Max Baucus

Mr. BAUCUS

Mr. BAUCUS. Mr. President, on behalf of Senator Mikulski, I send four amendments to the desk and ask unanimous consent that the pending amendments be set aside so that the amendments might be offered. I don't know whether it is permissible to get consent to offer all four or we have to do it individually? I send to the desk the four amendments en bloc and ask that the pending amendments be set aside. The amendments, for the purposes of consent, are to provide equal or equitable treatment for children's hospitals. Another is on the same subject. The third is to permit direct payment under the Medicare Program for clinical social worker services provided to residents of skilled nursing facilities. And the fourth is to extend certain municipal health service demonstration projects.

Mr. BAUCUS. Mr. President, first, I thank my good friend and colleague, the chairman of the committee, Senator Grassley, for his Job-like patience, as we have worked extremely hard with various Senators to try to come up with--and I think we have--a compromise, balanced solution as to how we spend the newly discovered $12 billion. I have a couple of points. The intent of this amendment and the language of this amendment accomplish a couple of purposes: No. 1, to evenly divide the $12 billion--$6 billion and $6 billion--to be available to be potentially used by PPOs in areas designated by the Secretary, and the other $6 billion to be spent in additional Medicare Programs for disease management, chronic care, and other ways to help particularly address the lack of coordination services for the chronically ill and those seniors who particularly need disease management. The amendment also has a couple other provisions, and to maintain the balance, maintain the symmetry is so important. I will remind my colleagues that in an attempt to get prescription drug benefits to seniors--something we all want to do--we are faced with two competing ideas. One is competition and the other is traditional Medicare. So the underlying bill is an attempt to work those two concepts together. This amendment follows on that tradition. It follows the same spirit, the same symmetry. I mentioned the $6 billion and $6 billion. In addition, the amendment provides the authority to continue in the applicable number of years-- beginning in 2009 through 2013--and the $12 billion is not available until then anyway. That is the problem we have. It doesn't start until 2009. But it is $6 billion available for potential PPO use and $6 billion for disease management, starting in 2009, for a 5-year period. In addition, the authority for both under this amendment continues into the future beyond the 5-year period. In addition, the language is written so it is an absolutely clear, ironclad guarantee that after the 5-year period no further dollars will be spent on either side, either the $6 billion available for PPOs or the $6 billion to be available for disease management, et cetera. It is very important to maintain that symmetry and balance in order to accomplish the spirit of cooperation so that we get this program started, get the prescription drug program that we want delivered and on its way. This is not perfect, but I can tell you that many hours have been devoted by many Senators on both sides of the aisle to come up with this solution, which does achieve that balance. I urge Senators to support this. This is going to break the logjam. This is the key amendment which has been topic A. Many Senators are wondering about this as they are thinking about other amendments they may or may not offer. I hope with the passage of this amendment we will be able to take up other amendments Senators have tomorrow and debate them and finally, hopefully, by sometime tomorrow and Thursday--perhaps at a late time on Thursday--pass this legislation and send it to conference. I yield the floor.

