women to their OB/GYN. I was disappointed that we were unable to address the rule XVI concerns with the amendment I had originally filed. My original amendment would simply allow women and their OB/GYNs to make important health care decisions without barriers or obstacles erected by insurance company policies. My amendment would have required that health plans give women direct access to their OB/GYN for all gynecological and obstetrical care and would have prohibited insurance companies from standing between a woman and her OB/GYN. However, it has been determined that my amendment would violate rule XVI. As a result of the announcement by the chairman of the Senate Appropriations Committee that he will make a point of order against all amendments that may violate rule XVI, I have modified my amendment. The modification still allows Members of the Senate to be on record in support of women's health or in opposition to removing barriers that hinder access for women to critical reproductive health care services. I am offering a sense-of-the-Senate that puts this question to each Member. I realize that this amendment is not binding, but due to opposition to my original amendment, I have been forced to offer this sense-of-the-Senate. I am disappointed that we could not act to provide this important protection to women, but I do believe this amendment will send an important message that the U.S. Senate does support greater access for women to quality health care benefits. I have offered this amendment due to my frustration and disappointment with managed care reform. I have become frustrated by stalling tactics and empty promises. The managed care reform bill that passed the Senate has [[Page S12195]] been referred to as an empty promise for women. I can assure my colleagues that women are much smarter than they may expect and will not be fooled by empty promises or arguments of procedural discipline. When a woman is denied direct access to the care provided by her OB/ GYN, she will not be interested in a discussion on ERISA or rule XVI. She wants direct access to her OB/GYN. She needs direct access, and she should have direct access. My amendment also reiterates the importance of ensuring that the OB/ GYN remains the coordinating physician. Any test or additional referral would be treated as if made by the primary care physician. This amendment does not call for the designation of an OB/GYN as a primary care physician, it simply says that if the OB/GYN decides additional care is necessary, the patient is not forced to seek approval from a primary care physician, who may not be familiar with her overall health care status. Why is this amendment important? The number one reason most women enter the health care system is to seek gynecological or obstetric care. This is the primary point of entry for women into the health care system. For most women, including myself, we consider our OB/GYN our primary care physician--maybe not as an insurance company defines it-- but, in practice, that's the reality. Does a woman go to her OB/GYN for an ear infection? No. But, does a pregnant woman consult with her OB/GYN prior to taking any antibiotic for the treatment of an ear infection? Yes, most women do. I know the policy endorsed in this amendment has in the past enjoyed bipartisan support. The requirements are similiar to S. 836, legislation introduced by Senator Specter and cosponsored by several Senators both Republican and Democrat. This amendment is similar to language that was adopted during committee consideration in the House of the fiscal year 1999 Labor, HHS appropriations bill. A similar directive is contained in the bipartisan House Patients' Bill of Rights legislation. It has the strong support of the American College of Obstetricians and Gynecologists and I know I have heard from several OB/GYNs in my own state testifying to the importance of direct access to the full range of care provided, not just routine care. I would also like to point out to my colleagues, that 39 states have similar requirements and that as participants in the Federal Employees Health Benefit Plan, all of us--as Senators--have this same guarantee as well as our family members. If we can guarantee this protection for ourselves and our families, we should do the same for women participating in a manager care plan. I realize that this appropriations bill may not be the best vehicle for offering this amendment. However, I have waited for final action on a Patients' Bill of Rights for too long. I have watched as patient protection bills have been stalled or delayed. Last year we were told that we would finish action on a good Patients' Bill of Rights package prior to adjournment. Well, here we sit--almost 12 months later--with little hope of finishing a good, comprehensive managed care reform bill prior to our scheduled adjournment this year. I also want to remind my colleagues that we have in the past used appropriations bills to address deficiencies in current law or to address an urgent need for action. I believe that addressing an urgent need in women's health care qualifies as a priority that we must address. I realize that the authorizing committee has objected to the original amendment I filed. As a member of the authorizing committee as well, I can understand this objection. But, again I have little choice but to proceed on this appropriations bill. We all know that it was only recently on the fiscal year 1999 supplemental appropriations bill that we authorized a significant change in Medicaid recoupment provisions despite strong objections from the Finance Committee. In last year's omnibus appropriations bill, we authorized a requirement that insurance companies must cover breast reconstruction surgery following a mastectomy. I can assure my colleagues that this provision never went through the authorizing committee. I would also point out that there are several antichoice riders contained in this appropriations bill that represent a major authorization. As these examples show, when we have to address these types issues through appropriations bills--we can do it. We have done it in the past, and we should do it today to meet this need. I urge my colleagues to support this amendment. We all talk about the need to ensure access for women to health care. I applaud Chairman Specter's efforts in this appropriations bill regarding women's health care. Adopting this amendment gives us the opportunity to do something that does ensure greater access for women. This is what women want. This is the chance for Senators to show their commitment to this critical benefit. I would like to quote a statement made by our subcommittee chairman that I believe more eloquently explains why I am urging this amendment. ``I believe it is clear that access to women's health care cuts across the intricacies of the complicated and often divisive managed care debate.'' I could not agree more. We know from the current state requirement and the Federal Employee Health Benefit Program requirement, this provision does not have a significant impact on costs of health care. We also know from experience that it has a positive impact on health care benefits. Since 60 percent of office visits to OB/GYNs are for preventive care, we could make the argument that adoption of this policy would reduce the overall costs of health care. I urge my colleagues to support this amendment and ask that we do more than simply make empty promises to women. We need an honest and

Summary:

All articles in Senate section

DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION AND RELATED AGENCIES APPROPRIATIONS ACT, 2000--Continued
(Senate - October 07, 1999)

Text of this article available as: TXT PDF [Pages S12188-S12215] DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION AND RELATED AGENCIES APPROPRIATIONS ACT, 2000--Continued Mr. SPECTER. Mr. President, I ask unanimous consent that we turn to the Senator from---- Mr. REID. Mr. President, will the Senator yield? Mr. SPECTER. Florida for 15 minutes. Mr. REID. Mr. President, will the Senator yield for a brief statement? Mr. SPECTER. Pardon me. I withdraw that because the Senators from New Mexico were here sequenced ahead of Senator Graham. Mr. REID. Mr. President, I appreciate the statements of the chairman of the Judiciary Committee and the statement of the Senator from Pennsylvania on the judicial controversy. I hope we can end all of that this afternoon and get this bill completed because now we have people on our side wanting to come and talk about this matter dealing with Judge White. I hope we can move and get this bill finished before we have further speeches on this judicial controversy. Mr. SPECTER. Mr. President, I ask unanimous consent that the remainder [[Page S12189]] of the time on this bill be directed to the amendment of the Senators from New Mexico, then 15 minutes to Senator Graham of Florida, then 10 minutes to be equally divided between the managers of the bill, and then go to final passage. Mr. REID. Reserving the right to object, if the ranking member of the Judiciary Committee wants to come over and speak on the judicial controversy, I want him to have 15 minutes, the same amount of time the chairman of the Judiciary Committee had. Mr. SPECTER. I incorporate that in the unanimous consent request. Mr. KENNEDY. If I could have 2 minutes. Mr. SPECTER. Two minutes for Senator Kennedy. Mr. INHOFE. Mr. President, reserving the right to object, for what purpose would the Senator be yielding to the Senator from Florida? Are we back on the judicial nominations? Mr. SPECTER. He is speaking on the bill. Mr. INHOFE. Is this on the nomination? Mr. SPECTER. Unless Senator Leahy comes and claims the time which Senator Reid has asked for. Mr. INHOFE. No objection. The PRESIDING OFFICER. Is there objection? Mr. HARKIN. Reserving the right to object. Mr. SPECTER. We added 5 more minutes for Senator Harkin: the managers, 15 minutes; Senator Harkin, 10; myself, 5. Mr. REID. And Senator Kennedy for 2 minutes. Mr. DOMENICI. I ask if Senator Kennedy is on the bill or something else? Mr. KENNEDY. All I want to do, indirectly on the bill, is just to announce that the House of Representatives passed the Patients' Bill of Rights 275-149. This is a hard-won victory for millions of patients and families throughout America, and a well-deserved defeat for HMOs and the Republican extremists in the House who put managed care profits ahead of patients' health. The Senate flunked this test in July, but the House has given us a new chance to do the right thing. The House-Senate conference should adopt the Norwood-Dingell provisions, without the costly and ineffective tax breaks added by House Republicans. Mr. DOMENICI. The Senator did it. Does he still need the 2 minutes? Mr. KENNEDY. No. I don't need the 2 minutes. I thank the Senator very much. Mr. SPECTER. Mr. President, exclude Senator Kennedy from the unanimous consent request. The PRESIDING OFFICER. Without objection, it is so ordered. Mr. SPECTER. Mr. President, I ask that we turn to the Senators from New Mexico. Mr. DOMENICI. Senator Bingaman has the floor. The PRESIDING OFFICER. The Senator from New Mexico. Amendment No. 2272 (Purpose: To require the Secretary of Health and Human Services to conduct a study on the geographic adjustment factors used in determining the amount of payment for physicians' services under the medicare program) Mr. BINGAMAN. Mr. President, I send an amendment to the desk. The PRESIDING OFFICER. The clerk will report. The legislative clerk read as follows: The Senator from New Mexico (Mr. Bingaman), for himself, and Mr. Domenici, proposes an amendment numbered 2272. Mr. BINGAMAN. Mr. President, I ask unanimous consent that reading of the amendment be dispensed with. The PRESIDING OFFICER. Without objection, it is so ordered. The amendment is as follows: At the end of title II, add the following: SEC. 216. STUDY AND REPORT ON THE GEOGRAPHIC ADJUSTMENT FACTORS UNDER THE MEDICARE PROGRAM. (a) Study.--The Secretary of Health and Human Services shall conduct a study on-- (1) the reasons why, and the appropriateness of the fact that, the geographic adjustment factor (determined under paragraph (2) of section 1848(e) (42 U.S.C. 1395w-4(e)) used in determining the amount of payment for physicians' services under the medicare program is less for physicians' services provided in New Mexico than for physicians' services provided in Arizona, Colorado, and Texas; and (2) the effect that the level of the geographic cost-of- practice adjustment factor (determined under paragraph (3) of such section) has on the recruitment and retention of physicians in small rural states, including New Mexico, Iowa, Louisiana, and Arkansas. (b) Report.--Not later than 3 months after the date of enactment of this Act, the Secretary of Health and Human Services shall submit a report to Congress on the study conducted under subsection (a), together with any recommendations for legislation that the Secretary determines to be appropriate as a result of such study. Mr. BINGAMAN. Mr. President, this is an amendment that Senator Domenici and I are offering to direct the Secretary of Health and Human Services to conduct a study of and the appropriateness of the geographic adjustment factor that is used in Medicare reimbursement calculations as it applies particularly to our State of New Mexico. We have a very serious problem in our State today; many of our physicians are leaving the State. The reimbursement that is available under Medicare, and accordingly under many of the health care plans in our State, is less for physicians performing procedures and practicing medicine in our State than it is in all of our surrounding States. We believe this is traceable to this adjustment factor, this geographic adjustment factor. This is a system that was put into place in 1992. It now operates, as I understand it, such that we have 89 geographic fee schedule payment areas in the country. We are not clear on the precise way in which our State has been so severely disadvantaged, but we believe it is a serious problem that needs attention. Our amendment directs that the Secretary conclude this study within 90 days, or 3 months, report back, and make recommendations on how to solve the problem. We believe it is a very good amendment. We recommend that Senators support the amendment. I yield the floor. The PRESIDING OFFICER. The Senator from New Mexico. Mr. DOMENICI. Mr. President, first, I am pleased to say I am a cosponsor of this amendment. I have helped Senator Bingaman with it. This is a good amendment. We aren't asking for any money. We are not asking that any law be changed. We are merely saying that something is not right for our State. The reimbursement--or some aspect of how we are paying doctors under Medicare--is causing us to have much lower fees than the surrounding States, and as a result two things are happening: One, doctors are leaving. In a State such as ours, we can ill afford that. Second, we are being told it is harder and harder to get doctors to come to our State. That was not the case years ago. They loved New Mexico. They came for lots of reasons. But certainly we cannot be an underprivileged State in terms of what we pay our doctors--be a poor State in addition--and expect our citizens to get good health care. We want to know what the real facts are: Why is this the case? Is it the result of the way the geographic evaluation is applied to our State because maybe rural communities aren't getting the right kind of emphasis in that formula? Whatever it is, we want to know. When we know, fellow Senators, we can assure Members, if we find out it is not right and it is not fair, we will be on the