John Chafee

Mr. CHAFEE

Mr. CHAFEE. Mr. President, I ask unanimous consent that when the Senate completes its business today, it stand in recess until the hour of 9 a.m. on Tuesday, September 12, 1995; that following the prayer, the Journal of proceedings be deemed approved to date, the time for the two leaders be reserved for their use later in the day, and the Senate immediately resume consideration of H.R. 4, the welfare reform bill. I ask further unanimous consent that the Senate recess between the hours of 12:30 and 2:15 for the weekly policy conferences to meet.

Mr. CHAFEE

Mr. CHAFEE. Mr. President, for the information of all Senators, the Senate will resume consideration of the welfare reform bill tomorrow morning. Under a previous consent agreement, there will be a rollcall vote at approximately 9:10 tomorrow morning on or in relation to the Conrad amendment. Following that vote and a 4-minute debate, there will be a rollcall vote on or in relation to the Feinstein amendment. All Senators can therefore expect two rollcall votes early tomorrow morning. Following those votes, the Senate will begin debate on the Breaux amendment on maintenance of effort, with a vote to occur on that amendment at 2:15. Senators are also reminded that a cloture motion was filed this evening but in accordance with the consent agreement reached on Friday, that cloture vote will not occur prior to 6 p.m. this forthcoming Wednesday.

Mr. CHAFEE

Mr. CHAFEE. Now, Mr. President, on behalf of Senator Cohen I send an amendment to the desk dealing with supplemental security income benefits, so-called SSI, and ask for its immediate consideration.

Mr. CHAFEE. Mr. President, just a brief explanation. Under the rules that we are operating, as I understand it, we are required to file any amendments that we have reserved spots for by 5 o'clock this evening. As such, this is that type of amendment. I do not seek its immediate consideration now. I will call it up in some sequence next week, whenever is a proper time. Basically, this amendment is the maintenance-of-effort amendment that requires 75 percent maintenance of effort based on 1964 State expenditures, and the maintenance of effort shall continue for 5 years. The State expenditures shall only be for those existing categories that State expenditures are now made for, to qualify for matching funds under the AFDC and the other payments. In other words, the Federal contribution. The point I am making here is that the State maintenance-of-efforts funds cannot be used, for example, for Medicaid, which they are not currently committed to be used for. Mr. President, I ask that the amendment be set aside and we take it up in whatever sequence is deemed proper next week.

Mr. CHAFEE. Mr. President, on behalf of Senator Cohen, I send to the desk a modification to a prior amendment.

Mr. CHAFEE. Mr. President, if this is complete, I have an amendment on behalf of Mr. Cohen. I will send it to the desk.

Mr. CHAFEE. Mr. President, I have just a procedural question. We are open for business for filing the amendments until 5, and to have an amendment count you have to send it to the desk. That is what offering an amendment is. So, as I understand it--so, therefore, presumably, the establishment has to stay in business until 5?

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

Mr. CHAFEE. Mr. President, I send to the desk an amendment, and ask for its immediate consideration.

Mr. CHAFEE

Mr. CHAFEE. Mr. President, I am not going to review the bidding of why we are here this afternoon, but I do want to express my sentiments toward Bob Packwood, for whom I have the greatest respect and affection. As Senator Packwood mentioned, we have played 400 squash matches over the past 12 years. Four hundred times we met at the squash club to play, and in the game of squash--many may not know how it works, but you are very dependent upon your opponent for calling whether a shot was fair or not. In those 400 matches, never once--never once--did I have the slightest inclination or reason to say that what the call that Bob Packwood made was other than perfect. Never once did I have any sense of questioning it, because I had total reliance on him, and I still have that total reliance and affection and respect for him. Bob Packwood has one of the finest minds that I have seen since I have been in the Senate. We have served together in the Finance Committee for 18 years, and it is Bob Packwood who is responsible for the Republican Party having as many Senators as we do here. When I first came to the Senate, there were 37 Republicans, and Bob Packwood was in the leadership at that time and conceived the idea of having retreats on the Eastern Shore where Republicans would get together and come up with plans for the future. It is Bob Packwood who came up with the idea of what is now the Republican Senatorial Campaign Committee, with the Republican Senatorial Trust that he formed. When I ran for office, I received a small amount of money from the Republicans in the Senate, a very modest amount. But Bob Packwood really conceived the machinery that we have now, and the result of the tremendous funding that Republican candidates at present are receiving. Many have talked about his legislative achievements, but to my mind, the greatest single achievement in Bob Packwood in legislative affairs was the 1986 tax bill. That bill was absolutely stalled, was going nowhere. It had come from the House, not much of a bill. It came over here. We argued with it. Everybody came up with suggestions on how to reduce expenditures or how to have greater tax breaks. We all competed with each other, took care of everybody in sight as the deficit rose and rose in our calculations. Then Bob Packwood said, ``That's it.'' It was he who came up with the final program that we had. It was the 1986 tax bill. It was a Packwood tax bill that I and many others unanimously voted in the committee. I will never forget that evening. Pat Moynihan was there. Senator Dole was there. When we finished that vote, a unanimous vote, everybody stood and applauded the chairman of the committee for the tremendous feat that he had accomplished. So we will miss him. We will miss a fine brain in this Senate. We will miss him pacing across down in the well as matters were debated and coming up and getting at his desk. Back and forth. I will miss that distinctive walk he had, bent forward slightly as he charges over here. I will miss that so much because we were very close friends and will remain close friends, and I will greatly miss him, as we all will. Thank you, Mr. President. Mr. MOYNIHAN addressed the Chair.

