Susan Collins

Ms. COLLINS

Ms. COLLINS. Mr. President, I ask unanimous consent the Senator from Arizona, Senator McCain, be added as a cosponsor of the Abraham amendment.

Ms. COLLINS. Mr. President, I want to start by commending the distinguished chairman of the Budget Committee for his outstanding work in producing this budget. He has been such a leader in fiscal responsibility. Once again he has done an outstanding job in crafting this budget resolution. I am pleased to be a cosponsor of the amendment offered by my friend and colleague from Michigan, Senator Abraham. This amendment would preserve and protect Social Security. I also commend Senator Domenici for his very innovative work in crafting this very important amendment. President Clinton has proposed devoting 62 percent of the surplus over the next 15 years to shoring up Social Security. On the surface, that sounds good. After all, we are all committed to protecting Social Security. But let's take a closer look at the President's proposal. On closer examination, the President's plan is nothing but a shell game. First, he devotes to the Social Security trust fund trust fund payroll taxes that already belong to Social Security. Then he lends this money to the Federal Government for new programs. The bottom line is that instead of preserving the money for Social Security, President Clinton actually ends up spending $158 billion of Social Security's money for programs completely unrelated to Social Security. Both the General Accounting Office and the Congressional Budget Office have pointed out the double counting and the other significant flaws in the President's proposal. Social Security is currently running a surplus because the program is taking in more in payroll taxes than it is paying out in benefits. But, as the Presiding Officer well knows, this will not always be the case. In 2013, payroll taxes will not be sufficient to pay benefits and the Social Security program will either have to raise taxes, cut spending, go further into debt, or use more general fund money, if we are to continue to meet our full obligation to Social Security beneficiaries. By the year 2030, the trust fund will be completely exhausted if we do not take steps to save the program. We certainly, given this dire picture, cannot afford to squander the Social Security surpluses by spending them on other programs. The current Social Security surplus conceals the true picture of our national budget. But for the temporary Social Security surplus, the Federal Government would actually be running a $6 billion deficit this year. I want to repeat that. There is a lot of misunderstanding. A lot of people think that we actually have a surplus in this upcoming year. The fact is, the surplus is due entirely to the surplus in the Social Security trust fund. If we take out the Social Security surplus, we would in fact be running a $6 billion deficit. The fact is, there is no real surplus in fiscal year 2000. We do not start to see real surpluses in the rest of the Government programs until the fiscal year 2001. The amendment that I have cosponsored, which is before us today, expresses the sense of the Senate that we pass legislation that would lock in Social Security surpluses by mandating that trust fund dollars could be spent only for the payment of Social Security benefits for Social Security reform or to pay down our national debt. Under this lockbox proposal, Social Security funds could not be spent on non- Social Security programs. They also could not be used to finance tax cuts. This legislation would establish in law a declining limit on the level of debt held by the public. These limits would decline in 2-year intervals by an amount equal to the Social Security trust fund surpluses for those years. Under this proposal, trust fund balances could be used to retire the debt, but not for new spending on programs unrelated to Social Security. The result of this innovative program is that public debt would decline by $417 billion. That is 32 percent more than it would under the President's proposal. Mr. President, in 1998 alone, the Federal Government spent nearly $162 billion to make interest payments on our national debt. That amounts to more than 6.7 percent of total Federal spending. In passing this important legislation, we would free up this money that otherwise would have to be spent on interest payments on our national debt. This amendment clearly affirms our commitment to preserving and protecting Social Security. It safeguards the Social Security trust fund from spending raids. It reduces our public debt. It lowers our interest payments. I urge all of my colleagues to join me in supporting this very important initiative. Once again, I commend the Senator from Michigan, Mr. Abraham, and the Senator from New Mexico, Mr. Domenici, for their innovative approach in coming up with a program that will truly protect our Social Security surpluses. I thank the Chair, and I yield the floor.

Ms. COLLINS

Ms. COLLINS. I thank the chairman and the ranking minority member of the Budget Committee for their cooperation.

Ms. COLLINS. I urge adoption of the amendment.

Ms. COLLINS. I ask unanimous consent that the pending amendment be set aside and send an amendment to the desk.

Ms. COLLINS

Ms. COLLINS. Mr. President, I rise today to engage the Senator from Missouri, Mr. Bond, the Chairman of the VA/HUD Subcommittee, in a colloquy. Senator Bond, you and I and the other members of the Northeast delegation have been working, for over a year now, to ensure that Maine and the Northeast have their needs from the January 1998 Ice Storm which devastated much of New England and upstate New York addressed.

Ms. COLLINS. It is my sincere hope that FEMA will expedite this process and provide to Maine the assistance it has been promised by the current Administration and has been in need of for over one year. I wish to thank the Senator from Missouri for his continuing efforts on behalf of the people of Maine. He has truly been a champion in this long process, and his cooperation is greatly appreciated by the people of Maine.