floor to talk about some real changes. Until we have that, we ask Members for help in obtaining a study. I yield the floor. Mr. SPECTER. The managers have taken a look at this amendment and are prepared to accept it. It is a good amendment. There is one concern, and that is a jurisdictional concern with respect to the Finance Committee. We have attempted to contact the chairman of the Finance Committee to see if there was any substantial reason we should not accept it. If it went to a vote, it would clearly be adopted. It merely asks for a report for a very good purpose. Therefore, the amendment is accepted. The PRESIDING OFFICER. The question is on agreeing to the amendment. The amendment (No. 2272) was agreed to. Mr. DOMENICI. I move to reconsider the vote. Mr. SPECTER. I move to lay that motion on the table. The motion to lay on the table was agreed to. [[Page S12190]] The PRESIDING OFFICER. The Senator from Florida. Mr. GRAHAM. Mr. President, I am here today, as I was in July, to point out to my colleagues another stealth effort to kill competition within the Medicare program. Title I, section 214, buried in the middle of this long appropriations bill on page 49, carries the following statement: None of the funds provided in this Act or in any other Act making appropriations for fiscal year 2000 may be used to administer or implement in Arizona or in Kansas City, Missouri or in the Kansas City, Kansas area the Medicare Competitive Pricing Demonstration Project operated by the Secretary of Health and Human Services under authority granted in the Balanced Budget Act of 1997. If that statement sounds familiar, it is. Almost the same language was buried in the HMO Patients' Bill of Rights bill as it passed the Senate back in July. It passed then undebated and undiscussed as to its implications--just as we are about to do here tonight. July's action was outrageous. This action is even more so. There is a certain irony here. We have just heard that the House of Representatives passed, by an overwhelming vote, a version of the HMO Patients' Bill of Rights which is very similar to the bipartisan bill offered but not considered in the Senate. Our bipartisan bill was strongly opposed by the HMO industry. Their basic argument is: let's keep government out of our business, let us operate based on a competitive model that will allow the consumer, the beneficiary of the HMO contract, to negotiate without government standards, without government sanctions for failure to deliver on those standards with the HMO industry. They wanted to have laissez-faire free enterprise; Adam Smith roams the land. However, today we are about to pass a provision that says when the HMOs are dealing with their pocketbook and the question of how they will get reimbursed, how much money they are going to get paid from Medicare, they don't want to have a free market of competition; they don't want to have a means by which the taxpayers can be assured what they are paying for the HMO product is what the market says they should be paying. There is a certain amount of irony there which I think underscores the motivations of a significant portion of this industry. There also is a procedural ploy here. If this provision I just quoted were to be offered as an amendment to this bill, it would be ruled out of order under rule XVI in part because it purports not only to control action in this act but in any other act that Congress might consider making in an appropriations bill. But this is not an amendment; this is in the bill itself as it has come out of the Appropriations Committee, and therefore rule XVI does not apply. Normally under the procedures the Congress has followed traditionally, we would be dealing with a House bill because the House traditionally has led in the appropriations process; therefore, we would be amending a House bill. Thus, we could have excised this provision. However, because we are violating tradition and taking up a Senate bill first, we do not have the opportunity to remove it by a point of order. I will state for the record that henceforth, when it is proposed we take up a Senate appropriations bill before a House bill, I am going to stand here and object. This is exactly the kind of procedural abuse we can expect in the future as is happening right now. If that isn't bad enough, this is just plain bad policy. It stifles innovation by eliminating the competitive demonstration which hopefully would have led to a competitive process of compensating HMOs. It forces Medicare to pay more than necessary for some services in certain areas of the country while it denies managed care to other areas of the country. This HMO pricing is not without its own history. The Balanced Budget Act of 1997 included the competitive pricing demonstration program for Medicare. That provision was fought in the committee and fought in the Senate in 1997 by the HMO industry and certain Members of this body, but it prevailed. One by one, the HMO industry has been able to kill or has attempted to kill demonstrations which have been scheduled in many communities across the country. Today it is Arizona and Kansas City. The equation is pretty simple. It does not take rocket science to understand what is happening. Who benefits by continuing a system of paying Medicare HMOs that are not subject to competition? The HMOs benefit. Who loses when the same system is open to competition? The HMOs, because they no longer have the gravy train that exists today. Who gains by competition? Beneficiaries gain, particularly in rural areas which don't have managed care today. It would be the marketplace that would be establishing what the appropriate reimbursement level should be for an HMO in a currently unserved or underserved rural area--not a formula which underpays what the real cost of providing managed care would be in such an area. And the taxpayers lose because they do not get the benefit of the marketplace as a discipline of what the HMO's compensation should be. It is curious that out of one side of their mouth, they are screaming the current system of reimbursement is putting them out of business and causing them to have to leave hundreds of thousands of former HMO beneficiaries high and dry and also to curtail benefits such as prescription drugs, but at the same time, they are saying out of the left side of their mouth they are doing everything they can to prevent the insertion of competitive bidding as a means of establishing what their HMO contracts are really worth and what they should be paid. They cannot have it both ways. It takes a certain degree of political courage to make this reform happen. Let me give an example. In my own State of Florida, we were part of this demonstration project. We were selected to have a demonstration for Part B services for what are referred to as durable medical equipment. Lakeland, FL, was selected as the place to demonstrate the potential savings for medical equipment such as oxygen supplies and equipment, hospital beds and accessories, surgical dressings, enteral nutrition, and urological supplies. The savings that have been achieved in this project are impressive. They are 18-percent savings for oxygen supplies. I know the Senator from Iowa has stood on this floor and at times has even wrapped himself in medical bandages to demonstrate how much more Medicare was paying than, for instance, the Veterans' Administration for the same items. This competitive bidding process is attempting to bring the forces of the market into Medicare, and an 18-percent savings by competitively bidding oxygen supplies and equipment over the old formula we used to use. There were 30-percent savings for hospital beds and accessories, 13-percent savings for surgical dressings, 31 percent for enteral nutrition products, and 20 percent for urological supplies. It has been estimated if that Lakeland, FL, project were to be applied on a nationwide basis, the savings over 10 years would be in excess of $1 billion. We are not talking about small change. Beneficiaries have saved money from this demonstration, and access and quality have been preserved and protected. I find it troubling we are again today, as we were in July, debating, at the end of a major piece of legislation, a silently, surreptitiously included item which has the effect of sheltering HMOs from the marketplace. We might find some HMOs cannot compete and others will thrive, but that is what the marketplace should determine. That is what competition is all about. I urge my colleagues to examine this provision, to examine the implications of this provision in this kind of legislation and the restraints it imposes upon us, as Members of the Senate, to excise it as inappropriate legislative language on an appropriations bill. I hope our conferees, as they meet with the House, will resist the inclusion of this in the final legislation we might be asked to vote upon when this measure comes back from conference. This disserves the beneficiaries of the Medicare program. It disserves the taxpayers of America. It disserves the standards of public policy development by the Senate. I hope we will not have a further repetition of this stealth attack on the Medicare program. Mr. ASHCROFT. Mr. President, I took great interest in the statement that Senator from Florida (Mr. Graham) made expressing his displeasure that this legislation contains [[Page S12191]] a provision--Section 214--halting implementation of the Medicare Prepaid Competitive Pricing Demonstration Project both in Arizona and in the Kansas City metropolitan area. The Senator from Florida claimed that the inclusion of this provision was accomplished by HMOs. I would like to take this opportunity to point out to him that it was Medicare beneficiaries and doctors who alerted me to their grave concerns that the project would create huge patient disruption in the Kansas City area. In fact, after the Senator from Florida made similar remarks during debate on the Patient's Bill of Rights legislation regarding a similar provision in that bill, the Metropolitan Medical Society of Greater Kansas City wrote him a letter conveying their concerns with the implementation of the demonstration project in Kansas City, and expressing support for congressional efforts to stop the demonstration in their area. I ask unanimous consent that a copy of this letter be inserted in the record at the conclusion of my remarks. The PRESIDING OFFICER. Without objection, it is so ordered. (See exhibit 1.) Mr. ASHCROFT. After hearing from a number of doctors and patients in my State over the past few months, I concluded that Kansas City is an inappropriate location for this project and that it will jeopardize the health care benefits that seniors currently enjoy in the area. I believe that halting this project is necessary to protect the health care of senior citizens and to assure that Medicare beneficiaries continue to have access to excellent health care at prices they can afford. HCFA's project is a clear and present danger to the health and well-being of my constituents. The Balanced Budget Act of 1997 created the Medicare Prepaid Competitive Pricing Demonstration Project to use competitive bidding among Medicare HMOs. Through the appointment of a Competitive Pricing Advisory Committee, HCFA was to select demonstration sites around the nation. Kansas City was one of the selected cities. As I understand it, the intent of the project was to bring greater competition to the Medicare managed care market, to address concerns that Medicare HMO reimbursement rates in some areas are too high, to expand benefits for Medicare HMO enrollees, and to restrain the cost of Medicare to the taxpayers. When considering these factors, it is clear that the Kansas City metropolitan area is not an appropriate choice for this demonstration. First, managed care competition in the Kansas City market is already vigorous, with six managed care companies currently offering Medicare HMOs in the area. Participation in Medicare HMOs is also high: As of July 1 of this year, nearly 23% of Medicare recipients in the Kansas City metropolitan area were in Medicare+Choice plans--approximately 50,000 of 230,000 total beneficiaries. Nationally, only 17% of Medicare recipients are enrolled in such plans. Second, Medicare managed care payments in the Kansas City area are below the national average. According to a recent analysis by the Congressional Research Service of the Library of Congress, 1999 payment rates per Medicare+Choice enrollee in Kansas City are $511, while the national rate is $541. Documents provided to me by HCFA also demonstrate that 75 other cities had a higher adjusted average per capita cost (AAPCC) rate for 1997 than Kansas City. I wonder why Kansas City was chosen for this experiment, when so many other cities have higher payment rates. Third, I am concerned that this demonstration project will not provide expanded benefits to Medicare HMO enrollees, but will instead cause severe disruption of Medicare services. It is important to note that customer dissatisfaction is low in current Medicare managed care plans in the Kansas City area. Only one in twelve seniors disenrolls from Medicare HMOs each year. Currently, 33,000, or 66% of the seniors in Medicare managed care plans in the Kansas City area do not pay any premium. Under the bidding process set up by CPAC for the demonstration, a plan that bids above the enrollment-weighted median--which becomes the reimbursement rate for all plans--will be forced to charge seniors a premium to make up the difference between the plan's bid and the reimbursement rate paid by the government. In essence, the penalty for a high bid will be imposed upon seniors. Under this scenario, it is virtually assured that some seniors who pay no premium today will be required to start paying one. Moreover, seniors who cannot afford to pay a premium would be forced to abandon their regular doctor when it becomes necessary to change plans. Both individual doctors as well as the Metropolitan Medical Society of Greater Kansas City have warned that the demonstration could cause extreme disruption of beneficiaries away from current doctor- patient relationships. I have also heard concerns that both health plans and physicians may withdraw from the Medicare program if reimbursements under the demonstration project prove financially untenable. As a result, Medicare beneficiaries may be left with fewer choices in care. This would be intolerable. I question why we should implement a project that will create more risk and uncertainty for my State's seniors, who are already satisfied with what they have. Finally, I question how the demonstration project would be able to provide us with useful information on how to improve the Medicare program if fee-for-service plans--which are generally the most expensive Medicare option--are not included in the project. In its January 6, 1999 Design Report, the Competitive Pricing Advisory Committee expressed the judgment that the exclusion of fee-for-service might ``limit HCFA's ability (a) to measure the impact of competitive pricing and (b) to generalize demonstration results to the entire Medicare program.'' After studying this issue, I concluded that implementation of the Medicare Managed Care Demonstration Project in the Kansas City metropolitan area should be halted immediately. HCFA must not be allowed to risk the ability of my State's seniors to continue to receive high quality health care at affordable costs. I have been working closely with my Senate colleagues from Missouri and Kansas to protect our Kansas City area seniors from the dangers and uncertainty of a planned federal experiment with their health care