Mr. CHAFEE

Mr. CHAFEE. I want to join with the Senator from New York. Those were very thoughtful remarks by the Senator from Louisiana. I hope we can get a bill out of this Senate that will really [[Page S 12694]] make some real progress in welfare reform. So I think the Senator from Louisiana has made a constructive contribution. I express my appreciation to him.

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

Mr. CHAFEE. I will be glad to.

Mr. CHAFEE

Mr. CHAFEE. I wish to make a few comments about my colleague from Rhode Island, Senator Pell, who today announced that after 36 years in this Chamber he will be retiring. This decision obviously cannot escape the reflection of the Senate whose Chamber has been given such dignity, such courtesy, such statesmanship through the dedicated service of Claiborne Pell. Nor can this announcement be taken lightly by our State, our joint State of Rhode Island. Our small State, as you can expect, makes big demands on its Senate delegation. We all know that the Senate was created in the Constitution in order to protect the smaller States from the will of the larger, more powerful, more prosperous States over the smaller ones. And over the years, different events have created special needs in our State that only the Federal Government has been able to adequately address. Now, there is no doubt, Mr. President, that the Senate and the State of Rhode Island will miss Senator Pell. Over 35 years--and 36 when he finishes--he has served our Nation and his State with great distinction. He not only lived up to the demands of his office, but, indeed, he left his handiwork on some of the most important areas and policy that our Nation has encountered. Let us just briefly take a look at them. First, I believe Senator Pell will be most remembered for his work in education, particularly providing for education for lower- and middle- income families in this Nation of ours. Now, many of the younger people today, even the younger Members of the Senate refer kind of casually to Pell grants, as though they have always been there. But they have not. The principle behind that program was not as widely accepted as today when they were started by Senator Pell. In recognition for the great accomplishment as the primary sponsor of the legislation creating these grants, as I recall, it was a Republican, Senator Javits, who proposed they be [[Page S 12558]] named the Pell grants. It was that, I think, that was a reflection of the bipartisanship that existed in the Foreign Relations Committee and in the Labor Committee among Senator Pell and his colleagues. And, indeed, it seems to me, as chairman of the Foreign Relations Committee, one of the things that Senator Pell had always strived for was bipartisanship, to reach a consensus, to have matters reported out unilaterally. That has been one of his goals. He certainly has achieved it. Now, another example has been Senator Pell's longstanding commitment to protection of the oceans and the coastal resources of our country. He has been a champion, originator of the Sea Grant Program, which is part of the National Oceanic and Atmospheric Administration. And he has been the leading Federal sponsor of the University of Rhode Island's School of Oceanography, which is the crown jewel of one of our State's fine institutions of higher education. Senator Pell has demonstrated his expertise in foreign affairs. He has been chairman of the Committee on Foreign Relations for several years. He distinguished himself as a man of peace. His active work to achieve agreements with other nations to limit chemical weapons, for example, and nuclear weapons nonproliferation are matters that he has worked on constantly ever since he has been in this Chamber. In addition, Senator Pell has been the leading advocate, the leading advocate in the Senate, for the betterment of our Nation's cultural life, primarily through his sponsorship and initiation of the National Endowment for the Arts. And I think he will long be remembered for that likewise. No question about it. Beyond these overarching policy concerns, Senator Pell has been a strong advocate for our State. And it is a pleasure that I have had in working with him since the years that I have been here on things like the preservation of historic Cliff Walk in Newport and the South East Light on Block Island or retaining the submarine construction industry in our State. And when one out of every three Rhode Islanders found themselves without access to deposits through failed credit unions--one out of every three Rhode Islanders, 33 percent of our State, had some money tied up in credit unions when they failed--Senator Pell greatly helped in crafting Federal assistance for that. Above all, I wish to emphasize those personal qualities that Senator Pell has brought to this Chamber as an example for all of us. At some point we have all been tired and contentious in debate with the sense that we will never finish some of this complicated legislation. But Senator Pell has never lost his pleasant disposition, his calmness, his sense of objectivity, his striving to achieve a consensus that I mentioned before. This is particularly important, his honesty coming through. And that is important in our State where we have had a series of mismanagement and scandals and outright failures. And, indeed, many people of our State have gotten very, very cynical about their elected officials, but not about Senator Pell, who has stayed on the high road ever since he came into public life. So, Senator Pell will leave the Senate a better place for his having been here. My father used to say, ``Try to leave, wherever you have been, your work station a better place than when you got there.'' And certainly Senator Pell has followed that admonition. His work station, this work station, the Senate of the United States, is a better place for his having been here. He has left an example for all of us to aspire to. So it is with regret and affection that I wish him well in the years to come and that he may enjoy the best of health and the pleasantries and good times that come with his family and with good health that I so hope that he will enjoy. I thank the Chair. I thank the distinguished Senator from New York for letting me proceed. Mr. MOYNIHAN addressed the Chair.