Ms. COLLINS. You have been a real champion for our state of Maine and of our efforts to ensure that the money this Senate appropriated went to alleviate some of the costs from the Ice Storm which could not be covered by FEMA.

Ms. COLLINS. For those that did not experience it, the devastation this storm caused in Maine is hard to imagine. Thick ice, in some cases up to ten inches thick, encased virtually every inch of the state and decimated our electric infrastructure. As a result of the Herculean efforts of hundreds of utility crews, power was restored to Maine after 17 long days. Like other Americans who have suffered natural disasters, Mainers need this assistance to recover from the costs incurred from the devastating blow nature dealt us.

Ms. COLLINS

Ms. COLLINS. Mr. President, today I am introducing a bill to make reorganization under Chapter 12 of the Bankruptcy Code applicable to family fishermen. In brief, the bill would allow family fishermen the opportunity to apply for the protections of reorganization in bankruptcy and provide to them the same protections and terms as those granted the family farmer who enters bankruptcy. Like many Americans, I'm appalled by those who live beyond their means, and use the bankruptcy code as a tool to cure their self-induced financial ills. I have supported and will continue to support alterations to the bankruptcy code that ensure the responsible use of its provisions. All consumers bear the burden of irresponsible debtors who abuse the system. Therefore, I believe bankruptcy should remain a tool of last resort for those in severe financial distress. As those familiar with the bankruptcy code know, business reorganization in bankruptcy is a different creature than the forgiveness of debt traditionally associated with bankruptcy. Reorganization embodies the hope that by providing business a break from creditors, and allowing debt to be adjusted, the business will have an opportunity to get back on sound financial footing and thrive. In that vein, Chapter 12 was added to the bankruptcy code in 1986 by the Senator from Iowa, Mr. Grassley, to provide for bankruptcy reorganization of the family farm and to give family farmers a ``fighting chance to reorganize their debts and keep their land''. To provide the ``fighting chance'' envisioned by the authors of Chapter 12, Congress provided a distinctive set of substantive and procedural rules to govern effective reorganization of the family farm. In essence, Chapter 12 was a recognition of the unique situation of family owned businesses and the enormous value of the family farmer to the American economy and our cultural heritage. Chapter 12 was modeled on bankruptcy Chapter 13 which governs the reorganization of individual debt. However, to address the unique problems encountered by farmers, Chapter 12 provided for significant advantages over the standard Chapter 13 filer. These advantages include a longer period of time to file a plan for relief, greater flexibility for the debtor to modify the debts secured by their assets, and alteration of the statutory time limit to repay secured debts. The Chapter 12 debtor is also given the freedom to sell off parts of his or her property as part of a reorganization plan. Unlike Chapter 13, which applies solely to individuals, Chapter 12 can apply to individuals, partnerships or corporations which fall under a $1.5 million debt threshold--a recognition of the common use of incorporation even among small family held farms. Without getting too technical, I should also mention that Chapter 12 also contains significant advantages over corporate reorganization which is governed by Chapter 11 of the Bankruptcy Code. For example, Chapter 12 creditors generally may not challenge a payment plan that is approved by the Court. Chapter 12 has been considered an enormous success in the farm community. According to a recent University of Iowa study, 74 percent of family farmers who filed Chapter 12 bankruptcy are still farming, and 61 percent of farmers who went through Chapter 12 believe that Chapter 12 was helpful in getting them back on their feet. Recognizing its effectiveness, my bill proposes that Chapter 12 should be made a permanent part of the bankruptcy code, and equally important, my bill would extend Chapter 12's protections to family fishermen. In my own state of Maine, fishing is a vital part of our economy and our way of life. The commercial fishing industry is made up of proud and fiercely independent individuals whose goal is simply to preserve their business, family income and community. In my opinion, for too long the fishing industry has been treated like an oddity, rather than a business through which courses the life's blood of families and communities. This bill attempts to bridge that gap and afford fishermen the protection of business reorganization as it is provided to family farmers. There are many similarities between the family farmer and the family fisherman. Like the family farmer, the fisherman should not only be respected as a businessman, but for his or her independence in the best tradition of our democracy. Like farmers, fishermen face perennial threats from nature and the elements, as well as changes to laws which threaten their existence. Like family farmers, fishermen are not seeking special treatment or a hand-out from the federal government, they seek only ``the fighting chance'' to remain afloat so that they can continue in their way of life. Although fishermen do not seek special treatment from the government, they play a special role in seafaring communities on our coasts, and they deserve protections granted others who face similar, often unavoidable, problems. Fishermen should not be denied the bankruptcy protections accorded to farmers solely because they harvest the sea and not the land. I have proposed not only to make Chapter 12 a permanent part of the bankruptcy code, but also to apply its provisions to the family fisherman. The bill I have proposed mirrors Chapter 12 with very few exceptions. Its protections are restricted to those fishermen with regular income who have total debt less than $1.5 Million, the bulk of which, eighty percent, must stem from commercial fishing. Moreover, families must rely on fishing income for these provisions to apply. Those same protections and flexibility we grant to farmers should also be granted to the family fisherman. By making this modest but important change to the bankruptcy code, we will express our respect for the business of fishing, and our shared wish that this unique way of life should continue.