arrangements. So, I want to make clear to my colleague from Florida that patients and doctors speaking on behalf of their patients were the ones who approached me and asked for my assistance in stopping the Medicare managed care demonstration project in the Kansas City area. I heard from a number of individual doctors, as well as medical societies in the State, expressing grave concerns about the project. The President of the Metropolitan Medical Society of Greater Kansas City even made the prediction that the unintended risk of the demonstration ``could dictate 100% disruption of beneficiaries away from their current relationships'' with their doctors. Clearly, this is unacceptable. Inclusion, Mr. President, I would like to quote from some of the letters I received from the seniors themselves, voicing their opposition to the Medicare managed care demonstration project coming to their area. Elizabeth Weekley Sutton, of Independence, Missouri, wrote to me: Dear Senator Ashcroft: We need help. My husband, my friends, and I are very concerned and worried that our health care will be very limited by the end of the Competitive Pricing Demonstration that will be starting in January. Of all the HMO's in the U.S., only the entire K.C. area and Maricopa County in Arizona will be conducting this competition for the next 5 years! And here are some excerpts from a letter sent by Edward Smith of Platte City, Missouri: I am totally opposed to the Health Care Financing Administration competitive pricing demonstration project to take place here in the Kansas City area. My health will not permit me to be a guinea pig for a total of five years when the rest of the country will have business as usual. He continues: Instead of the Health Care Financing Administration determining what is best for the beneficiaries I would prefer to do that myself. And finally, Mr. Smith says: If this plan is adopted my HMO could choose to leave the market. Then what is gained? Certainly not my health. Mr. President, we need to listen to the voice of our seniors. We cannot afford to jeopardize their health with a [[Page S12192]] risky experiment that could raise costs, limit choices, and cause doctor-patient disruption. For this reason, I have continued--and will continue--to work to halt this project in its present form in the Kansas City area. Exhibit 1 Metropolitan Medical Society of Greater Kansas City, July 21, 1999. Hon. Bob Graham, U.S. Senate, Washington, DC. Dear Senator Graham: I was concerned to read in the July 16, 1999, Congressional Record your dissatisfaction about the Senate's passage of the moratorium on the Medicare Prepaid Competitive Pricing Demonstration Project in Kansas City and Arizona. On behalf of the more than 2500 physicians of the Metropolitan Medical Society of Greater Kansas City and its affiliated organizations, I want to assure you that doctors strongly support the moratorium that was passed in the Senate Patient Bill of Rights legislation last week. The physicians of Kansas City have expressed serious concerns about the demonstration project since April, and we continue to be concerned. We believe the experiment will bring unacceptable levels of disruption to our Medicare patients and the local health care market. Additionally, I worry that quality care, which is often more expensive, will be less available to Medicare patients. In Kansas City, the opposition to the project is widespread. Our senators acted on behalf of our entire health care community, including patients, doctors, hospitals, and health care plans. The medical community has participated in the discussions about the demonstration with the Health Care Financing Administration (HCFA) and the local Area Advisory Committee for the demonstration project. Despite these discussions, problems with the experiment remain. We support congressional efforts to stop the demonstration project in the Kansas City area. I remain concerned that under-funded HMOs place our most vulnerable Medicare recipients at risk of getting less attention to their health care needs. I expect to hear more cases of catastrophes to Medicare recipients when the care given is too little, too late. You may be aware that Jacksonville, Florida is another potential site for the demonstration. Thank you for your consideration of my concerns. I hope I've helped to clarify the existence of broad based support in Kansas City for the moratorium on the competitive pricing demonstration. Sincerely, Richard Hellman, MD, President-Elect and Chair, National Government Relations Committee. amendment no. 1845 (Purpose: To express the sense of the Senate regarding school infrastructure) The PRESIDING OFFICER (Mr. Smith of Oregon). The Senator from Iowa. Mr. HARKIN. Mr. President, Senator Robb and I have an amendment at the desk. I call it up at this time, No. 1845. The PRESIDING OFFICER. The clerk will report. The legislative clerk read as follows: The Senator from Iowa [Mr. Harkin], for himself, and Mr. Robb, proposes an amendment numbered 1845. Mr. HARKIN. Mr. President, I ask unanimous consent that reading of the amendment be dispensed with. The PRESIDING OFFICER. Without objection, it is so ordered. The amendment is as follows: At the end of title III, add the following: SEC. ____. SENSE OF THE SENATE REGARDING SCHOOL INFRASTRUCTURE. (a) Findings.--The Senate makes the following findings: (1) The General Accounting Office has performed a comprehensive survey of the Nation's public elementary and secondary school facilities and has found severe levels of disrepair in all areas of the United States. (2) The General Accounting Office has concluded that more than 14,000,000 children attend schools in need of extensive repair or replacement, 7,000,000 children attend schools with life threatening safety code violations, and 12,000,000 children attend schools with leaky roofs. (3) The General Accounting Office has found the problem of crumbling schools transcends demographic and geographic boundaries. At 38 percent of urban schools, 30 percent of rural schools, and 29 percent of suburban schools, at least one building is in need of extensive repair or should be completely replaced. (4) The condition of school facilities has a direct affect on the safety of students and teachers and on the ability of students to learn. Academic research has provided a direct correlation between the condition of school facilities and student achievement. At Georgetown University, researchers have found the test scores of students assigned to schools in poor condition can be expected to fall 10.9 percentage points below the test scores of students in buildings in excellent condition. Similar studies have demonstrated up to a 20 percent improvement in test scores when students were moved from a poor facility to a new facility. (5) The General Accounting Office has found most schools are not prepared to incorporate modern technology in the classroom. Forty-six percent of schools lack adequate electrical wiring to support the full-scale use of technology. More than a third of schools lack the requisite electrical power. Fifty-six percent of schools have insufficient phone lines for modems. (6) The Department of Education has reported that elementary and secondary school enrollment, already at a record high level, will continue to grow over the next 10 years, and that in order to accommodate this growth, the United States will need to build an additional 6,000 schools. (7) The General Accounting Office has determined the cost of bringing schools up to good, overall condition to be $112,000,000,000, not including the cost of modernizing schools to accommodate technology, or the cost of building additional facilities needed to meet record enrollment levels. (8) Schools run by the Bureau of Indian Affairs (BIA) for Native American children are also in dire need of repair and renovation. The General Accounting Office has reported that the cost of total inventory repairs needed for BIA facilities is $754,000,000. The December 1997 report by the Comptroller General of the United States states that, ``Compared with other schools nationally, BIA schools are generally in poorer physical condition, have more unsatisfactory environmental factors, more often lack key facilities requirements for education reform, and are less able to support computer and communications technology.''. (9) State and local financing mechanisms have proven inadequate to meet the challenges facing today's aging school facilities. Large numbers of local educational agencies have difficulties securing financing for school facility improvement. (10) The Federal Government has provided resources for school construction in the past. For example, between 1933 and 1939, the Federal Government assisted in 70 percent of all new school construction. (11) The Federal Government can support elementary and secondary school facilities without interfering in issues of local control, and should help communities leverage additional funds for the improvement of elementary and secondary school facilities. (b) Sense of the Senate.--It is the sense of the Senate that Congress should provide at least $3,700,000,000 in Federal resources to help communities leverage funds to modernize public school facilities. Mr. HARKIN. Mr. President, Senator Robb and I are going to take a few minutes. I know the time is late. I know people want to get to a final vote on this. I want to talk about how good this bill is and to urge people to vote for it. This is a sense-of-the-Senate resolution. I will not go through the whole thing. It basically is a sense-of-the-Senate resolution saying Congress should appropriate at least $3.7 billion in Federal resources to help communities leverage funds to modernize public school facilities, otherwise known as public school construction. What we have in this country is schools that are on the average 40 to 50 years old. We are getting great teachers, new methodologies, new math, new science, new reading programs, and the schools are crumbling down around us. They are getting older every day. Day after day, kids go to schools with leaky ceilings, inadequate heat, inadequate air conditioning for hot summer days and the fall when the school year is extended. They are finding a lot of these buildings still have asbestos in them, and it needs to be taken out. Yet we are shirking our responsibilities to refurbish, renovate, and rebuild the schools in this country. The General Accounting Office estimates 14 million American children attend classes in schools that are unsafe or inadequate. They estimate it will cost $112 billion to upgrade existing public schools to just ``good'' condition. In addition, the GAO reports 46 percent of schools lack adequate electrical wiring to support the full-scale use of technology. We want to get computers in the classrooms, we want to hook them to the Internet, and yet almost 50 percent of the schools in this country are inadequate in their internal wiring so kids cannot hook up with the Internet. The American Society of Civil Engineers reports public schools are in worse condition than any other sector of our national infrastructure. Think about that. According to the American Society of Civil Engineers--they are the ones who build our buildings, build our bridges and roads and highways and streets and sewers and water systems, and our schools--they say our schools are in the worst state of any part of the physical infrastructure of this country. Mr. HARKIN. Mr. President, if the nicest things our kids ever see or go to [[Page S12193]] is shopping malls and sports arenas and movie theaters, and the most run-down places are their schools, what kind of signal are we sending them about the value we place on education and their future? This is a sense-of-the-Senate resolution which simply outlines the terrible situation we have in this country and calls on the Senate and the Congress to respond by providing at least $3.7 billion, a small fraction of what is needed but a step in the right direction--$3.7 billion in Federal resources to modernize our Nation's schools. I yield the floor to my distinguished colleague and cosponsor, Senator Robb. The PRESIDING OFFICER. The Senator from Virginia. Mr. ROBB. Mr. President, I thank my friend and colleague from Iowa. Senator Harkin and I have offered a sense of the Senate amendment relating to school construction, as Senator Harkin has just explained. The amendment is not unlike the amendment Senators Lautenberg, Harkin, and I offered to the Budget Resolution earlier this year. That amendment assumed that given the levels in the budget resolution, Congress would enact ``legislation to allow States and school districts to issue at least $24.8 billion worth of zero-interest bonds to rebuild and modernize our nation's schools, and to provide Federal income tax credits to the purchasers of those bonds in lieu of interest payments.'' The actual cost as it was scored was referred to by the Senator from Iowa. That amendment was accepted and put the entire Senate on record as supporting the concept of providing federal assistance in the area of school construction and renovation. Understanding that Rule 16 prevents us from doing anything of significance at this time with respect to school construction, Senator Harkin and I in just a moment will withdraw our amendment. But every day that passes, this Congress misses an opportunity to help our States and localities fix the leaky roofs, get rid of all the trailers, and install the wiring needed to bring technology to all of our children. These are real problems--problems that our nation's mayors, school boards, and families simply need some help in addressing. While school infrastructure improvement is typically a local responsibility, it is now a national need. Our schools, as the Senator from Iowa has indicated, are over 40 years old, on average; our school- aged population is at record levels; and our States and localities can't keep up, despite their surpluses. Abstract talk about State surpluses provides little solace to our nation's teachers and students who are forced to deal with wholly inadequate conditions. In Alabama, the roof of an elementary school collapsed. Fortunately, it occurred just after the children had left for the day. In Chicago, teachers place cheesecloth over air vents to filter out lead-based paint flecks. In Maine, teachers have to turn out the lights when it rains because their electrical wiring is exposed under their leaky roofs. Mr. President, we are missing an opportunity to help our States and localities with a pressing need. I will continue to work for and press forward on this issue because I think it's an area where the Federal Government can be extremely constructive. When our children are asked about ``Bleak House,'' they should refer to a novel by Dickens and not the place where they go to school. In my own State of Virginia, there are over 3,000 trailers being used to educate students. And there are over $4 billion worth of unbudgeted, unmet needs for our schools. This is a problem that is not going to go away, and it's a problem that our nation's schools need our help to solve. And I regret that Rule 16 precludes us from considering legislation which would reaffirm the commitment that we made earlier this year. I thank the distinguished Senator from Iowa for his continued work on the subject of school construction, and I yield the floor. Amendment No. 1845 Withdrawn The PRESIDING OFFICER. The Senator from Iowa. Mr. HARKIN. Mr. President, I understand this amendment is not acceptable to the other side. It is late in the day. I know people have to get on with other things, and we want to get to a final vote on the bill. I believe strongly in this. It is a sense-of-the-Senate amendment. Also, Senators Kennedy, Reid, Murray, and Johnson are added as cosponsors. In the spirit of moving this bill along and trying to wrap this up as quickly as possible, I ask unanimous consent to withdraw the amendment at this time, but it will be revisited. The PRESIDING OFFICER. The Senator from Pennsylvania. Mr. SPECTER. I thank my distinguished colleague. I am very sympathetic to the purpose of the sense-of-the-Senate amendment. He is correct; there would be objection, and I think it would not be adopted. I thank him for withdrawing the amendment. The PRESIDING OFFICER. The amendment is withdrawn. Amendments Nos. 2273 through 2289, 1852, 1869, and 1882 Mr. SPECTER. Mr. President, I now submit the managers' package which has been cleared on both sides. The PRESIDING OFFICER. The clerk will report. The legislative clerk read as follows: The Senator from Pennsylvania [Mr. Specter] proposes amendments numbered 2273 through 2289, 1852, 1869 and 1882. The amendments are as follows: amendment no. 2273 At the appropriate place in the bill add the following: SEC. . CONFOUNDING BIOLOGICAL AND PHYSIOLOGICAL INFLUENCES ON POLYGRAPHY. (a) Findings.