Mr. CHAFEE

Mr. CHAFEE. Mr. President I ask unanimous consent that I might proceed for 20 minutes.

Mr. CHAFEE. I thank the Chair.

Mr. CHAFEE. Mr. President, as I understand, we are in morning business, and I am permitted to speak for 10 minutes.

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

Mr. CHAFEE

Mr. CHAFEE. Mr. President, when the Congress returns from the August recess we are going to begin work in earnest on a very difficult part of the balanced budget effort which we are all dedicated to achieving, certainly on this side of the aisle. Mr. President, I enthusiastically support our efforts to achieve the balanced budget by the year 2002. It is absolutely essential that we get Federal spending under control. The 1996 budget resolution, the orders that came down from the Budget Committee to the Finance Committee, said that the Finance Committee must reduce spending within its programs by $530 billion over the next 7 years. That is not a cut from existing levels, it is a reduction from where the [[Page S 12340]] spending otherwise would have gone--$530 billion in 7 years. That is a monstrous task to achieve. Then the Budget Committee made some suggestions--not mandates, but suggestions--on how that $530 billion reduction in what otherwise would have been spent can be achieved. The Budget Committee recommended that there be a reduction in the rate of growth of Medicaid by $182 billion over the 7-year period. The remainder of the Finance Committee's objectives would be achieved by slowing the growth in other programs such as Medicare, AFDC, and other spending programs. Now, the resolution from the Budget Committee did not specifically require or call for Medicaid being transferred into a block grant. However, many believe that we cannot achieve these savings of the $182 billion without converting the program into a block grant. Mr. President, I do not share that conclusion. I will spend a few minutes discussing the challenges confronting us as we attempt to achieve those reductions in growth. First, a little bit about Medicaid. What is Medicaid? Who does it serve? Medicaid is a means-tested entitlement program, jointly financed by the States and the Federal Government, based on a formula that has the maximum contribution by the States being 50 percent in some wealthier States and going down as low as 20 percent in some States such as Mississippi, for example. This is a program, financed jointly by the Federal Government and by the States, which is fully administered by the States. Federal law requires States to cover certain groups of individuals and to provide certain benefits to those individuals. States receive matching payments based on a per capita income. Now, not all individuals who are poor qualify for Medicaid. There is a belief if you are poor you get Medicaid. That is not necessarily so. The eligibility for Medicaid is limited to the following: Low-income families who receive cash assistance under programs such as AFDC; or children and pregnant women who do not qualify for AFDC but whose family incomes are at or near the poverty level. Now, note this is not an adult male whose earnings are at or below the poverty level. He is not covered under this program. It is children and pregnant women who do not qualify for AFDC but whose families are at or near the poverty level. Another group, the acute and long-term care costs of persons with disabilities--the disabled communities. In addition, certain health care services for the elderly. Now, what are these? Medicaid pays the cost of Medicare part B premium. This is part of Medicare. The premium normally is paid by the beneficiary, but in very, very low-income Medicaid beneficiaries the part B premium is paid by Medicaid. What about for that same group of people on Medicaid, those over 65 in most instances, who have to pay the deductibles or the copayments? If the individual is, again, a low-income individual, elderly, Medicaid pays those deductibles or copayments. Medicaid also pays for services not covered by Medicare in some instances. For example, prescription drugs for our poorest senior citizens are paid for by Medicaid. Medicaid also pays to sustain three out of every four persons in nursing homes. That is a startling figure. Mr. President, 75 percent of the people, residents of nursing homes in the United States of America, are being paid for by Medicaid. Now, I have here, Mr. President, a chart and it looks a little busy but I will explain it. This is the population of the Medicare beneficiaries, recipients. Mr. President, 50 percent of the Medicaid population, those receiving benefits under Medicaid, are children. This shows the population percentage in Medicaid; this shows the expenditures for that population. For example, although 50 percent of Medicaid recipients are children, they only absorb 15 percent of the moneys spent by Medicaid. Or another case, adults receiving--the pregnant mother I talked about--adults constitute 23 percent of the population receiving Medicaid, but only consume 12 percent of the funds. This group I have just described, the pregnant mother with her children who are receiving AFDC or are poor--below the poverty level-- constitute 73 percent of those receiving Medicaid, but they only consume 27 percent of the moneys. The blind and disabled constitute 15 percent of the Medicaid population, but consume 31 percent of the money. The elderly constitute 12 percent of the population but consume 28 percent of the money. The elderly and the disabled constitute 27 percent of the population, yet they consume 60 percent of the moneys. That is very important to bear in mind as we move through this little discussion. Now, let me return to the budget issue. Republican Governors appear to be advocating that Congress enact legislation to convert the Medicaid program to a block grant to meet the savings targets contained in the budget resolution. This approach has been seized upon by many Republicans in Congress as a panacea to our Medicaid problems. This is a great way to solve everything--just block grant it. The advocates of block grant propose that Congress repeal all Federal requirements with respect to eligibility, benefits, and quality standards. In other words, we would not have those anymore under the Medicaid program under a block grant. Moreover, the proposal frequently made by this group is that the Federal dollars flow out with no State contribution. As I previously mentioned, the program currently is partly State, partly Federal. In most on average the Federal share would be about 55 percent and the State share about 45 percent. That is what we call maintenance of effort, that the State has to continue to contribute. The proposal is that we do not require that anymore. That the Federal Government turn over $773 billion with only one requirement over the 7- year period. Mr. President, $773 billion of Federal money would go out to the States with only one requirement on the States--that these moneys be spent on health care for low-income citizens. It does not define who would be eligible. It does not define health care services. It does not define what the quality standards. This is a very, very, dramatic proposal. I