Ms. COLLINS

Ms. COLLINS. Mr. President, today I am introducing a bill to make reorganization under Chapter 12 of the Bankruptcy Code applicable to family fishermen. In brief, the bill would allow family fishermen the opportunity to apply for the protections of reorganization in bankruptcy and provide to them the same protections and terms as those granted the family farmer who enters bankruptcy. Like many Americans, I'm appalled by those who live beyond their means, and use the bankruptcy code as a tool to cure their self-induced financial ills. I have supported and will continue to support alterations to the bankruptcy code that ensure the responsible use of its provisions. All consumers bear the burden of irresponsible debtors who abuse the system. Therefore, I believe bankruptcy should remain a tool of last resort for those in severe financial distress. As those familiar with the bankruptcy code know, business reorganization in bankruptcy is a different creature than the forgiveness of debt traditionally associated with bankruptcy. Reorganization embodies the hope that by providing business a break from creditors, and allowing debt to be adjusted, the business will have an opportunity to get back on sound financial footing and thrive. In that vein, Chapter 12 was added to the bankruptcy code in 1986 by the Senator from Iowa, Mr. Grassley, to provide for bankruptcy reorganization of the family farm and to give family farmers a ``fighting chance to reorganize their debts and keep their land''. To provide the ``fighting chance'' envisioned by the authors of Chapter 12, Congress provided a distinctive set of substantive and procedural rules to govern effective reorganization of the family farm. In essence, Chapter 12 was a recognition of the unique situation of family owned businesses and the enormous value of the family farmer to the American economy and our cultural heritage. Chapter 12 was modeled on bankruptcy Chapter 13 which governs the reorganization of individual debt. However, to address the unique problems encountered by farmers, Chapter 12 provided for significant advantages over the standard Chapter 13 filer. These advantages include a longer period of time to file a plan for relief, greater flexibility for the debtor to modify the debts secured by their assets, and alteration of the statutory time limit to repay secured debts. The Chapter 12 debtor is also given the freedom to sell off parts of his or her property as part of a reorganization plan. Unlike Chapter 13, which applies solely to individuals, Chapter 12 can apply to individuals, partnerships or corporations which fall under a $1.5 million debt threshold--a recognition of the common use of incorporation even among small family held farms. Without getting too technical, I should also mention that Chapter 12 also contains significant advantages over corporate reorganization which is governed by Chapter 11 of the Bankruptcy Code. For example, Chapter 12 creditors generally may not challenge a payment plan that is approved by the Court. Chapter 12 has been considered an enormous success in the farm community. According to a recent University of Iowa study, 74 percent of family farmers who filed Chapter 12 bankruptcy are still farming, and 61 percent of farmers who went through Chapter 12 believe that Chapter 12 was helpful in getting them back on their feet. Recognizing its effectiveness, my bill proposes that Chapter 12 should be made a permanent part of the bankruptcy code, and equally important, my bill would extend Chapter 12's protections to family fishermen. In my own state of Maine, fishing is a vital part of our economy and our way of life. The commercial fishing industry is made up of proud and fiercely independent individuals whose goal is simply to preserve their business, family income and community. In my opinion, for too long the fishing industry has been treated like an oddity, rather than a business through which courses the life's blood of families and communities. This bill attempts to bridge that gap and afford fishermen the protection of business reorganization as it is provided to family farmers. There are many similarities between the family farmer and the family fisherman. Like the family farmer, the fisherman should not only be respected as a businessman, but for his or her independence in the best tradition of our democracy. Like farmers, fishermen face perennial threats from nature and the elements, as well as changes to laws which threaten their existence. Like family farmers, fishermen are not seeking special treatment or a hand-out from the federal government, they seek only ``the fighting chance'' to remain afloat so that they can continue in their way of life. Although fishermen do not seek special treatment from the government, they play a special role in seafaring communities on our coasts, and they deserve protections granted others who face similar, often unavoidable, problems. Fishermen should not be denied the bankruptcy protections accorded to farmers solely because they harvest the sea and not the land. I have proposed not only to make Chapter 12 a permanent part of the bankruptcy code, but also to apply its provisions to the family fisherman. The bill I have proposed mirrors Chapter 12 with very few exceptions. Its protections are restricted to those fishermen with regular income who have total debt less than $1.5 Million, the bulk of which, eighty percent, must stem from commercial fishing. Moreover, families must rely on fishing income for these provisions to apply. Those same protections and flexibility we grant to farmers should also be granted to the family fisherman. By making this modest but important change to the bankruptcy code, we will express our respect for the business of fishing, and our shared wish that this unique way of life should continue.