--The Senate finds that-- (1) The use of polygraph tests as a screening tool for federal employees and contractor personnel is increasing. (2) A 1983 study by the Office of Technology Assessment found little scientific evidence to support the validity of polygraph tests in such screening applications. (3) The 1983 study further found that little or no scientific study had been undertaken on the effects of prescription and non-prescription drugs on the validity of polygraph tests, as well as differential responses to polygraph tests according to biological and physiological factors that may vary according to age, gender, or ethnic backgrounds, or other factors relating to natural variability in human populations. (4) A scientific evaluation of these important influences on the potential validity of polygraph tests should be studied by a neutral agency with biomedical and physiological expertise in order to evaluate the further expansion of the use of polygraph tests on federal employees and contractor personnel. (b) Sense of the Senate.--It is the Sense of the Senate that the Director of the National Institutes of Health should enter into appropriate arrangements with the National Academy of Sciences to conduct a comprehensive study and investigation into the scientific validity of polygraphy as a screening tool for federal and federal contractor personnel, with particular reference to the validity of polygraph tests being proposed for use in proposed rules published at 64 Fed. Reg. 45062 (August 18, 1999). ____ AMENDMENT NO. 2274 (Purpose: To provide funding for a dental sealant demonstration program) At the end of title II, add the following: dental sealant demonstration program Sec. ____. From amounts appropriated under this title for the Health Resources and Services Administration, sufficient funds are available to the Maternal Child Health Bureau for the establishment of a multi-State preventive dentistry demonstration program to improve the oral health of low- income children and increase the access of children to dental sealants through community- and school-based activities. ____ AMENDMENT NO. 2275 (Purpose: To limit the withholding of substance abuse funds from certain States) At the end of title II, add the following: withholding of substance abuse funds Sec. ____. (a) In General.--None of the funds appropriated by this Act may be used to withhold substance abuse funding from a State pursuant to section 1926 of the Public Health Service Act (42 U.S.C. 300x-26) if such State certifies to the Secretary of Health and Human Services that the State will commit additional State funds, in accordance with subsection (b), to ensure compliance with State laws prohibiting the sale of tobacco products to individuals under 18 years of age. (b) Amount of State Funds.--The amount of funds to be committed by a State under subsection (a) shall be equal to one percent of such State's substance abuse block grant allocation for each percentage point by which the State misses the retailer compliance rate goal established by the Secretary of Health and Human Services under section 1926 of such Act, except that the Secretary may agree to a smaller commitment of additional funds by the State. (c) Supplement not Supplant.--Amounts expended by a State pursuant to a certification under subsection (a) shall be used to supplement and not supplant State funds [[Page S12194]] used for tobacco prevention programs and for compliance activities described in such subsection in the fiscal year preceding the fiscal year to which this section applies. (d) The Secretary shall exercise discretion in enforcing the timing of the State expenditure required by the certification described in subsection (a) as late as July 31, 2000. ____ AMENDMENT NO. 2276 (Purpose: To express the sense of the Senate that funding for prostate cancer research should be increased substantially) At the appropriate place add the following: Sec. ____. (a) Findings.--Congress makes the following findings: (1) In 1999, prostate cancer is expected to kill more than 37,000 men in the United States and be diagnosed in over 180,000 new cases. (2) Prostate cancer is the most diagnosed nonskin cancer in the United States. (3) African Americans have the highest incidence of prostate cancer in the world. (4) Considering the devastating impact of the disease among men and their families, prostate cancer research remains underfunded. (5) More resources devoted to clinical and translational research at the National Institutes of Health will be highly determinative of whether rapid advances can be attained in treatment and ultimately a cure for prostate cancer. (6) The Congressionally Directed Department of Defense Prostate Cancer Research Program is making important strides in innovative prostate cancer research, and this Program presented to Congress in April of 1998 a full investment strategy for prostate cancer research at the Department of Defense. (7) The Senate expressed itself unanimously in 1998 that the Federal commitment to biomedical research should be doubled over the next 5 years. (b) Sense of the Senate.--It is the sense of the Senate that-- (1) finding treatment breakthroughs and a cure for prostate cancer should be made a national health priority; (2) significant increases in prostate cancer research funding, commensurate with the impact of the disease, should be made available at the National Institutes of Health and to the Department of Defense Prostate Cancer Research Program; and (3) these agencies should prioritize prostate cancer research that is directed toward innovative clinical and translational research projects in order that treatment breakthroughs can be more rapidly offered to patients. ____ amendment no. 2277 On page 59, line 25, strike ``$1,404,631,000'' and insert ``$1,406,631,000'' in lieu thereof. On page 60, before the period on line 10, insert the following: ``: Provided further, That $2,000,000 shall be for carrying out Part C of Title VIII of the Higher Education Amendments of 1998.'' On page 62, line 23, decrease the figure by $2,000,000. ____ amendment no. 2278 (Purpose: To clarify provisions relating to the United States-Mexico Border Health Commission) At the appropriate place, insert the following: Sec. . The United States-Mexico Border Health Commission Act (22 U.S.C. 290n et seq.) is amended-- (1) by striking section 2 and inserting the following: ``SEC. 2. APPOINTMENT OF MEMBERS OF BORDER HEALTH COMMISSION. ``Not later than 30 days after the date of enactment of this section, the President shall appoint the United States members of the United States-Mexico Border Health Commission, and shall attempt to conclude an agreement with Mexico providing for the establishment of such Commission.''; and (2) in section 3-- (A) in paragraph (1), by striking the semicolon and inserting ``; and''; (B) in paragraph (2)(B), by striking ``; and'' and inserting a period; and (C) by striking paragraph (3). ____ amendment no. 2279 On page 50, line 17, strike ``$459,000,000'' and insert in lieu thereof ``$494,000,000''. ____ amendment no. 2280 On page 66, line 24, strike out all after the colon up to the period on line 18 of page 67. ____ amendment no. 2281 On page 42, before the period on line 8, insert the following: ``: Provided further, That sufficient funds shall be available from the Office on Women's Health to support biological, chemical and botanical studies to assist in the development of the clinical evaluation of phytomedicines in women's health''. ____ amendment no. 2282 (Purpose: To provide for a report on promoting a legal domestic workforce and improving the compensation and working conditions of agricultural workers) On page 19, line 6, insert before the period the following: ``: Provided further, That funds made available under this heading shall be used to report to Congress, pursuant to section 9 of the Act entitled `An Act to create a Department of Labor' approved March 4, 1913 (29 U.S.C. 560), with options that will promote a legal domestic work force in the agricultural sector, and provide for improved compensation, longer and more consistent work periods, improved benefits, improved living conditions and better housing quality, and transportation assistance between agricultural jobs for agricultural workers, and address other issues related to agricultural labor that the Secretary of Labor determines to be necessary''. ____ AMENDMENT NO. 2283 (Purpose: To express the sense of the Senate concerning women's access to obstetric and gynecological services) Beginning on page 1 of the amendment, strike all after the first word and insert the following: ____. SENSE OF THE SENATE ON WOMEN'S ACCESS TO OBSTETRICAND GYNECOLOGICAL SERVICES. (a) Findings.--Congress makes the following findings: (1) In the 1st session of the 106th Congress, 23 bills have been introduced to allow women direct access to their ob-gyn provider for obstetric and gynecologic services covered by their health plans. (2) Direct access to ob-gyn care is a protection that has been established by Executive Order for enrollees in medicare, medicaid, and Federal Employee Health Benefit Programs. (3) American women overwhelmingly support passage of federal legislation requiring health plans to allow women to see their ob-gyn providers without first having to obtain a referral. A 1998 survey by the Kaiser FamilyFoundation and Harvard University found that 82 percent of Americans support passage of a direct access law. (4) While 39 States have acted to promote residents' access to ob- gyn providers, patients in other State- or in Federally-governed health plans are not protected from access restrictions or limitations. (5) In May of 1999 the Commonwealth Fund issued a survey on women's health, determining that 1 of 4 women (23 percent) need to first receive permission from their primary care physician before they can go and see their ob-gyn provider for covered obstetric or gynecologic care. (6) Sixty percent of all office visits to ob-gyn providers are for preventive care. (b) Sense of the Senate.--It is the sense of the Senate that Congress should enact legislation that requires health plans to provide women with direct access to a participating health provider who specializes in obstetrics and gynecological services, and that such direct access should be provided for all obstetric and gynecologic care covered by their health plans, without first having to obtain a referral from a primary care provider or the health plan. Mrs. MURRAY. Mr. President, included in the Manager's amendment is an important provision relating to women's health and access to reproductive health care services. I am pleased to have worked with the managers of this bill to send a strong message on the importance of direct access for women to their OB/GYN. I was disappointed that we were unable to address the rule XVI concerns with the amendment I had originally filed. My original amendment would simply allow women and their OB/GYNs to make important health care decisions without barriers or obstacles erected by insurance company policies. My amendment would have required that health plans give women direct access to their OB/GYN for all gynecological and obstetrical care and would have prohibited insurance companies from standing between a woman and her OB/GYN. However, it has been determined that my amendment would violate rule XVI. As a result of the announcement by the chairman of the Senate Appropriations Committee that he will make a point of order against all amendments that may violate rule XVI, I have modified my amendment. The modification still allows Members of the Senate to be on record in support of women's health or in opposition to removing barriers that hinder access for women to critical reproductive health care services. I am offering a sense-of-the-Senate that puts this question to each Member. I realize that this amendment is not binding, but due to opposition to my original amendment, I have been forced to offer this sense-of-the-Senate. I am disappointed that we could not act to provide this important protection to women, but I do believe this amendment will send an important message that the U.S. Senate does support greater access for women to quality health care benefits. I have offered this amendment due to my frustration and disappointment with managed care reform. I have become frustrated by stalling tactics and empty promises. The managed care reform bill that passed the Senate has [[Page S12195]] been referred to as an empty promise for women. I can assure my colleagues that women are much smarter than they may expect and will not be fooled by empty promises or arguments of procedural discipline. When a woman is denied direct access to the care provided by her OB/ GYN, she will not be interested in a discussion on ERISA or rule XVI. She wants direct access to her OB/GYN. She needs direct access, and she should have direct access. My amendment also reiterates the importance of ensuring that the OB/ GYN remains the coordinating physician. Any test or additional referral would be treated as if made by the primary care physician. This amendment does not call for the designation of an OB/GYN as a primary care physician, it simply says that if the OB/GYN decides additional care is necessary, the patient is not forced to seek approval from a primary care physician, who may not be familiar with her overall health care status. Why is this amendment important? The number one reason most women enter the health care system is to seek gynecological or obstetric care. This is the primary point of entry for women into the health care system. For most women, including myself, we consider our OB/GYN our primary care physician--maybe not as an insurance company defines it-- but, in practice, that's the reality. Does a woman go to her OB/GYN for an ear infection? No. But, does a pregnant woman consult with her OB/GYN prior to taking any antibiotic for the treatment of an ear infection? Yes, most women do. I know the policy endorsed in this amendment has in the past enjoyed bipartisan support. The requirements are similiar to S. 836, legislation introduced by Senator Specter and cosponsored by several Senators both Republican and Democrat. This amendment is similar to language that was adopted during committee consideration in the House of the fiscal year 1999 Labor, HHS appropriations bill. A similar directive is contained in the bipartisan House Patients' Bill of Rights legislation. It has the strong support