think this approach is fraught with problems. First and foremost, I am concerned that States will be forced to make drastic reductions in services and eligibility to live within the 4 percent growth cap that is envisioned under the budget resolution. Under the budget resolution, we provide the States with money we gave them in 1994 and then we go up by 4 percent, realizing the Medicaid population will probably increase over that period. What I am worried about is the effect would be more Americans without any type of health insurance. Already in our Nation, there are about 38 million people who are uninsured. I am very reluctant to see that pool of Americans without health insurance increase. Even more troubling is my concern that there will be an attempt to reduce the rate of growth in Medicaid even more than that required in the budget resolution. As I say, the Finance Committee has a lot of flexibility here. We do not have to reduce Medicaid by $182 billion. We can reduce it by $190 billion or $200 billion. And, unquestionably, there will be a tendency, when we look at the large target of savings that have to be achieved under Medicare, to say, ``$270 billion out of Medicare, that is a lot. Let us just increase the savings somewhat in Medicaid''--Medicare being the program for those over 65, Medicaid being for that group that I previously discussed, primarily low-income families and low-income seniors. If the Finance Committee adopts the budget resolution recommendations, Medicare growth rates are 7 percent and Medicaid 4 percent. These already, it seems to me, are disproportional, and any attempts to further reduce the rate of growth in Medicaid would cause me great concern. Second, I am concerned about the complete lack of accountability, with no kind of strings attached to this block grant proposal. Surely we ought to have some guarantees that these funds will be spent for their intended purpose. How do we do that? That is left undescribed, so far. A third, but very real, problem is the formula. This is a huge amount of [[Page S 12341]] money. How is it to be equitably divided among the States? We have wrestled with that in welfare, but that is really the minor leagues compared to the expenditures and problems that come up with Medicaid. In Medicaid, we are dealing with hundreds of billions of dollars--not the tens of billions of dollars that we have so struggled with in determining a correct formula under AFDC. I would like to touch on each of those matters just briefly in a little more detail. Living within the block grant: The budget resolution recommends the growth rate be brought down and leveled off at 4 percent by 1998. We can grow a little more in Medicaid next year, 7 percent, but by 1998 it has to be at 4 percent. That translates, as I said before, to a $182 billion reduction in the rate of growth over the next 7 years. Under the block grant approach, each State would receive a fixed allocation. If there are more people eligible for Medicaid --which might be because of a recession or something similar--the States would either have to make up the difference or cut back on services and eligibility. The Governors who advocate the block grant assured Congress they would live within this absolute cap. It is true a number of States have begun enrolling families with children into managed care. That seems to be the solution that is proposed. States argue that they can achieve these savings by enrolling the Medicaid population into managed care. And, indeed, those States that have tried it have had some success. However, Mr. President, here we get back to the percentage of eligibles in each category compared with the spending. Yes, you can use managed care with the 73 percent of the Medicaid population, the children and adults. It is possible to enroll this population in managed care and achieve savings. But the trouble is, you are only dealing with 27 percent of the expenditures. What about managed care for the elderly, and those up here, who constitute 27 percent of the population but are consuming 60 percent of the moneys? The reality is that States have little or no managed care experience when it comes to long-term care. These folks, the elderly, this group-- they are in nursing homes, for the most part. Arizona is the only State which has its entire Medicaid population in managed care. Its growth rate over 13 years of experience averages 7 percent, not the 4 percent we are trying to achieve. Mr. President, 7 percent is a long ways from 4 percent. What about other administrative efficiencies? Some say we can do it under the block grant by repealing the so-called Boren amendment, which is a Federal requirement that State payments to providers under Medicaid be ``reasonable and adequate.'' The view is that you can repeal the Boren amendment and there will be tremendous savings. Yet, the Congressional Budget Office estimates that repeal of the Boren amendment would only yield $7 billion over this 7- year period--about $1 billion a year. June O'Neill, director of CBO, in recent testimony before the House Commerce Committee, said the following: Improving the efficiency by itself almost certainly could not achieve reductions in the rate of growth in the order of magnitude being discussed. [She is talking about the delivery of services under Medicaid.] Some combination of cutbacks in eligibility, covered services or payments to providers [the nursing homes, the doctors, the hospital] would be necessary. In testimony before the Finance Committee last month, Governor Lawton Chiles, our former colleague here, U.S. Senator for 12 years, now Governor of Florida, said under the block grant approach he would have no choice but to cut back on services and eligibility. As States are forced to ration finite resources under a block grant, Governors and legislators would be forced to choose among three very compelling groups of beneficiaries. Who are they? Children--here they are right here--children, the elderly, and the disabled. They are the groups that primarily they would have to choose amongst. Unfortunately, I suspect in that children would be the ones who would lose out. My second concern is the issue of accountability. As I mentioned earlier, block grant proponents are pressing for a ``no strings'' approach--give us the money and do not tell us how we are going to spend it. As Governor Engler of Michigan made clear in testimony before the House Commerce Committee: * * * any financing mechanism that continues a Federal matching formula is not acceptable. I repeat: Not acceptable. In other words, they do not want this so-called maintenance of effort. I am confident that many States would use block grant funds appropriately. However, those who are familiar with the Medicaid Program need look no further than the so-called disproportionate share hospital program to find examples of diversion of funds, of Medicaid funds. I suspect the American public would be shocked to hear how many miles of highway have been paid for with Federal Medicaid dollars, or that at least one college stadium is reportedly known as the ``Medicaid Dome.'' As a former Governor, I am sympathetic to the urgent pleas of the National Governors