Ms. COLLINS

Ms. COLLINS. Mr. President, I would like to announce for the information of the Senate and the public that the Permanent Subcommittee on Investigations of the Committee on Governmental Affairs, will hold hearings entitled ``Securities Fraud On The Internet.'' The upcoming hearings will examine the common securities frauds perpetrated on the Internet and the ways consumers can protect themselves from such frauds, as well as current online trading issues. Specifically, the hearing will focus on federal and state enforcement efforts to combat securities fraud on the Internet, particularly penny stock fraud, and whether federal and state consumer education programs designed to disseminate information about securities fraud on the Internet are adequate. The hearings will take place on Monday, March 22nd at 1:30 p.m. in room 342 of the Dirksen Senate Office Building and Tuesday, March 23rd, at 9:30 a.m. in room 342 of the Dirksen Senate Office Building. For further information, please contact Timothy J. Shea of the subcommittee staff at 224-3721. committee on energy and natural resources

Ms. COLLINS

Ms. COLLINS. Mr. President, I am pleased to be joining my colleague from West Virginia, Senator Rockefeller, in introducing the Advance Planning and Compassionate Care Act, which is intended to improve the way we care for people at the end of their lives. Noted health economist Uwe Reinhardt once observed that ``Americans are the only people on earth who believe that death is negotiable.'' Advancements in medicine, public health, and technology have enabled more and more of us to live longer and healthier lives. However, when medical treatment can no longer promise a continuation of life, patients and their families should not have to fear that the process of dying will be marked by preventable pain, avoidable distress, or care that is inconsistent with their values or wishes. The fact is, dying is a universal experience, and it is time to re- examine how we approach death and dying and how we care for people at the end of their lives. Clearly, there is more that we can do to relieve suffering, respect personal choice and dignity, and provide opportunities for people to find meaning and comfort at life's conclusion. Unfortunately, most Medicare patients and their physicians do not currently discuss death or routinely make advance plans for end-of-life care. As a result, about one-fourth of Medicare funds are now spent on care at the end of life that is geared toward expensive, high- technology interventions and ``rescue'' care. While most Americans say they would prefer to die at home, studies show that almost 80 percent die in institutions where they may be in pain, and where they are subjected to high-tech treatments that merely prolong suffering. Moreover, according to a Dartmouth study conducted by Dr. Jack Wennberg, where a patient lives has a direct impact on how that patient dies. The study found that the amount of medical treatment Americans receive in their final months varies tremendously in the different parts of the country, and it concluded that the determination of whether or not an older patient dies in the hospital probably has more to do with the supply of hospital beds than the patient's needs or preference. The Advance Planning and Compassionate Care Act is intended to help us improve the way our health care system serves patients at the end of their lives. Among other provisions, the bill makes a number of changes to the Patient Self-Determination Act of 1990 to facilitate appropriate discussions and individual autonomy in making difficult discussions about end-of-life care. For instance, the legislation requires that every Medicare beneficiary receiving care in a hospital or nursing facility be given the opportunity to discuss end-of-life care and the preparation of an advanced directive with an appropriately trained professional within the institution. The legislation also requires that if a patient has an advanced directive, it must be displayed in a prominent place in the medical record so that all the doctors and nurses can clearly see it. The legislation will expand access to effective and appropriate pain medications for Medicare beneficiaries at the end of their lives. Severe pain, including breakthrough pain that defies usual methods of pain control, is one of the most debilitating aspects of terminal illness. However, the only pain medication currently covered by Medicare in an outpatient setting is that which is administered by a portable pump. It is widely recognized among physicians treating patients with cancer and other life-threatening diseases that self-administered pain medications, including oral drugs and transdermal patches, offer alternatives that are equally effective in controlling pain, more comfortable for the patient, and much less costly than the pump. Therefore, the Advance Planning and Compassionate Care Act would expand Medicare to cover self-administered pain medications prescribed for the relief of chronic pain in life-threatening diseases or conditions. In addition, the legislation authorizes the Department of Health and Human Services to study end-of-life issues for Medicare and Medicaid patients and also to develop demonstration projects to develop models for end-of-life care for Medicare beneficiaries who do not qualify for the hospice benefit, but who still have chronic debilitating and ultimately fatal illnesses. Currently, in order for a Medicare beneficiary to qualify for the hospice benefit, a physician must document that the person has a life expectancy of six months or less. With some conditions--like congestive heart failure--it is difficult to project life expectancy with any certainty. However, these patients still need hospice-like services, including advance planning, support services, symptom management, and other services that are not currently available. Finally, the legislation establishes a telephone hotline to provide consumer information and advice concerning advance directives, end-of- life issues and medical decision making and directs the Agency for Health Care Policy and Research to develop a research agenda for the development of quality measures for end-of-life care. In this regard, Senator Rockefeller and I are particularly appreciative that Senator Bill Frist has incorporated our recommendation that end-of-life healthcare be added as a priority population in the Agency for Health Care Policy and Research's overall mission and duties in the bipartisan legislation he introduced last week to reauthorize the Agency. The legislation we are introducing today is particularly important in light of the current debate on physician-assisted suicide. The desire for assisted suicide is generally driven by concerns about the quality of care for the terminally ill; by the fear of prolonged pain, loss of dignity and emotional strain on family members. Such worries would recede and support for assisted suicide would evaporate if better palliative care and more effective pain management were widely available. Mr. President, patients and their families should be able to trust that the care they receive at the end of their lives is not only of high quality, but also that it respects their desires for peace, autonomy and dignity. The Advanced Planning and Compassionate Care Act that Senator Rockefeller and I are introducing today will give us some of the tools that we need to improve care of the dying in this country, and I urge all of my colleagues to join us as cosponsors.