of the American College of Obstetricians and Gynecologists and I know I have heard from several OB/GYNs in my own state testifying to the importance of direct access to the full range of care provided, not just routine care. I would also like to point out to my colleagues, that 39 states have similar requirements and that as participants in the Federal Employees Health Benefit Plan, all of us--as Senators--have this same guarantee as well as our family members. If we can guarantee this protection for ourselves and our families, we should do the same for women participating in a manager care plan. I realize that this appropriations bill may not be the best vehicle for offering this amendment. However, I have waited for final action on a Patients' Bill of Rights for too long. I have watched as patient protection bills have been stalled or delayed. Last year we were told that we would finish action on a good Patients' Bill of Rights package prior to adjournment. Well, here we sit--almost 12 months later--with little hope of finishing a good, comprehensive managed care reform bill prior to our scheduled adjournment this year. I also want to remind my colleagues that we have in the past used appropriations bills to address deficiencies in current law or to address an urgent need for action. I believe that addressing an urgent need in women's health care qualifies as a priority that we must address. I realize that the authorizing committee has objected to the original amendment I filed. As a member of the authorizing committee as well, I can understand this objection. But, again I have little choice but to proceed on this appropriations bill. We all know that it was only recently on the fiscal year 1999 supplemental appropriations bill that we authorized a significant change in Medicaid recoupment provisions despite strong objections from the Finance Committee. In last year's omnibus appropriations bill, we authorized a requirement that insurance companies must cover breast reconstruction surgery following a mastectomy. I can assure my colleagues that this provision never went through the authorizing committee. I would also point out that there are several antichoice riders contained in this appropriations bill that represent a major authorization. As these examples show, when we have to address these types issues through appropriations bills--we can do it. We have done it in the past, and we should do it today to meet this need. I urge my colleagues to support this amendment. We all talk about the need to ensure access for women to health care. I applaud Chairman Specter's efforts in this appropriations bill regarding women's health care. Adopting this amendment gives us the opportunity to do something that does ensure greater access for women. This is what women want. This is the chance for Senators to show their commitment to this critical benefit. I would like to quote a statement made by our subcommittee chairman that I believe more eloquently explains why I am urging this amendment. ``I believe it is clear that access to women's health care cuts across the intricacies of the complicated and often divisive managed care debate.'' I could not agree more. We know from the current state requirement and the Federal Employee Health Benefit Program requirement, this provision does not have a significant impact on costs of health care. We also know from experience that it has a positive impact on health care benefits. Since 60 percent of office visits to OB/GYNs are for preventive care, we could make the argument that adoption of this policy would reduce the overall costs of health care. I urge my colleagues to support this amendment and ask that we do more than simply make empty promises

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DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION AND RELATED AGENCIES APPROPRIATIONS ACT, 2000--Continued
(Senate - October 07, 1999)

Text of this article available as: TXT PDF [Pages S12188-S12215] DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION AND RELATED AGENCIES APPROPRIATIONS ACT, 2000--Continued Mr. SPECTER. Mr. President, I ask unanimous consent that we turn to the Senator from---- Mr. REID. Mr. President, will the Senator yield? Mr. SPECTER. Florida for 15 minutes. Mr. REID. Mr. President, will the Senator yield for a brief statement? Mr. SPECTER. Pardon me. I withdraw that because the Senators from New Mexico were here sequenced ahead of Senator Graham. Mr. REID. Mr. President, I appreciate the statements of the chairman of the Judiciary Committee and the statement of the Senator from Pennsylvania on the judicial controversy. I hope we can end all of that this afternoon and get this bill completed because now we have people on our side wanting to come and talk about this matter dealing with Judge White. I hope we can move and get this bill finished before we have further speeches on this judicial controversy. Mr. SPECTER. Mr. President, I ask unanimous consent that the remainder [[Page S12189]] of the time on this bill be directed to the amendment of the Senators from New Mexico, then 15 minutes to Senator Graham of Florida, then 10 minutes to be equally divided between the managers of the bill, and then go to final passage. Mr. REID. Reserving the right to object, if the ranking member of the Judiciary Committee wants to come over and speak on the judicial controversy, I want him to have 15 minutes, the same amount of time the chairman of the Judiciary Committee had. Mr. SPECTER. I incorporate that in the unanimous consent request. Mr. KENNEDY. If I could have 2 minutes. Mr. SPECTER. Two minutes for Senator Kennedy. Mr. INHOFE. Mr. President, reserving the right to object, for what purpose would the Senator be yielding to the Senator from Florida? Are we back on the judicial nominations? Mr. SPECTER. He is speaking on the bill. Mr. INHOFE. Is this on the nomination? Mr. SPECTER. Unless Senator Leahy comes and claims the time which Senator Reid has asked for. Mr. INHOFE. No objection. The PRESIDING OFFICER. Is there objection? Mr. HARKIN. Reserving the right to object. Mr. SPECTER. We added 5 more minutes for Senator Harkin: the managers, 15 minutes; Senator Harkin, 10; myself, 5. Mr. REID. And Senator Kennedy for 2 minutes. Mr. DOMENICI. I ask if Senator Kennedy is on the bill or something else? Mr. KENNEDY. All I want to do, indirectly on the bill, is just to announce that the House of Representatives passed the Patients' Bill of Rights 275-149. This is a hard-won victory for millions of patients and families throughout America, and a well-deserved defeat for HMOs and the Republican extremists in the House who put managed care profits ahead of patients' health. The Senate flunked this test in July, but the House has given us a new chance to do the right thing. The House-Senate conference should adopt the Norwood-Dingell provisions, without the costly and ineffective tax breaks added by House Republicans. Mr. DOMENICI. The Senator did it. Does he still need the 2 minutes? Mr. KENNEDY. No. I don't need the 2 minutes. I thank the Senator very much. Mr. SPECTER. Mr. President, exclude Senator Kennedy from the unanimous consent request. The PRESIDING OFFICER. Without objection, it is so ordered. Mr. SPECTER. Mr. President, I ask that we turn to the Senators from New Mexico. Mr. DOMENICI. Senator Bingaman has the floor. The PRESIDING OFFICER. The Senator from New Mexico. Amendment No. 2272 (Purpose: To require the Secretary of Health and Human Services to conduct a study on the geographic adjustment factors used in determining the amount of payment for physicians' services under the medicare program) Mr. BINGAMAN. Mr. President, I send an amendment to the desk. The PRESIDING OFFICER. The clerk will report. The legislative clerk read as follows: The Senator from New Mexico (Mr. Bingaman), for himself, and Mr. Domenici, proposes an amendment numbered 2272. Mr. BINGAMAN. Mr. President, I ask unanimous consent that reading of the amendment be dispensed with. The PRESIDING OFFICER. Without objection, it is so ordered. The amendment is as follows: At the end of title II, add the following: SEC. 216. STUDY AND REPORT ON THE GEOGRAPHIC ADJUSTMENT FACTORS UNDER THE MEDICARE PROGRAM. (a) Study.--The Secretary of Health and Human Services shall conduct a study on-- (1) the reasons why, and the appropriateness of the fact that, the geographic adjustment factor (determined under paragraph (2) of section 1848(e) (42 U.S.C. 1395w-4(e)) used in determining the amount of payment for physicians' services under the medicare program is less for physicians' services provided in New Mexico than for physicians' services provided in Arizona, Colorado, and Texas; and (2) the effect that the level of the geographic cost-of- practice adjustment factor (determined under paragraph (3) of such section) has on the recruitment and retention of physicians in small rural states, including New Mexico, Iowa, Louisiana, and Arkansas. (b) Report.--Not later than 3 months after the date of enactment of this Act, the Secretary of Health and Human Services shall submit a report to Congress on the study conducted under subsection (a), together with any recommendations for legislation that the Secretary determines to be appropriate as a result of such study. Mr. BINGAMAN. Mr. President, this is an amendment that Senator Domenici and I are offering to direct the Secretary of Health and Human Services to conduct a study of and the appropriateness of the geographic adjustment factor that is used in Medicare reimbursement calculations as it applies particularly to our State of New Mexico. We have a very serious problem in our State today; many of our physicians are leaving the State. The reimbursement that is available under Medicare, and accordingly under many of the health care plans in our State, is less for physicians performing procedures and practicing medicine in our State than it is in all of our surrounding States. We believe this is traceable to this adjustment factor, this geographic adjustment factor. This is a system that was put into place in 1992. It now operates, as I understand it, such that we have 89 geographic fee schedule payment areas in the country. We are not clear on the precise way in which our State has been so severely disadvantaged, but we believe it is a serious problem that needs attention. Our amendment directs that the Secretary conclude this study within 90 days, or 3 months, report back, and make recommendations on how to solve the problem. We believe it is a very good amendment. We recommend that Senators support the amendment. I yield the floor. The PRESIDING OFFICER. The Senator from New Mexico. Mr. DOMENICI. Mr. President, first, I am pleased to say I am a cosponsor of this amendment. I have helped Senator Bingaman with it. This is a good amendment. We aren't asking for any money. We are not asking that any law be changed. We are merely saying that something is not right for our State. The reimbursement--or some aspect of how we are paying doctors under Medicare--is causing us to have much lower fees than the surrounding States, and as a result two things are happening: One, doctors are leaving. In a State such as ours, we can ill afford that. Second, we are being told it is harder and harder to get doctors to come to our State. That was not the case years ago. They loved New Mexico. They came for lots of reasons. But certainly we cannot be an underprivileged State in terms of what we pay our doctors--be a poor State in addition--and expect our citizens to get good health care. We want to know what the real facts are: Why is this the case? Is it the result of the way the geographic evaluation is applied to our State because maybe rural communities aren't getting the right kind of emphasis in that formula? Whatever it is, we want to know. When we know, fellow Senators, we can assure Members, if we find out it is not right and it is not fair, we will be on the floor to talk about some real changes. Until we have that, we ask Members for help in obtaining a study. I yield the floor. Mr. SPECTER. The managers have taken a look at this amendment and are prepared to accept it. It is a good amendment. There is one concern, and that is a jurisdictional concern with respect to the Finance Committee. We have attempted to contact the chairman of the Finance Committee to see if there was any substantial reason we should not accept it. If it went to a vote, it would clearly be adopted. It merely asks for a report for a very good purpose. Therefore, the amendment is accepted. The PRESIDING OFFICER. The question is on agreeing to the amendment. The amendment (No. 2272) was agreed to. Mr. DOMENICI. I move to reconsider the vote. Mr. SPECTER. I move to lay that motion on the table. The motion to lay on the table was agreed to. [[Page S12190]] The PRESIDING OFFICER. The Senator from Florida. Mr. GRAHAM. Mr. President, I am here today, as I was in July, to point out to my colleagues another stealth effort to kill competition within the Medicare program. Title I, section 214, buried in the middle of this long appropriations bill on page 49, carries the following statement: None of the funds provided in this Act or in any other Act making appropriations for fiscal year 2000 may be used to administer or implement in Arizona or in Kansas City, Missouri or in the Kansas City, Kansas area the Medicare Competitive Pricing Demonstration Project operated by the Secretary of Health and Human Services under authority granted in the Balanced Budget Act of 1997. If that statement sounds familiar, it is. Almost the same language was buried in the HMO Patients' Bill of Rights bill as it passed the Senate back in July. It passed then undebated and undiscussed as to its implications--just as we are about to do here tonight. July's action was outrageous. This action is even more so. There is a certain irony here. We have just heard that the House of Representatives passed, by an overwhelming vote, a version of the HMO Patients' Bill of Rights which is very similar to the bipartisan bill offered but not considered in the Senate. Our bipartisan bill was strongly opposed by the HMO industry. Their basic argument is: let's keep government out of our business, let us operate based on a competitive model that will allow the consumer, the beneficiary of the HMO contract, to negotiate without government standards, without government sanctions for failure to deliver on those standards with the HMO industry. They wanted to have laissez-faire free enterprise; Adam Smith roams the land. However, today we are about to pass a provision that says when the HMOs are dealing with their pocketbook and the question of how they will get reimbursed, how much money they are going to get paid from Medicare, they don't want to have a free market of competition; they don't want to have a means by which the taxpayers can be assured what they are paying for the HMO product is what the market says they should be paying. There is a certain amount of irony there which I think underscores the motivations of a significant portion of this industry. There also is a procedural ploy here. If this provision I just quoted were to be offered as an amendment to this bill, it would be ruled out of order under rule XVI in part because it purports not only to control action in this act but in any other act that Congress might consider making in an appropriations bill. But this is not an amendment; this is in the bill itself as it has come out of the Appropriations Committee, and therefore rule XVI does not apply. Normally under the procedures the Congress has followed traditionally, we would be dealing with a House bill because the House