Association for more flexibility. Every Governor wants that. Most of us would agree that the Medicaid Program could be greatly improved by repealing some of the more complex and burdensome requirements. However, I find the concept of completely abandoning all Federal standards troubling. What are some of the standards that would be lost under the ``no strings'' approach of the block grant method? What are we talking about when we are talking standards? Federal nursing home standards, for one. During the 1980's, many nursing homes were warehouses for the elderly. Residents were left tied to their beds lying, in some instances, in their own filth. During the 1970's, we saw managed care plans in California receiving huge sums of Medicaid dollars for health care services they never provided. It turned out that one managed care plan in California had a 24-hour emergency number, and that turned out to be a phone booth on a street corner. Under current Medicaid law, physicians and other providers of health care services are required to be licensed and hospitals have to be accredited. I think these are important quality standards. Perhaps some States would enact their own laws to address these concerns. But when we are dealing with hundreds of billions of dollars and millions of lives, I hate to take anything for granted. It is perhaps because of my own experience as a Governor that I know the value of making Federal funds contingent upon a sizable State contribution. I just want to relate a little anecdote. When I was Governor of Rhode Island, I went out with our director of public works driving over a new interstate highway we had just built. I saw a lot of lights along the highway. Immediately my thought was, What are all these lights doing there? That has to be terribly expensive. So I turned to the director of the department of public works. ``What about all those lights? Why do you have them?'' ``Oh, do not worry. That is 90-10 money,'' meaning the Federal Government pays 90 cents and the State only paid 10 cents. So why should we worry about some unnecessary frills such as this abundance of lights? I found that a perfectly acceptable explanation. Why not take it, 90-10? But from that lesson, I realized that unless there is a sizable contribution percentagewise by the States, then there is a casualness in the expenditure of Federal dollars. My last concern deals with how we go about allocating funds among the States under the block grant. We had, as I mentioned before, great struggles on the welfare bill that we are dealing with now on the allocation of funds. If we adopt the formula based on current Federal spending on Medicaid in each State, all States would get about a 19- percent decrease below the levels anticipated under current law. And reducing that rate of growth to achieve the $182 billion of savings would require every State to go down under its present allocation about 19 percent from where they otherwise would be. What do we do with those States that are anticipating high population growth? There are many factors that could be taken into account. Some suggest that the allocation should be [[Page S 12342]] based upon population. Under this scenario we would see a massive shifting of funding from the Northeast, from Pennsylvania, Connecticut, New York, and Rhode Island, a shift from those States to the South and to the West. The State of Rhode Island would see a 42-percent reduction in Medicaid funds from what it otherwise would have received. New York would see a 50-percent reduction if we use the formula based on population and projected population growth. Utah would see a 30-percent increase in Medicaid money. Oregon would receive an 11-percent increase. I chose Oregon, New York, Utah, and Rhode Island because all of those States have representation on the Finance Committee. You can see right away that a major battle would ensue. Having voiced my concern about the block grant, I would like to outline an alternative approach which I am currently working on to meet the savings targets contained in the budget resolution. Whatever we do, I am going to stick by those targets. As far as I am concerned nothing can come out of the Finance Committee wherein we do not meet our targets. But here is another way of doing it which would provide the additional flexibility the Governors need to make their systems more efficient. Two steps could go a long way--not all the way but a long way--toward meeting our reconciliation responsibilities with respect to Medicaid. First, a per capita cap on Federal spending for each beneficiary; x amount of dollars for every beneficiary. That would encourage the States to provide more cost-effective care, without sacrificing access to additional Federal funds in times of recession, as would result under a block grant approach. Second, let us reduce and redirect the so-called Federal disproportionate share payments going to hospitals. I am not going to go into a great deal of description of disproportionate share. All I can say is it is fraught with abuse. These two options that I mentioned--the per capita cap on Federal spending and reducing and redirecting disproportionate share payments to hospitals--could yield between $100 and $130 billion savings over the next 7 years. Our second objective of giving the Governors additional flexibility to achieve efficiency could be realized. What can we do to help the Governors? One, eliminate the requirements that States obtain Federal waivers before moving forward to implement managed care. Get away from this waiver business. Two, repeal the payment requirements, such as the Boren amendment and its so-called reasonable-cost reimbursement. Three, replace what is known as the Qualified Medicare Beneficiary [QMB] Program, which requires States to pay Medicare premiums and cost sharing for low-income seniors, and replace this with a more rational federally financed system. In conclusion, Mr. President, we have two choices. We can convert the Medicaid Program to a block grant and send out the checks, tell the States, ``You are on your own. Take care of health care for low income. That is it.'' Or, Mr. President, we can acknowledge that the Federal Government has a greater responsibility in this than just sending the checks off in the mail. In partnership with the States, I think we have a responsibility to provide health care services to low-income seniors, children and the disabled. The point I wish to make today is that with work and tough choices, we can meet our budget responsibilities without throwing this Federal- State partnership overboard as would result in the block grant approach. Certainly, that will be my preference between now and September 22, when the authorizing committees--in this instance the Finance Committee--must report their reconciliation legislation. I intend to continue to explore ways to reform the Medicaid Program. In that regard, I welcome input. My tilt, as you know, is away from the block grant approach. We need help. It is a tremendous goal that is set out, not only for the Medicaid Program but the Medicare likewise. The Finance Committee has tremendous challenges before us. So, Mr. President, I thank you for this.