Ms. COLLINS

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

Ms. COLLINS

Ms. COLLINS. Mr. President, I as unanimous consent that the Committee on Health, Education, Labor, and Pensions be authorized to meet for a hearing on ``Medical Records Privacy'' during the session of the Senate on Monday, March 15, 1999, at 9 a.m.

Ms. COLLINS. Mr. President, the Finance Committee requests unanimous consent to conduct a hearing on Monday, March 15, 1999 beginning at 10 a.m. in room 215 Dirksen.

Ms. COLLINS

Ms. COLLINS. Mr. President, diabetes is a serious and potentially life-threatening disease affecting more than 16 million Americans at a cost of more than $105 billion annually. Moreover, since 3 million elderly Medicare beneficiaries have been diagnosed with diabetes, and another 3 million are likely to have the disease but not know it, nowhere is the economic impact of diabetes felt more strongly than in the Medicare Program. Treating these seniors for the often devastating complications associated with diabetes accounts for more than one-quarter of all Medicare expenditures. Therefore, helping diabetic seniors avoid the complications of their disease will not only improve the quality of their lives but also help reduce the economic burden that diabetes places on Medicare. While there is no known cure, diabetes is largely a treatable disease. Many people who have diabetes can often lead relatively normal, active lives as long as they stick to a proper diet, carefully monitor the amount of sugar or glucose in their blood and take their medication, which may or may not include insulin. However, if these people with diabetes are unable to follow or do not follow this regimen, they put themselves at risk of blindness, loss of limbs and have an increased chance of heart disease, kidney failure and stroke. Therefore, preventive services for people with diabetes has the potential to save a great deal of money that would otherwise go for hospitalizations or acute care costs--not to mention a great deal of unnecessary pain and suffering. Congress recently took a number of important steps to improve Medicare coverage of preventive care for diabetics. Prior to the enactment of the balanced budget amendment in 1997, Medicare covered diabetics' self-maintenance education services in inpatient or hospital-based settings and in limited outpatient settings, specifically hospital outpatient departments or rural health clinics. Medicare did not, however, cover education services if they were given in any other outpatient setting, such as a doctor's office. Moreover, while Medicare did cover the cost of blood-testing strips used to monitor the sugar in the blood, the program did so for only Type I diabetics who require insulin to control their disease. The balanced budget amendment of 1997 rightly expanded Medicare to cover all outpatient self-management training services as well as providing uniform coverage of blood-testing strips for all persons with diabetes. With the enactment of the balanced budget amendment, we made significant progress toward improving care for our senior citizens with diabetes. However, there is more that we can do. External insulin infusion pumps have proven to be much more effective in controlling blood glucose levels than conventional therapy injection therapy for insulin-dependent diabetics whose blood sugar levels are difficult to control. Such pumps help them to avoid the expensive complications and suffering resulting from uncontrolled diabetes. However, Medicare currently does not cover these pumps, even when they have been prescribed as medically necessary by a patient's physician. I am, therefore, pleased to introduce today legislation, the Medicare Insulin Pump Coverage Act of 1999, that would expand Medicare coverage to include insulin infusion pumps for certain Type I diabetics. External insulin pumps are neither investigational nor experimental. They are widely accepted by health care professionals involved in treating parties with diabetes. Moreover, studies such as the Diabetes Control and Complications Trial sponsored by the National Institutes of Health have established that maintaining blood glucose levels as close to normal as possible is the key to preventing devastating complications from this disease. For many patients, the use of an infusion pump is the only way that optimal blood glucose control can be safely achieved. That is why virtually all other third party payers--including many State Medicaid Programs and CHAMPUS--cover the device. Moreover, there is precedent in Medicare since it currently does cover infusion pumps for numerous cancer drugs, as well as for pain control medications. The need for this legislation became apparent to me based on my attempts to help one of my constituents, Nona Frederich of Raymond, ME. She is an example of the Medicare patient who would benefit from the pump but who is currently being denied what is for her the most effective form of glucose control. Nona has been an insulin-dependent diabetic since 1962. Because of her extremely volatile insulin sensitivity, her diabetic specialists placed her on an insulin infusion pump in January 1982. Until she reached the age of 65, the cost of the pump and operating supplies were underwritten in large part by her insurer. In March of 1995 it became necessary for Nona to purchase a new infusion pump. However, by this time, she was now on Medicare and Medicare refused to cover it, even though her doctor had prescribed it as clearly being medically necessary. With the help of my Portland office, the Frederichs worked their way through the Health Care Financing Administration system of appeals. Unfortunately, in January of last year, they received final notification of a negative decision. Their only remaining option is to file a civil suit which they are simply not in a position to pursue. The Frederichs literally have notebooks filled with documentation of the procedures they followed and the evidence they submitted. Moreover, they personally paid close to $5,000 in original pump costs and supplies for which they received no reimbursement. For a Medicare beneficiary with a limited income, these kinds of costs would be devastating and would place the pump--the medically necessary pump-- completely out of reach. In such a case, they would be forced to return to or to continue with conventional insulin therapy which simply just may not be as effective in controlling blood sugar. As a consequence, these patients are admitted to the hospital over and over again, and Medicare now picks up the bill--a far greater bill than if Medicare had simply paid for the pump in the first place. While potentially devastating for an individual, the financial costs to Medicare of expanding coverage to include the insulin infusion pump will not be great. Under my bill, the pump would have to be prescribed by a physician and the beneficiary would have to be a Type I diabetic experiencing severe swings of high and low blood glucose levels. Of the estimated 3 million Medicare beneficiaries with diabetes, only about 5 percent are Type I, or insulin dependent; of these, it is estimated that the pump would be appropriate for only about 4 percent. Mr. President, what a difference it would make for those individuals. The American Diabetes Association, the Juvenile Diabetes Foundation, the American Association of Clinical Endocrinologists and the American Association of Diabetes Educators, as well as officials at the Centers for Disease Control, all have advocated expanding Medicare to cover insulin infusion pumps for Type I diabetics who otherwise would have great difficulty in controlling their blood sugars. I am pleased to introduce legislation today to do just that. I urge all of my colleagues to join me in support of this important legislation, legislation that would not cost much money but would enrich the lives of those diabetics who need these pumps immeasurably. I ask unanimous consent that the text of the legislation as well as the letters of support from the American Diabetes Association and the Juvenile Diabetes Foundation be printed in the Record.