traditionally has led in the appropriations process; therefore, we would be amending a House bill. Thus, we could have excised this provision. However, because we are violating tradition and taking up a Senate bill first, we do not have the opportunity to remove it by a point of order. I will state for the record that henceforth, when it is proposed we take up a Senate appropriations bill before a House bill, I am going to stand here and object. This is exactly the kind of procedural abuse we can expect in the future as is happening right now. If that isn't bad enough, this is just plain bad policy. It stifles innovation by eliminating the competitive demonstration which hopefully would have led to a competitive process of compensating HMOs. It forces Medicare to pay more than necessary for some services in certain areas of the country while it denies managed care to other areas of the country. This HMO pricing is not without its own history. The Balanced Budget Act of 1997 included the competitive pricing demonstration program for Medicare. That provision was fought in the committee and fought in the Senate in 1997 by the HMO industry and certain Members of this body, but it prevailed. One by one, the HMO industry has been able to kill or has attempted to kill demonstrations which have been scheduled in many communities across the country. Today it is Arizona and Kansas City. The equation is pretty simple. It does not take rocket science to understand what is happening. Who benefits by continuing a system of paying Medicare HMOs that are not subject to competition? The HMOs benefit. Who loses when the same system is open to competition? The HMOs, because they no longer have the gravy train that exists today. Who gains by competition? Beneficiaries gain, particularly in rural areas which don't have managed care today. It would be the marketplace that would be establishing what the appropriate reimbursement level should be for an HMO in a currently unserved or underserved rural area--not a formula which underpays what the real cost of providing managed care would be in such an area. And the taxpayers lose because they do not get the benefit of the marketplace as a discipline of what the HMO's compensation should be. It is curious that out of one side of their mouth, they are screaming the current system of reimbursement is putting them out of business and causing them to have to leave hundreds of thousands of former HMO beneficiaries high and dry and also to curtail benefits such as prescription drugs, but at the same time, they are saying out of the left side of their mouth they are doing everything they can to prevent the insertion of competitive bidding as a means of establishing what their HMO contracts are really worth and what they should be paid. They cannot have it both ways. It takes a certain degree of political courage to make this reform happen. Let me give an example. In my own State of Florida, we were part of this demonstration project. We were selected to have a demonstration for Part B services for what are referred to as durable medical equipment. Lakeland, FL, was selected as the place to demonstrate the potential savings for medical equipment such as oxygen supplies and equipment, hospital beds and accessories, surgical dressings, enteral nutrition, and urological supplies. The savings that have been achieved in this project are impressive. They are 18-percent savings for oxygen supplies. I know the Senator from Iowa has stood on this floor and at times has even wrapped himself in medical bandages to demonstrate how much more Medicare was paying than, for instance, the Veterans' Administration for the same items. This competitive bidding process is attempting to bring the forces of the market into Medicare, and an 18-percent savings by competitively bidding oxygen supplies and equipment over the old formula we used to use. There were 30-percent savings for hospital beds and accessories, 13-percent savings for surgical dressings, 31 percent for enteral nutrition products, and 20 percent for urological supplies. It has been estimated if that Lakeland, FL, project were to be applied on a nationwide basis, the savings over 10 years would be in excess of $1 billion. We are not talking about small change. Beneficiaries have saved money from this demonstration, and access and quality have been preserved and protected. I find it troubling we are again today, as we were in July, debating, at the end of a major piece of legislation, a silently, surreptitiously included item which has the effect of sheltering HMOs from the marketplace. We might find some HMOs cannot compete and others will thrive, but that is what the marketplace should determine. That is what competition is all about. I urge my colleagues to examine this provision, to examine the implications of this provision in this kind of legislation and the restraints it imposes upon us, as Members of the Senate, to excise it as inappropriate legislative language on an appropriations bill. I hope our conferees, as they meet with the House, will resist the inclusion of this in the final legislation we might be asked to vote upon when this measure comes back from conference. This disserves the beneficiaries of the Medicare program. It disserves the taxpayers of America. It disserves the standards of public policy development by the Senate. I hope we will not have a further repetition of this stealth attack on the Medicare program. Mr. ASHCROFT. Mr. President, I took great interest in the statement that Senator from Florida (Mr. Graham) made expressing his displeasure that this legislation contains [[Page S12191]] a provision--Section 214--halting implementation of the Medicare Prepaid Competitive Pricing Demonstration Project both in Arizona and in the Kansas City metropolitan area. The Senator from Florida claimed that the inclusion of this provision was accomplished by HMOs. I would like to take this opportunity to point out to him that it was Medicare beneficiaries and doctors who alerted me to their grave concerns that the project would create huge patient disruption in the Kansas City area. In fact, after the Senator from Florida made similar remarks during debate on the Patient's Bill of Rights legislation regarding a similar provision in that bill, the Metropolitan Medical Society of Greater Kansas City wrote him a letter conveying their concerns with the implementation of the demonstration project in Kansas City, and expressing support for congressional efforts to stop the demonstration in their area. I ask unanimous consent that a copy of this letter be inserted in the record at the conclusion of my remarks. The PRESIDING OFFICER. Without objection, it is so ordered. (See exhibit 1.) Mr. ASHCROFT. After hearing from a number of doctors and patients in my State over the past few months, I concluded that Kansas City is an inappropriate location for this project and that it will jeopardize the health care benefits that seniors currently enjoy in the area. I believe that halting this project is necessary to protect the health care of senior citizens and to assure that Medicare beneficiaries continue to have access to excellent health care at prices they can afford. HCFA's project is a clear and present danger to the health and well-being of my constituents. The Balanced Budget Act of 1997 created the Medicare Prepaid Competitive Pricing Demonstration Project to use competitive bidding among Medicare HMOs. Through the appointment of a Competitive Pricing Advisory Committee, HCFA was to select demonstration sites around the nation. Kansas City was one of the selected cities. As I understand it, the intent of the project was to bring greater competition to the Medicare managed care market, to address concerns that Medicare HMO reimbursement rates in some areas are too high, to expand benefits for Medicare HMO enrollees, and to restrain the cost of Medicare to the taxpayers. When considering these factors, it is clear that the Kansas City metropolitan area is not an appropriate choice for this demonstration. First, managed care competition in the Kansas City market is already vigorous, with six managed care companies currently offering Medicare HMOs in the area. Participation in Medicare HMOs is also high: As of July 1 of this year, nearly 23% of Medicare recipients in the Kansas City metropolitan area were in Medicare+Choice plans--approximately 50,000 of 230,000 total beneficiaries. Nationally, only 17% of Medicare recipients are enrolled in such plans. Second, Medicare managed care payments in the Kansas City area are below the national average. According to a recent analysis by the Congressional Research Service of the Library of Congress, 1999 payment rates per Medicare+Choice enrollee in Kansas City are $511, while the national rate is $541. Documents provided to me by HCFA also demonstrate that 75 other cities had a higher adjusted average per capita cost (AAPCC) rate for 1997 than Kansas City. I wonder why Kansas City was chosen for this experiment, when so many other cities have higher payment rates. Third, I am concerned that this demonstration project will not provide expanded benefits to Medicare HMO enrollees, but will instead cause severe disruption of Medicare services. It is important to note that customer dissatisfaction is low in current Medicare managed care plans in the Kansas City area. Only one in twelve seniors disenrolls from Medicare HMOs each year. Currently, 33,000, or 66% of the seniors in Medicare managed care plans in the Kansas City area do not pay any premium. Under the bidding process set up by CPAC for the demonstration, a plan that bids above the enrollment-weighted median--which becomes the reimbursement rate for all plans--will be forced to charge seniors a premium to make up the difference between the plan's bid and the reimbursement rate paid by the government. In essence, the penalty for a high bid will be imposed upon seniors. Under this scenario, it is virtually assured that some seniors who pay no premium today will be required to start paying one. Moreover, seniors who cannot afford to pay a premium would be forced to abandon their regular doctor when it becomes necessary to change plans. Both individual doctors as well as the Metropolitan Medical Society of Greater Kansas City have warned that the demonstration could cause extreme disruption of beneficiaries away from current doctor- patient relationships. I have also heard concerns that both health plans and physicians may withdraw from the Medicare program if reimbursements under the demonstration project prove financially untenable. As a result, Medicare beneficiaries may be left with fewer choices in care. This would be intolerable. I question why we should implement a project that will create more risk and uncertainty for my State's seniors, who are already satisfied with what they have. Finally, I question how the demonstration project would be able to provide us with useful information on how to improve the Medicare program if fee-for-service plans--which are generally the most expensive Medicare option--are not included in the project. In its January 6, 1999 Design Report, the Competitive Pricing Advisory Committee expressed the judgment that the exclusion of fee-for-service might ``limit HCFA's ability (a) to measure the impact of competitive pricing and (b) to generalize demonstration results to the entire Medicare program.'' After studying this issue, I concluded that implementation of the Medicare Managed Care Demonstration Project in the Kansas City metropolitan area should be halted immediately. HCFA must not be allowed to risk the ability of my State's seniors to continue to receive high quality health care at affordable costs. I have been working closely with my Senate colleagues from Missouri and Kansas to protect our Kansas City area seniors from the dangers and uncertainty of a planned federal experiment with their health care arrangements. So, I want to make clear to my colleague from Florida that patients and doctors speaking on behalf of their patients were the ones who approached me and asked for my assistance in stopping the Medicare managed care demonstration project in the Kansas City area. I heard from a number of individual doctors, as well as medical societies in the State, expressing grave concerns about the project. The President of the Metropolitan Medical Society of Greater Kansas City even made the prediction that the unintended risk of the demonstration ``could dictate 100% disruption of beneficiaries away from their current relationships'' with their doctors. Clearly, this is unacceptable. Inclusion, Mr. President, I would like to quote from some of the letters I received from the seniors themselves, voicing their opposition to the Medicare managed care demonstration project coming to their area. Elizabeth Weekley Sutton, of Independence, Missouri, wrote to me: Dear Senator Ashcroft: We need help. My husband, my friends, and I are very concerned and worried that our health care will be very limited by the end of the Competitive Pricing Demonstration that will be starting in January. Of all the HMO's in the U.S., only the entire K.C. area and Maricopa County in Arizona will be conducting this competition for the next 5 years! And here are some excerpts from a letter sent by Edward Smith of Platte City, Missouri: I am totally opposed to the Health Care Financing Administration competitive pricing demonstration project to take place here in the Kansas City area. My health will not permit me to be a guinea pig for a total of five years when the rest of the country will have business as usual. He continues: Instead of the Health Care Financing Administration determining what is best for the beneficiaries I would prefer to do that myself. And finally, Mr. Smith says: If this plan is adopted my HMO could choose to leave the market. Then what is gained? Certainly not my health. Mr. President, we need to listen to the voice of our seniors. We cannot afford to jeopardize their health with a [[Page S12192]] risky experiment that could raise costs, limit choices, and cause doctor-patient disruption. For this reason, I have continued--and will continue--to work to halt this project in its present form in the Kansas City area. Exhibit 1 Metropolitan Medical Society of Greater Kansas City, July 21, 1999. Hon. Bob Graham, U.S. Senate, Washington, DC. Dear Senator Graham: I was concerned to read in the July 16, 1999, Congressional Record your dissatisfaction about the Senate's passage of the moratorium on the Medicare Prepaid Competitive Pricing Demonstration Project in Kansas City and Arizona. On behalf of the more than 2500 physicians of the Metropolitan Medical Society of Greater Kansas City and its affiliated organizations, I want to assure you that doctors strongly support the moratorium that was passed in the Senate Patient Bill of Rights legislation last week. The physicians of Kansas City have expressed serious concerns about the demonstration project since April, and we continue to be concerned. We believe the experiment will bring unacceptable levels of disruption to our Medicare patients and the local health care market. Additionally, I worry that quality care, which is often more expensive, will be less available to Medicare patients. In Kansas City, the opposition to the project is widespread. Our senators acted on behalf of our entire health care community, including patients, doctors, hospitals, and health care plans. The medical community has participated in the discussions about the demonstration with the Health Care Financing Administration (HCFA) and the local Area Advisory Committee for the demonstration project. Despite these discussions, problems with the experiment remain. We support congressional efforts to stop the demonstration project in the Kansas City area. I remain concerned that under-funded HMOs place our most vulnerable Medicare recipients at risk of getting less attention to their health care needs. I expect to hear more cases of catastrophes to Medicare recipients when the care given is too little, too late. You may be aware that Jacksonville, Florida is another potential site for the demonstration. Thank you for your consideration of my concerns. I hope I've helped to clarify the existence of broad based support in Kansas City for the moratorium on the competitive pricing demonstration. Sincerely, Richard Hellman, MD, President-Elect and Chair, National Government Relations Committee. amendment no. 1845 (Purpose: To express the sense of the Senate regarding school infrastructure) The PRESIDING OFFICER (Mr. Smith of Oregon). The Senator from Iowa. Mr. HARKIN. Mr. President, Senator Robb and I have an amendment at the desk. I call it up at this time, No. 1845. The PRESIDING OFFICER. The clerk will report. The legislative clerk read as follows: The Senator from Iowa [Mr. Harkin], for himself, and Mr. Robb, proposes an amendment numbered 1845. Mr. HARKIN. Mr. President, I ask unanimous consent that reading of the amendment be dispensed with. The PRESIDING OFFICER. Without objection, it is so ordered. The amendment is as follows: At the end of title III, add the following: SEC. ____. SENSE OF THE SENATE REGARDING SCHOOL INFRASTRUCTURE. (a) Findings.