Mr. CHAFEE

Mr. CHAFEE. Mr. President, today, I am introducing the Cancer Screening and Prevention Act of 1995. This bill targets colorectal cancer, one of this Nation's leading causes of death by cancer, by providing coverage under Medicare for prevention and early detection of colorectal cancer services. Medicare already provides for the treatment of colorectal cancer, but the treatment of this disease in its later stages is much more expensive than finding it early and treating it early. Last year, a Senate amendment--offered by my colleague from Utah, Mr. Hatch--was adopted during the health reform debate with strong bipartisan support. It directed that colorectal cancer screening benefits consistent with the guide to clinical preventive services, recommended by the U.S. Preventive Services Task Force, be included in any health care reform comprehensive benefits package. An amendment virtually identical to the bill I am introducing today, was passed with strong bipartisan support last year by the relevant House committees. A companion bill was introduced again this year in the House and has well over 40 cosponsors. I am hopeful our bill will receive similar strong support. I believe it is important for the Congress to act on this bill in order to stop the deaths this disease causes without prevention screening. In 1995 alone, 55,300 people are expected to die from colorectal cancer, and 138,200 new cases will be found. Colorectal cancer is the second leading cause of cancer death in this Nation--far more men and women die each year of colorectal cancer than with breast cancer or prostate cancer. In fact, colorectal cancer strikes men and women equally but is easily treated when found early. If colorectal cancer is not found early, the 5-year survival rate is 60 percent or lower. Early detection, however, can boost patients' 5- year survival rate to 91 percent. That differential is astonishing when measured in terms of lives and dollars saved. In recent years, colon cancers have become almost completely preventable by using techniques which became readily available only during the past decade. The vast majority of those afflicted with colorectal cancer are over the age of 50. Unfortunately, Medicare does not specifically cover colorectal cancer screening and prevention services and it should. In recent years, scientific developments have made clear that colorectal cancer can be eradicated. Just as Medicare now covers other preventive services such as mammography screening and flu shots, its time to add colorectal screening and prevention services. Several years ago, we moved aggressively to ensure that women took appropriate steps to prevent cervical cancer. It is time now to move aggressively to provide the preventive services necessary to eradicate this lethal cancer in the population most at risk. A study recently published in the Journal of the National Cancer Institute evaluated the effect of various factors on the costs of colon and other cancers. Not surprisingly, the study found that the costs associated with initial care of colon cancer was higher than when the cancer was first detected in its later stages. Based on these findings, the study concluded that interventions that prevent colon cancer will afford the greatest immediate cost savings. Under this act, all Medicare recipients will be eligible for limited cancer screening or preventive services. For certain high risk individuals a more comprehensive examination is available. The legislation enables early detection of colon cancer by providing for an annual fecal occult blood test. This low-cost, noninvasive blood-screening test allows for early detection of colorectal cancer. Research shows that this test, as well as a followup exam of a positive result, reduces cancer risks from 33 to 43 percent. The average cost of this test is only $5. Second, this legislation includes limited coverage of a flexible sigmoidoscopy exam which enables a doctor to inspect the lower part of the colon where 50 to 60 percent of polyps and cancers occur. This preventive service would be available no more than once every 4 years and is an essential component of the basic screening regimen recommended by the American Cancer Society for all asymptomatic, average risk Americans over the age of 50. Third, this act would allow individuals at high risk for getting colon cancer to receive a screening colonoscopy exam no more than once every 2 years. A screening colonoscopy allows a doctor to inspect the entire colon. This procedure also enables doctors contemporaneously to perform biopsies and to remove potentially precancerous polyps. [[Page S 12276]] The Cancer Screening and Prevention Act of 1995 specifically delineates those individuals at high risk for colon cancer, and allows the Secretary of Health and Human Services the authority to revise the category of high risk individuals. An individual faces a high risk of colon cancer if he or she has a history of cancer, suspicious polyps, or chronic digestive diseases such as inflammatory bowel disease, Crohn's disease, or ulcerative colitis, or if the individual has any gene markers for colorectal cancer present, or has a family history of colon cancer. The preventive screening services in this act are all standard medical procedures which are recommended by the American Cancer Society, the National Cancer Institute, the American College of Gastroenterology, the American Gastroenterological Association, and the American College of Physicians. Patient and professional groups alike support this legislation. The American College of Gastroenterology worked closely in providing scientific and technical information. This bill also enjoys the strong support of the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. It is strongly supported by consumer groups including the Crohn's and Colitis Foundation, the United Ostomy Association, and the other 10 patient care groups which comprise the Digestive Disease National Coalition. It is my understanding that a group of radiologists are concerned that their diagnostic procedures is not named as a covered service in this legislation. It is my hope that should this bill move through the Finance Committee and the Senate, we will work with these groups to resolve this issue. Several of my colleagues have indicated their strong support by sending a letter urging other Members to support this legislation. I ask unanimous consent that the letter of Senators Mack and Lieberman be included in the Record. I urge my colleagues to cosponsor the Cancer Screening and Prevention Act. Mr. President, I ask unanimous consent that additional material be printed in the Record.