Ms. COLLINS

Ms. COLLINS. Mr. President, diabetes is a serious and potentially life-threatening disease affecting more than 16 million Americans at a cost of more than $105 billion annually. Moreover, since 3 million elderly Medicare beneficiaries have been diagnosed with diabetes, and another 3 million are likely to have the disease but not know it, nowhere is the economic impact of diabetes felt more strongly than in the Medicare Program. Treating these seniors for the often devastating complications associated with diabetes accounts for more than one-quarter of all Medicare expenditures. Therefore, helping diabetic seniors avoid the complications of their disease will not only improve the quality of their lives but also help reduce the economic burden that diabetes places on Medicare. While there is no known cure, diabetes is largely a treatable disease. Many people who have diabetes can often lead relatively normal, active lives as long as they stick to a proper diet, carefully monitor the amount of sugar or glucose in their blood and take their medication, which may or may not include insulin. However, if these people with diabetes are unable to follow or do not follow this regimen, they put themselves at risk of blindness, loss of limbs and have an increased chance of heart disease, kidney failure and stroke. Therefore, preventive services for people with diabetes has the potential to save a great deal of money that would otherwise go for hospitalizations or acute care costs--not to mention a great deal of unnecessary pain and suffering. Congress recently took a number of important steps to improve Medicare coverage of preventive care for diabetics. Prior to the enactment of the balanced budget amendment in 1997, Medicare covered diabetics' self-maintenance education services in inpatient or hospital-based settings and in limited outpatient settings, specifically hospital outpatient departments or rural health clinics. Medicare did not, however, cover education services if they were given in any other outpatient setting, such as a doctor's office. Moreover, while Medicare did cover the cost of blood-testing strips used to monitor the sugar in the blood, the program did so for only Type I diabetics who require insulin to control their disease. The balanced budget amendment of 1997 rightly expanded Medicare to cover all outpatient self-management training services as well as providing uniform coverage of blood-testing strips for all persons with diabetes. With the enactment of the balanced budget amendment, we made significant progress toward improving care for our senior citizens with diabetes. However, there is more that we can do. External insulin infusion pumps have proven to be much more effective in controlling blood glucose levels than conventional therapy injection therapy for insulin-dependent diabetics whose blood sugar levels are difficult to control. Such pumps help them to avoid the expensive complications and suffering resulting from uncontrolled diabetes. However, Medicare currently does not cover these pumps, even when they have been prescribed as medically necessary by a patient's physician. I am, therefore, pleased to introduce today legislation, the Medicare Insulin Pump Coverage Act of 1999, that would expand Medicare coverage to include insulin infusion pumps for certain Type I diabetics. External insulin pumps are neither investigational nor experimental. They are widely accepted by health care professionals involved in treating parties with diabetes. Moreover, studies such as the Diabetes Control and Complications Trial sponsored by the National Institutes of Health have established that maintaining blood glucose levels as close to normal as possible is the key to preventing devastating complications from this disease. For many patients, the use of an infusion pump is the only way that optimal blood glucose control can be safely achieved. That is why virtually all other third party payers--including many State Medicaid Programs and CHAMPUS--cover the device. Moreover, there is precedent in Medicare since it currently does cover infusion pumps for numerous cancer drugs, as well as for pain control medications. The need for this legislation became apparent to me based on my attempts to help one of my constituents, Nona Frederich of Raymond, ME. She is an example of the Medicare patient who would benefit from the pump but who is currently being denied what is for her the most effective form of glucose control. Nona has been an insulin-dependent diabetic since 1962. Because of her extremely volatile insulin sensitivity, her diabetic