Mr. BAUCUS. I have been explaining various provisions in the bill that I think largely address concerns that some on the Democrat side have and I suppose on the Republican side of the aisle, too; namely, potential premium variation. Premiums that seniors pay might vary. Much confusion might occur for seniors and anyone else involved in prescription drug benefits that would be distributed under this legislation. As I mentioned, the actuaries say there should not be much change. Also, the risk pool will include all Medicare beneficiaries, ensuring an adequate number of low-drug-cost beneficiaries will be able to subsidize the few beneficiaries with the high drug costs. Already, there is a huge risk pool. There is kind of a cross subsidization. Those with very low drug costs will help pay for those much higher costs of other seniors. The larger risk pool will prevent premium variation because we use the whole pool. In addition, the bill will calculate Federal contributions toward plan premiums based on the national average of all plan bids. This contribution is then adjusted geographically for differences in prices. This is a so-called geographic adjustor. We want to make sure one part of the country is not discriminated against compared to another part of the country or vice versa, and we included the geographic adjustment on prices. We have not included so far, because it is difficult to calculate, geographic adjustment based on utilization. As we know, in some parts of the country there is more utilization. That is a fancy term for saying there is a lot more care given to people than in other parts of the country. More care, the greater utilization, tends to be in parts of the country with more hospitals, more specialty health care providers. There is an interesting study I urge my colleagues to read by Dr. Wennberg. I have not found anyone who refutes it. Looking at the country as a whole, there are parts of the country where utilization is twice as high and more than twice as high as other parts of the country. People, because of where they live, get twice as much health care in some parts of the country than in other parts of the country. This is adjusted for age, for race, for gender. It is adjusted for all the factors that can possibly be thought of. The more interesting part of this study, even though some parts of the country get twice as much health care as other parts of the country--and it is because there are twice as many doctors or hospitals in some parts of the country as in others--the interesting part of the study is, the actual care given is no better, and in fact in some cases it is worse. That is, if you get twice as much health care, that is, twice as many visits to the doctor or the hospital, particularly for chronic diseases, you will not be twice as healthy; you will not be any healthier, on average, than you will be in parts of the country where there is less utilization. The point is that we are trying to adjust, as I mentioned earlier, and have a geographic adjustment based on the costs. We have not yet figured out a way to adjust for different utilization mainly because, when it comes to prescription drug benefits for seniors, there is virtually no data because we have not had prescription drug benefits for seniors yet. Obviously, it is hard to get the data if we have not had the program. There are other provisions in the bill that enable us to get more data, so fairly quickly we can get better utilization data and therefore have a geographic adjustment based not only on price but also on utilization. That will go a long way to address some of the concerns people have about potential premium variation and complexity. When we get that data, as I said, we will have a lot more information, but there is enough information already to have the effect of minimizing concern about premium variations. There is another provision in the bill to help address this potential problem. That is, we have included in this bill a provision based on the Federal Employees Health Benefits Program--otherwise known as FEHBP--that prohibits plans from changing premiums that are unreasonably higher than the costs of the benefits provider. In other words, plans are prohibited from price gouging. That standard currently is in the law with respect to the FEHBP plan. That is in the law. There is a provision in current law that prohibits the FEHBP plans from charging premiums that are unreasonably higher than the cost that has been provided. I believe that same provision as applied to prescription drug pricing is an additional guarantee against gouging and certainly against unconscionable premium variation. Finally, this bill allows the Secretary to refuse to contract with the plan. That is in the bill. Maybe a plan leans toward enrolling healthier beneficiaries. Maybe the Secretary determines that this plan is not a good actor; this plan is price gouging; this plan is engaging in cherrypicking; it is engaging in adverse selection at the expense of an American; or maybe it seems less committed to staying in the program; maybe there is a shady operation; who knows, maybe it seems more likely to drop out fairly quickly and it is not solvent or financially healthy; maybe the premiums seem inconsistent with others in the region. For any of these reasons and reasons not contemplated at this time, the Secretary can decide, at his discretion, not to contract with a drug plan that has submitted a bid to participate in Medicare. That option is still there as a protection for our senior citizens. It is my hope that this discretion will help assure better plan choices for seniors and the benefits and premiums will, in fact, be fair and reasonable. In short, in developing this compromise bill, Senator Grassley and I have tried to allow a level of variation in premiums and benefits so as to foster innovation and to foster efficiency but not so much variation that seniors will be confused or plans will game the system. I think we have done a pretty good job of ending confusion and a pretty good job of preventing plans from gaming the system. I hope my colleagues will agree this proposal strikes at that. Madam President, I yield the floor. Amendment No. 1040 (Purpose: To provide for equitable reimbursement rates in 2004 and 2005 for Medicare+Choice organizations making the transition to MedicareAdvantage organizations)

Mr. BAUCUS

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

Mr. BAUCUS. I move to lay that motion on the table. The motion to lay on the table was agreed to. Amendment No. 982

Mr. BAUCUS. I yield the floor and withdraw my request.

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

Mr. BAUCUS. I know the Senator from New Hampshire would like to go ahead. I will speak for just a minute or 2 before he does. I very much agree with the Senator. It seems absurd that we have to wait until 2006 before this program goes into effect. I very much understand the concern of the Senator. Let me say this to all of us who are concerned. Before the conference report comes back, I am going to do my level best by pushing the CBO and CMS, asking a lot of tough questions of these agencies, to see if there is some way we can get this put together earlier. It is my hope we could bring back a conference report that has an earlier date, significantly earlier date. My guess is the private sector could get this done pretty quickly. It would not take a full 2 years to get it done. I just pledge to my colleagues, this is one Senator who is going to do his level best to try to get an earlier date. The current date just doesn't make sense. We need to ask some tough questions and get some answers. I yield the floor.

Mr. BAUCUS

Mr. BAUCUS. Mr. President, it is unfortunate we did not get the score on the Senator's amendment until just recently. The chairman and I have been in constant contact. I have called several times today the CBO Director in order to get the scores in time for amendments. The good news is Senators have come to us so we are able to prioritize amendments and therefore calls to CBO are on amendments that will be sequenced so we can help them get the scores. We are trying our best to get CBO scores. The Senators can help us and help CBO get the scores by getting amendments to us early so we can sequence them. On the other hand, it is very helpful if CBO can work as diligently as possible themselves and live up to their side of the bargain and get the scores to us. I hope we do not face this situation again where we get the score moments before an amendment is voted on, even though CBO knew this amendment was coming up; they had at least 24 hours' advance notice.

Mr. BAUCUS. Mr. President, I ask that all pending amendments be temporarily laid aside so the Senator from Arkansas can offer an amendment.

Mr. BAUCUS

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

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

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

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

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

Mr. BAUCUS. Yes, we do.

Mr. BAUCUS. Absolutely. How many minutes does the Senator want?

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

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

Mr. BAUCUS. I yield the Senator 2 minutes.

Mr. BAUCUS. Mr. President, the author of the amendment is not here. I think he was caught a bit off guard when it was announced the vote would be on his amendment at 5:30. I understand he is on his way over here. I think it is only fair he be allowed to speak for a couple or 3 minutes at least on his amendment. I ask consent the vote on the Bingaman amendment not be at 5:30 but at 5:40, and the remaining 10 minutes be equally divided.

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

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

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

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