Mr. CHAFEE

Mr. CHAFEE. Mr. President, I move to reconsider the vote.

Mr. CHAFEE. Mr. President, first, I want to thank the distinguished Senator from Nevada, Senator Reid, for the excellent work he has done on this amendment. He has really been a powerhouse in protecting the Endangered Species Act and working on it to make it more effective. I want to express to him the appreciation, not only of myself but I think of all Americans who believe in preserving the diversity that now exists in our nature. But for the Endangered Species Act, we would not be where we are. Yes, it is all right to talk about the visible things that have been saved, like the grizzly, the American eagle, or the California condor, but it is the thousands of other less prestigious, if you will, plants and animals that also have been protected during these 20 years, 25 years since the Endangered Species Act was first enacted, and it is due to Senators that have gone before us, such as Ed Muskie and others. But in that role of champions, there is none better than Harry Reid in working for an effective Endangered Species Act. Mr. President, the Endangered Species Act is funded at a very modest level. In the current year, $69 million. We had one witness come before us and say, ``Just remember, what you are spending on endangered species is about what it costs to build 2 miles of urban interstate highway''--2 miles of urban interstate highway. Overall in the interstate system, we have 45,000 miles, and 2 miles of that would provide for the funding of the Endangered Species Act for an entire year. The bill, as originally proposed, provided for a 20-percent cut in the funding for the Endangered Species Act; namely, going from $69 to $55 million. I want to express my appreciation to the senior Senator from Washington, the floor manager of the bill, Senator Gorton, for his working with us, and Senator Byrd, likewise, the distinguished former chairman of the Appropriations Committee, for working with us in the restoration of $4.5 million of that $14 million cut. I might say that what the Reid amendment would do with that $4.5 million, it will go for prelisting, for consultation, and for recovery activities by the Fish and Wildlife Service. All of those services are required by the law. The law says you have to have recovery, you have to have prelisting, you have to have consultation. Thus, a reduction in the funding will only make it more difficult for the Fish and Wildlife Service to do its job and will compound the problems that exist out there with local governments and with landowners. This amendment, I might say, Mr. President, does not affect listing. Under this bill we have before us, listing will be forbidden. There is a moratorium on any new listings or any new critical habitat designation until September 30, 1996, over a year from now, or until the Endangered Species Act is reauthorized. I am not enthusiastic about that, but as Senator Reid said, that is the way things go, and that is the will of the majority here. So there it is. It is my hope that in the Environment and Public Works Committee, we can come forward with a reauthorization of the Endangered Species Act, under the able leadership of the subcommittee dealing with this matter, the leader of that committee being Senator Kempthorne, doing a splendid job, five hearings have been held on the reauthorization of the Endangered Species Act, extremely constructive hearings with many good proposals for reform of the act. We have another hearing coming up in Wyoming a week from today, that is, if we are not here, and I greatly hope that we will not be. As chairman of the Environment and Public Works Committee, I want to make it clear that I am in favor of passing legislation to reauthorize, to improve the Endangered Species Act and hope to have that done this calendar year. Several of the witnesses who testified in favor of changes to the ESA, the Endangered Species Act, made a point of stating support for adequate funding. What did they say? Are they tree huggers who only believe in the Endangered Species Act? This is what Paul Harja, testifying in behalf of the Western Governors Association, said on July 13. He stated: A lot of the Governors are very concerned that funds to actually implement the act--I'm not talking about acquisition funds--worry that funds will be cut, resulting in an even worse problem than we have now. On behalf of the Western Governors, Mr. Harja stated in testimony: Reform of the act could prove meaningless if technical and financial assistance cannot be provided for the renewed public-private partnership that is essential to achieving the goals of the Endangered Species Act. The building industry of southern California wrote about ``the critical need for Federal funding.'' This letter closed by saying: Congressional action to reliably fund multispecies planning programs such as California's Natural Communities