specialists placed her on an insulin infusion pump in January 1982. Until she reached the age of 65, the cost of the pump and operating supplies were underwritten in large part by her insurer. In March of 1995 it became necessary for Nona to purchase a new infusion pump. However, by this time, she was now on Medicare and Medicare refused to cover it, even though her doctor had prescribed it as clearly being medically necessary. With the help of my Portland office, the Frederichs worked their way through the Health Care Financing Administration system of appeals. Unfortunately, in January of last year, they received final notification of a negative decision. Their only remaining option is to file a civil suit which they are simply not in a position to pursue. The Frederichs literally have notebooks filled with documentation of the procedures they followed and the evidence they submitted. Moreover, they personally paid close to $5,000 in original pump costs and supplies for which they received no reimbursement. For a Medicare beneficiary with a limited income, these kinds of costs would be devastating and would place the pump--the medically necessary pump-- completely out of reach. In such a case, they would be forced to return to or to continue with conventional insulin therapy which simply just may not be as effective in controlling blood sugar. As a consequence, these patients are admitted to the hospital over and over again, and Medicare now picks up the bill--a far greater bill than if Medicare had simply paid for the pump in the first place. While potentially devastating for an individual, the financial costs to Medicare of expanding coverage to include the insulin infusion pump will not be great. Under my bill, the pump would have to be prescribed by a physician and the beneficiary would have to be a Type I diabetic experiencing severe swings of high and low blood glucose levels. Of the estimated 3 million Medicare beneficiaries with diabetes, only about 5 percent are Type I, or insulin dependent; of these, it is estimated that the pump would be appropriate for only about 4 percent. Mr. President, what a difference it would make for those individuals. The American Diabetes Association, the Juvenile Diabetes Foundation, the American Association of Clinical Endocrinologists and the American Association of Diabetes Educators, as well as officials at the Centers for Disease Control, all have advocated expanding Medicare to cover insulin infusion pumps for Type I diabetics who otherwise would have great difficulty in controlling their blood sugars. I am pleased to introduce legislation today to do just that. I urge all of my colleagues to join me in support of this important legislation, legislation that would not cost much money but would enrich the lives of those diabetics who need these pumps immeasurably. I ask unanimous consent that the text of the legislation as well as the letters of support from the American Diabetes Association and the Juvenile Diabetes Foundation be printed in the Record.

Ms. COLLINS

Ms. COLLINS. Mr. President, I thank the chairman and again commend Senator Frist, chief sponsor of this legislation, and the chairman of the committee. I am pleased to join with them in this effort. Mr. President, the question before us is simple. This is not a question of who is for better schools; this is not a question of who is for putting more Federal resources in education; because both Democrats and Republicans alike share those two goals. The question before us is whom do you trust to make education decisions? Should education decisions be decided in Washington? Should every Federal dollar be attached to a string? Or should we trust the people at the local level--our school board members, our teachers, our parents, to make the best decisions for the students in local schools? To me, the answer is clear. We should increase the Federal commitment to education, but empower local school boards, teachers and parents to make the best decisions in keeping with the needs of their communities. That is the question before us. The second question before us is, Is the Government, is Congress, going to keep its promise with regard to funding special education? I say the answer to that should be yes. Let's keep the promise that was made more than 20 years ago when Congress passed the legislation mandating special ed. Let's keep our promise. Let's fully fund that important program before creating a whole lot of new categorical grant programs with strings attached. That is the debate. Everyone here is for better schools, better teachers, but that is not the issue.