--The Senate makes the following findings: (1) The General Accounting Office has performed a comprehensive survey of the Nation's public elementary and secondary school facilities and has found severe levels of disrepair in all areas of the United States. (2) The General Accounting Office has concluded that more than 14,000,000 children attend schools in need of extensive repair or replacement, 7,000,000 children attend schools with life threatening safety code violations, and 12,000,000 children attend schools with leaky roofs. (3) The General Accounting Office has found the problem of crumbling schools transcends demographic and geographic boundaries. At 38 percent of urban schools, 30 percent of rural schools, and 29 percent of suburban schools, at least one building is in need of extensive repair or should be completely replaced. (4) The condition of school facilities has a direct affect on the safety of students and teachers and on the ability of students to learn. Academic research has provided a direct correlation between the condition of school facilities and student achievement. At Georgetown University, researchers have found the test scores of students assigned to schools in poor condition can be expected to fall 10.9 percentage points below the test scores of students in buildings in excellent condition. Similar studies have demonstrated up to a 20 percent improvement in test scores when students were moved from a poor facility to a new facility. (5) The General Accounting Office has found most schools are not prepared to incorporate modern technology in the classroom. Forty-six percent of schools lack adequate electrical wiring to support the full-scale use of technology. More than a third of schools lack the requisite electrical power. Fifty-six percent of schools have insufficient phone lines for modems. (6) The Department of Education has reported that elementary and secondary school enrollment, already at a record high level, will continue to grow over the next 10 years, and that in order to accommodate this growth, the United States will need to build an additional 6,000 schools. (7) The General Accounting Office has determined the cost of bringing schools up to good, overall condition to be $112,000,000,000, not including the cost of modernizing schools to accommodate technology, or the cost of building additional facilities needed to meet record enrollment levels. (8) Schools run by the Bureau of Indian Affairs (BIA) for Native American children are also in dire need of repair and renovation. The General Accounting Office has reported that the cost of total inventory repairs needed for BIA facilities is $754,000,000. The December 1997 report by the Comptroller General of the United States states that, ``Compared with other schools nationally, BIA schools are generally in poorer physical condition, have more unsatisfactory environmental factors, more often lack key facilities requirements for education reform, and are less able to support computer and communications technology.''. (9) State and local financing mechanisms have proven inadequate to meet the challenges facing today's aging school facilities. Large numbers of local educational agencies have difficulties securing financing for school facility improvement. (10) The Federal Government has provided resources for school construction in the past. For example, between 1933 and 1939, the Federal Government assisted in 70 percent of all new school construction. (11) The Federal Government can support elementary and secondary school facilities without interfering in issues of local control, and should help communities leverage additional funds for the improvement of elementary and secondary school facilities. (b) Sense of the Senate.--It is the sense of the Senate that Congress should provide at least $3,700,000,000 in Federal resources to help communities leverage funds to modernize public school facilities. Mr. HARKIN. Mr. President, Senator Robb and I are going to take a few minutes. I know the time is late. I know people want to get to a final vote on this. I want to talk about how good this bill is and to urge people to vote for it. This is a sense-of-the-Senate resolution. I will not go through the whole thing. It basically is a sense-of-the-Senate resolution saying Congress should appropriate at least $3.7 billion in Federal resources to help communities leverage funds to modernize public school facilities, otherwise known as public school construction. What we have in this country is schools that are on the average 40 to 50 years old. We are getting great teachers, new methodologies, new math, new science, new reading programs, and the schools are crumbling down around us. They are getting older every day. Day after day, kids go to schools with leaky ceilings, inadequate heat, inadequate air conditioning for hot summer days and the fall when the school year is extended. They are finding a lot of these buildings still have asbestos in them, and it needs to be taken out. Yet we are shirking our responsibilities to refurbish, renovate, and rebuild the schools in this country. The General Accounting Office estimates 14 million American children attend classes in schools that are unsafe or inadequate. They estimate it will cost $112 billion to upgrade existing public schools to just ``good'' condition. In addition, the GAO reports 46 percent of schools lack adequate electrical wiring to support the full-scale use of technology. We want to get computers in the classrooms, we want to hook them to the Internet, and yet almost 50 percent of the schools in this country are inadequate in their internal wiring so kids cannot hook up with the Internet. The American Society of Civil Engineers reports public schools are in worse condition than any other sector of our national infrastructure. Think about that. According to the American Society of Civil Engineers--they are the ones who build our buildings, build our bridges and roads and highways and streets and sewers and water systems, and our schools--they say our schools are in the worst state of any part of the physical infrastructure of this country. Mr. HARKIN. Mr. President, if the nicest things our kids ever see or go to [[Page S12193]] is shopping malls and sports arenas and movie theaters, and the most run-down places are their schools, what kind of signal are we sending them about the value we place on education and their future? This is a sense-of-the-Senate resolution which simply outlines the terrible situation we have in this country and calls on the Senate and the Congress to respond by providing at least $3.7 billion, a small fraction of what is needed but a step in the right direction--$3.7 billion in Federal resources to modernize our Nation's schools. I yield the floor to my distinguished colleague and cosponsor, Senator Robb. The PRESIDING OFFICER. The Senator from Virginia. Mr. ROBB. Mr. President, I thank my friend and colleague from Iowa. Senator Harkin and I have offered a sense of the Senate amendment relating to school construction, as Senator Harkin has just explained. The amendment is not unlike the amendment Senators Lautenberg, Harkin, and I offered to the Budget Resolution earlier this year. That amendment assumed that given the levels in the budget resolution, Congress would enact ``legislation to allow States and school districts to issue at least $24.8 billion worth of zero-interest bonds to rebuild and modernize our nation's schools, and to provide Federal income tax credits to the purchasers of those bonds in lieu of interest payments.'' The actual cost as it was scored was referred to by the Senator from Iowa. That amendment was accepted and put the entire Senate on record as supporting the concept of providing federal assistance in the area of school construction and renovation. Understanding that Rule 16 prevents us from doing anything of significance at this time with respect to school construction, Senator Harkin and I in just a moment will withdraw our amendment. But every day that passes, this Congress misses an opportunity to help our States and localities fix the leaky roofs, get rid of all the trailers, and install the wiring needed to bring technology to all of our children. These are real problems--problems that our nation's mayors, school boards, and families simply need some help in addressing. While school infrastructure improvement is typically a local responsibility, it is now a national need. Our schools, as the Senator from Iowa has indicated, are over 40 years old, on average; our school- aged population is at record levels; and our States and localities can't keep up, despite their surpluses. Abstract talk about State surpluses provides little solace to our nation's teachers and students who are forced to deal with wholly inadequate conditions. In Alabama, the roof of an elementary school collapsed. Fortunately, it occurred just after the children had left for the day. In Chicago, teachers place cheesecloth over air vents to filter out lead-based paint flecks. In Maine, teachers have to turn out the lights when it rains because their electrical wiring is exposed under their leaky roofs. Mr. President, we are missing an opportunity to help our States and localities with a pressing need. I will continue to work for and press forward on this issue because I think it's an area where the Federal Government can be extremely constructive. When our children are asked about ``Bleak House,'' they should refer to a novel by Dickens and not the place where they go to school. In my own State of Virginia, there are over 3,000 trailers being used to educate students. And there are over $4 billion worth of unbudgeted, unmet needs for our schools. This is a problem that is not going to go away, and it's a problem that our nation's schools need our help to solve. And I regret that Rule 16 precludes us from considering legislation which would reaffirm the commitment that we made earlier this year. I thank the distinguished Senator from Iowa for his continued work on the subject of school construction, and I yield the floor. Amendment No. 1845 Withdrawn The PRESIDING OFFICER. The Senator from Iowa. Mr. HARKIN. Mr. President, I understand this amendment is not acceptable to the other side. It is late in the day. I know people have to get on with other things, and we want to get to a final vote on the bill. I believe strongly in this. It is a sense-of-the-Senate amendment. Also, Senators Kennedy, Reid, Murray, and Johnson are added as cosponsors. In the spirit of moving this bill along and trying to wrap this up as quickly as possible, I ask unanimous consent to withdraw the amendment at this time, but it will be revisited. The PRESIDING OFFICER. The Senator from Pennsylvania. Mr. SPECTER. I thank my distinguished colleague. I am very sympathetic to the purpose of the sense-of-the-Senate amendment. He is correct; there would be objection, and I think it would not be adopted. I thank him for withdrawing the amendment. The PRESIDING OFFICER. The amendment is withdrawn. Amendments Nos. 2273 through 2289, 1852, 1869, and 1882 Mr. SPECTER. Mr. President, I now submit the managers' package which has been cleared on both sides. The PRESIDING OFFICER. The clerk will report. The legislative clerk read as follows: The Senator from Pennsylvania [Mr. Specter] proposes amendments numbered 2273 through 2289, 1852, 1869 and 1882. The amendments are as follows: amendment no. 2273 At the appropriate place in the bill add the following: SEC. . CONFOUNDING BIOLOGICAL AND PHYSIOLOGICAL INFLUENCES ON POLYGRAPHY. (a) Findings.--The Senate finds that-- (1) The use of polygraph tests as a screening tool for federal employees and contractor personnel is increasing. (2) A 1983 study by the Office of Technology Assessment found little scientific evidence to support the validity of polygraph tests in such screening applications. (3) The 1983 study further found that little or no scientific study had been undertaken on the effects of prescription and non-prescription drugs on the validity of polygraph tests, as well as differential responses to polygraph tests according to biological and physiological factors that may vary according to age, gender, or ethnic backgrounds, or other factors relating to natural variability in human populations. (4) A scientific evaluation of these important influences on the potential validity of polygraph tests should be studied by a neutral agency with biomedical and physiological expertise in order to evaluate the further expansion of the use of polygraph tests on federal employees and contractor personnel. (b) Sense of the Senate.--It is the Sense of the Senate that the Director of the National Institutes of Health should enter into appropriate arrangements with the National Academy of Sciences to conduct a comprehensive study and investigation into the scientific validity of polygraphy as a screening tool for federal and federal contractor personnel, with particular reference to the validity of polygraph tests being proposed for use in proposed rules published at 64 Fed. Reg. 45062 (August 18, 1999). ____ AMENDMENT NO. 2274 (Purpose: To provide funding for a dental sealant demonstration program) At the end of title II, add the following: dental sealant demonstration program Sec. ____. From amounts appropriated under this title for the Health Resources and Services Administration, sufficient funds are available to the Maternal Child Health Bureau for the establishment of a multi-State preventive dentistry demonstration program to improve the oral health of low- income children and increase the access of children to dental sealants through community- and school-based activities. ____ AMENDMENT NO. 2275 (Purpose: To limit the withholding of substance abuse funds from certain States) At the end of title II, add the following: withholding of substance abuse funds Sec. ____. (a) In General.