Conservation Plan, is essential to a workable Endangered Species Act. The theme through all this is, ``We've got the act, it has to be funded properly.'' The Western Urban Water Coalition, an association that represents water utilities for the largest cities in the Western United States, has written a letter dated July 24, just last month, urging that funding of the Endangered Species Act not be reduced. Their letter states: Federal agencies must be given the current resources needed to do their jobs. If they cannot perform, the lack of staff and funding for technical work and cooperation with our utilities will cause ESA implementation problems to grow, and our water consumers, rather than the Federal bureaucracy, will be penalized. The Western Lands Commission has passed a resolution urging Congress to provide adequate funding of the ESA. This is what that resolution said in part: The members urge Congress to fund implementation of ESA at a level that will permit, among other things, the required consultation under sections 7 and 10, to be conducted in a timely and expeditious manner . . . Restoring funds to the Fish and Wildlife Service will help the ESA work better on private lands. By providing funds for prelisting activities, Fish and Wildlife Service can avoid additional listings. Mr. President, why should those who oppose the existing Endangered Species Act support this amendment? The answer is clear. It is because problems under ESA will get worse, not better, if we fail to provide adequate funds. On the prelisting, some of the money goes for that. Funds for prelisting activities are used by the Fish and Wildlife Service for cooperative efforts with States and private landowners and Federal agencies to conserve a candidate species before it becomes threatened or endangered. The Reid amendment provides $3.8 million for prelisting. What about consultation? That is part of section 7 of the Endangered Species Act, Funds for consultation activities are used by the Fish and Wildlife Service to meet obligations under section 7 of the ESA. Section 7 requires agencies to consult with Fish and Wildlife to ensure that Federal actions do not jeopardize the continued existence of listed species. The Service also uses funds under the consultation account to pay for work of landowners on habitat conservation plans. In a recent hearing, a representative from Riverside County, CA, urged that financial assistance be provided to local communities to aid in the development of the habitat conservation plans. What about recovery, the last section? Funds for the recovery program are used to develop and implement recovery plans so that species no longer need to be listed. The whole thrust of this is to keep the species from becoming endangered. Do not get it on the list, if possible. The recovery of wildlife and plants that are on the threatened and endangered species lists is the ultimate goal of the ESA. Once they are on the endangered and threatened list, we want to get them off. That is why the recovery is so important throughout the whole Endangered Species Act. The Senate bill would reduce funds for recovery efforts by $10 billion. The Reid amendment restores $1.7 million of that funding. Again, Mr. President, neither the current Endangered Species Act, nor any of the proposed reform bills--I know the Senator from Washington has one and, clearly, out of the Environment Committee we will have a reform bill--will be successful without adequate funding. Eliminating the funds necessary for the Fish and Wildlife Service to do its job is counterproductive. The funding levels provided under the Senate bills will exacerbate current problems with the ESA. That is why it is so important this $4.8 million be added. I want to thank the distinguished senior Senator from West Virginia for his cooperation in this. The money does come from an area where he is deeply concerned. It is a cut to a modest degree--4 percent in the Bureau of Mines. Without the support of the distinguished Senator from West Virginia, who I can say is a real friend of mine since I have been here--for 19 years, it has been my privilege to have worked all that time with the Senator from West Virginia, and I am very proud that we have developed a friendship over that time, which I greatly value.

Mr. CHAFEE. I am sorry. I nearly got away with $300,000 more, Mr. President. It is $4.5 million, and that is what my notes say.

Mr. CHAFEE. We would not like a friendship broken up over a mere $300,000. I thank, again, my cosponsor, whom I have worked with, Senator Reid, and the distinguished Senator from New Jersey, Senator Lautenberg, who has been very helpful and persistent in this. I must say we need lots of friends in the Endangered Species Act, and we have two good ones in those two distinguished Senators. I yield the floor.

Mr. CHAFEE. I move to lay that motion on the table. The motion to lay on the table was agreed to.