--None of the funds appropriated by this Act may be used to withhold substance abuse funding from a State pursuant to section 1926 of the Public Health Service Act (42 U.S.C. 300x-26) if such State certifies to the Secretary of Health and Human Services that the State will commit additional State funds, in accordance with subsection (b), to ensure compliance with State laws prohibiting the sale of tobacco products to individuals under 18 years of age. (b) Amount of State Funds.--The amount of funds to be committed by a State under subsection (a) shall be equal to one percent of such State's substance abuse block grant allocation for each percentage point by which the State misses the retailer compliance rate goal established by the Secretary of Health and Human Services under section 1926 of such Act, except that the Secretary may agree to a smaller commitment of additional funds by the State. (c) Supplement not Supplant.--Amounts expended by a State pursuant to a certification under subsection (a) shall be used to supplement and not supplant State funds [[Page S12194]] used for tobacco prevention programs and for compliance activities described in such subsection in the fiscal year preceding the fiscal year to which this section applies. (d) The Secretary shall exercise discretion in enforcing the timing of the State expenditure required by the certification described in subsection (a) as late as July 31, 2000. ____ AMENDMENT NO. 2276 (Purpose: To express the sense of the Senate that funding for prostate cancer research should be increased substantially) At the appropriate place add the following: Sec. ____. (a) Findings.--Congress makes the following findings: (1) In 1999, prostate cancer is expected to kill more than 37,000 men in the United States and be diagnosed in over 180,000 new cases. (2) Prostate cancer is the most diagnosed nonskin cancer in the United States. (3) African Americans have the highest incidence of prostate cancer in the world. (4) Considering the devastating impact of the disease among men and their families, prostate cancer research remains underfunded. (5) More resources devoted to clinical and translational research at the National Institutes of Health will be highly determinative of whether rapid advances can be attained in treatment and ultimately a cure for prostate cancer. (6) The Congressionally Directed Department of Defense Prostate Cancer Research Program is making important strides in innovative prostate cancer research, and this Program presented to Congress in April of 1998 a full investment strategy for prostate cancer research at the Department of Defense. (7) The Senate expressed itself unanimously in 1998 that the Federal commitment to biomedical research should be doubled over the next 5 years. (b) Sense of the Senate.--It is the sense of the Senate that-- (1) finding treatment breakthroughs and a cure for prostate cancer should be made a national health priority; (2) significant increases in prostate cancer research funding, commensurate with the impact of the disease, should be made available at the National Institutes of Health and to the Department of Defense Prostate Cancer Research Program; and (3) these agencies should prioritize prostate cancer research that is directed toward innovative clinical and translational research projects in order that treatment breakthroughs can be more rapidly offered to patients. ____ amendment no. 2277 On page 59, line 25, strike ``$1,404,631,000'' and insert ``$1,406,631,000'' in lieu thereof. On page 60, before the period on line 10, insert the following: ``: Provided further, That $2,000,000 shall be for carrying out Part C of Title VIII of the Higher Education Amendments of 1998.'' On page 62, line 23, decrease the figure by $2,000,000. ____ amendment no. 2278 (Purpose: To clarify provisions relating to the United States-Mexico Border Health Commission) At the appropriate place, insert the following: Sec. . The United States-Mexico Border Health Commission Act (22 U.S.C. 290n et seq.) is amended-- (1) by striking section 2 and inserting the following: ``SEC. 2. APPOINTMENT OF MEMBERS OF BORDER HEALTH COMMISSION. ``Not later than 30 days after the date of enactment of this section, the President shall appoint the United States members of the United States-Mexico Border Health Commission, and shall attempt to conclude an agreement with Mexico providing for the establishment of such Commission.''; and (2) in section 3-- (A) in paragraph (1), by striking the semicolon and inserting ``; and''; (B) in paragraph (2)(B), by striking ``; and'' and inserting a period; and (C) by striking paragraph (3). ____ amendment no. 2279 On page 50, line 17, strike ``$459,000,000'' and insert in lieu thereof ``$494,000,000''. ____ amendment no. 2280 On page 66, line 24, strike out all after the colon up to the period on line 18 of page 67. ____ amendment no. 2281 On page 42, before the period on line 8, insert the following: ``: Provided further, That sufficient funds shall be available from the Office on Women's Health to support biological, chemical and botanical studies to assist in the development of the clinical evaluation of phytomedicines in women's health''. ____ amendment no. 2282 (Purpose: To provide for a report on promoting a legal domestic workforce and improving the compensation and working conditions of agricultural workers) On page 19, line 6, insert before the period the following: ``: Provided further, That funds made available under this heading shall be used to report to Congress, pursuant to section 9 of the Act entitled `An Act to create a Department of Labor' approved March 4, 1913 (29 U.S.C. 560), with options that will promote a legal domestic work force in the agricultural sector, and provide for improved compensation, longer and more consistent work periods, improved benefits, improved living conditions and better housing quality, and transportation assistance between agricultural jobs for agricultural workers, and address other issues related to agricultural labor that the Secretary of Labor determines to be necessary''. ____ AMENDMENT NO. 2283 (Purpose: To express the sense of the Senate concerning women's access to obstetric and gynecological services) Beginning on page 1 of the amendment, strike all after the first word and insert the following: ____. SENSE OF THE SENATE ON WOMEN'S ACCESS TO OBSTETRICAND GYNECOLOGICAL SERVICES. (a) Findings.--Congress makes the following findings: (1) In the 1st session of the 106th Congress, 23 bills have been introduced to allow women direct access to their ob-gyn provider for obstetric and gynecologic services covered by their health plans. (2) Direct access to ob-gyn care is a protection that has been established by Executive Order for enrollees in medicare, medicaid, and Federal Employee Health Benefit Programs. (3) American women overwhelmingly support passage of federal legislation requiring health plans to allow women to see their ob-gyn providers without first having to obtain a referral. A 1998 survey by the Kaiser FamilyFoundation and Harvard University found that 82 percent of Americans support passage of a direct access law. (4) While 39 States have acted to promote residents' access to ob- gyn providers, patients in other State- or in Federally-governed health plans are not protected from access restrictions or limitations. (5) In May of 1999 the Commonwealth Fund issued a survey on women's health, determining that 1 of 4 women (23 percent) need to first receive permission from their primary care physician before they can go and see their ob-gyn provider for covered obstetric or gynecologic care. (6) Sixty percent of all office visits to ob-gyn providers are for preventive care. (b) Sense of the Senate.--It is the sense of the Senate that Congress should enact legislation that requires health plans to provide women with direct access to a participating health provider who specializes in obstetrics and gynecological services, and that such direct access should be provided for all obstetric and gynecologic care covered by their health plans, without first having to obtain a referral from a primary care provider or the health plan. Mrs. MURRAY. Mr. President, included in the Manager's amendment is an important provision relating to women's health and access to reproductive health care services. I am pleased to have worked with the managers of this bill to send a strong message on the importance of direct access for women to their OB/GYN. I was disappointed that we were unable to address the rule XVI concerns with the amendment I had originally filed. My original amendment would simply allow women and their OB/GYNs to make important health care decisions without barriers or obstacles erected by insurance company policies. My amendment would have required that health plans give women direct access to their OB/GYN for all gynecological and obstetrical care and would have prohibited insurance companies from standing between a woman and her OB/GYN. However, it has been determined that my amendment would violate rule XVI. As a result of the announcement by the chairman of the Senate Appropriations Committee that he will make a point of order against all amendments that may violate rule XVI, I have modified my amendment. The modification still allows Members of the Senate to be on record in support of women's health or in opposition to removing barriers that hinder access for women to critical reproductive health care services. I am offering a sense-of-the-Senate that puts this question to each Member. I realize that this amendment is not binding, but due to opposition to my original amendment, I have been forced to offer this sense-of-the-Senate. I am disappointed that we could not act to provide this important protection to women, but I do believe this amendment will send an important message that the U.S. Senate does support greater access for women to quality health care benefits. I have offered this amendment due to my frustration and disappointment with managed care reform. I have become frustrated by stalling tactics and empty promises. The managed care reform bill that passed the Senate has [[Page S12195]] been referred to as an empty promise for women. I can assure my colleagues that women are much smarter than they may expect and will not be fooled by empty promises or arguments of procedural discipline. When a woman is denied direct access to the care provided by her OB/ GYN, she will not be interested in a discussion on ERISA or rule XVI. She wants direct access to her OB/GYN. She needs direct access, and she should have direct access. My amendment also reiterates the importance of ensuring that the OB/ GYN remains the coordinating physician. Any test or additional referral would be treated as if made by the primary care physician. This amendment does not call for the designation of an OB/GYN as a primary care physician, it simply says that if the OB/GYN decides additional care is necessary, the patient is not forced to seek approval from a primary care physician, who may not be familiar with her overall health care status. Why is this amendment important? The number one reason most women enter the health care system is to seek gynecological or obstetric care. This is the primary point of entry for women into the health care system. For most women, including myself, we consider our OB/GYN our primary care physician--maybe not as an insurance company defines it-- but, in practice, that's the reality. Does a woman go to her OB/GYN for an ear infection? No. But, does a pregnant woman consult with her OB/GYN prior to taking any antibiotic for the treatment of an ear infection? Yes, most women do. I know the policy endorsed in this amendment has in the past enjoyed bipartisan support. The requirements are similiar to S. 836, legislation introduced by Senator Specter and cosponsored by several Senators both Republican and Democrat. This amendment is similar to language that was adopted during committee consideration in the House of the fiscal year 1999 Labor, HHS appropriations bill. A similar directive is contained in the bipartisan House Patients' Bill of Rights legislation. It has the strong support of the American College of Obstetricians and Gynecologists and I know I have heard from several OB/GYNs in my own state testifying to the importance of direct access to the full range of care provided, not just routine care. I would also like to point out to my colleagues, that 39 states have similar requirements and that as participants in the Federal Employees Health Benefit Plan, all of us--as Senators--have this same guarantee as well as our family members. If we can guarantee this protection for ourselves and our families, we should do the same for women participating in a manager care plan. I realize that this appropriations bill may not be the best vehicle for offering this amendment. However, I have waited for final action on a Patients' Bill of Rights for too long. I have watched as patient protection bills have been stalled or delayed. Last year we were told that we would finish action on a good Patients' Bill of Rights package prior to adjournment. Well, here we sit--almost 12 months later--with little hope of finishing a good, comprehensive managed care reform bill prior to our scheduled adjournment this year. I also want to remind my colleagues that we have in the past used appropriations bills to address deficiencies in current law or to address an urgent need for action. I believe that addressing an urgent need in women's health care qualifies as a priority that we must address. I realize that the authorizing committee has objected to the original amendment I filed. As a member of the authorizing committee as well, I can understand this objection. But, again I have little choice but to proceed on this appropriations bill. We all know that it was only recently on the fiscal year 1999 supplemental appropriations bill that we authorized a significant change in Medicaid recoupment provisions despite strong objections from the Finance Committee. In last year's omnibus appropriations bill, we authorized a requirement that insurance companies must cover breast reconstruction surgery following a mastectomy. I can assure my colleagues that this provision never went through the authorizing committee. I would also point out that there are several antichoice riders contained in this appropriations bill that represent a major authorization. As these examples show, when we have to address these types issues through appropriations bills--we can do it. We have done it in the past, and we should do it today to meet this need. I urge my colleagues to support this amendment. We all talk about the need to ensure access for women to health care. I applaud Chairman Specter's efforts in this appropriations bill regarding women's health care. Adopting this amendment gives us the opportunity to do something that does ensure greater access for women. This is what women want. This is the chance for Senators to show their commitment to this critical benefit. I would like to quote a statement made by our subcommittee chairman that I believe more eloquently explains why I am urging this amendment. ``I believe it is clear that access to women's health care cuts across the intricacies of the complicated and often divisive managed care debate.'' I could not agree more. We know from the current state requirement and the Federal Employee Health Benefit Program requirement, this provision does not have a significant impact on costs of health care. We also know from experience that it has a positive impact on health care benefits. Since 60 percent of office visits to OB/GYNs are for preventive care, we could make the argument that adoption of this policy would reduce the overall costs of health care. I urge my colleagues to support this amendment and ask that we do more than simply make empty promises to women. We need an honest and