Ms. COLLINS

Ms. COLLINS. Mr. President, I thank the sponsor of this bill. I am pleased to be an original cosponsor. Mr. President, let's get on with the task before us. The Educational Flexibility Partnership Act is a straightforward bill. It is a bipartisan proposal. It has been endorsed by the Governors of all 50 States. It will make a positive difference in the lives of students throughout this Nation. It will give to every State the flexibility that 12 States have had for the past 5 years--flexibility that will allow our States and our local schools to pursue innovative efforts to improve K-through-12 education. We should invoke cloture and take this important step toward improving our schools. In support of the need for this legislation, let me cite one example from my home State of Maine. Maine is one of the 38 States that are currently not eligible for Ed-Flex waivers. When Maine examined its educational system several years ago, the State found out that its schools had made significant progress in improving the achievement of Maine's students in K through 8. But in Maine, as in most of America, student achievement in secondary schools lagged far behind. Maine's schools simply were not sustaining the progress of the early years all the way until graduation. To the Maine commissioner of education, to local school boards, and to teachers and parents throughout the State, the need for change was clear. Maine needed to focus its efforts on improving secondary education; therefore, the commissioner of education applied to the Federal Secretary of Education for waivers from Federal requirements in order to use Federal education funding to address the true needs facing our State. Unfortunately, Mr. President, the Federal Department of Education did not share the conclusions of Maine's local educators; it resisted Maine's request for a waiver. Eventually, the waivers were indeed granted, but only after a lengthy battle between Maine and the Washington education bureaucracy. Time, effort, resources, and money were needlessly wasted. This should not have occurred. Passing the Education Flexibility Partnership Act will prevent other States from enduring the same frustration and delay that Maine experienced. It will allow us to use education dollars to address real needs and not the priorities set in Washington, DC. I thank the Chair and the sponsor of the bill.

Ms. COLLINS

Ms. COLLINS. Mr. President, I am pleased to be an original cosponsor of the amendment offered by Senator Jeffords. The amendment would require the federal government to make good on its commitment to fund special education before it made any additional promises it might not keep. When Congress passed the Individuals with Disabilities Education Act in 1975, the federal government made a commitment to the states and to the local school districts to help states meet the cost of special education. The federal government promised to pay each state 40 percent of the national average per capita cost of providing elementary and secondary education for each student receiving special education. For the school year 1996-1997, the national average expenditure was $5,913 per student. The federal payment to the states, however, was only $636 per student or slightly more than ten percent of the total cost and about one fourth of the $2,365 promised. We must meet our commitment to special education and end this unfunded mandate. Maine is promised $80 million by the Individuals with Disabilities Education Act. Yet, in 1998, it received less than $20 million toward the $200 million federal law requires the state to spend on special education. In short, special education is an unfunded federal mandate of $60 million that must be met by the citizens of Maine through already burdensome state income and local property taxes. This accounts for millions of dollars annually that can not be used for school construction, for teacher salaries, for new computers, or for any other state effort to improve the performance of our elementary and secondary school students. We need to increase federal spending on education, but we do not need new federal categorical programs with more federal regulations and dollars wasted on administrative costs. Rather, we need to meet our commitment to bear our fair share of special education costs. As the Governor of Maine told President Clinton last week, ``If you want to do something for schools in Maine, then fund special education and we can hire our own teachers and build our own schools.'' This is true for every state. The best thing this Congress can do for education is to fully fund our share of special education and at the same time return control of the schools to the states and local communities by passing the Education Flexibility Act. These two actions will empower our states and communities to meet the challenge of improving schools. Instead of presuming that we in Washington know what is best for every school across the country, let us acknowledge that each of our individual states and towns knows what is needed on a state-by-state and community-by-community basis. I urge my colleagues to give our states and local communities the financial support they have been promised and the freedom to educate our students as they see fit. We can do this by adopting this amendment to fully fund the federal share of special education and then passing the Local Control of Education Act.

Ms. COLLINS

Ms. COLLINS. Mr. President, I am pleased to be joining my colleague from Alaska, Senator Murkowski, in introducing the Graduate Medical Education Technical Amendments Act of 1999, which is intended to address some of the problems that small family practice residency programs in Maine and elsewhere are experiencing as a result of provisions in the Balanced Budget Act (BBA) of 1997 that were intended to control the growth in Medicare graduate medical education spending. Of specific concern are the provisions in the BBA that cap the total number of residents in a program at the level included in the 1996 Medicare cost reports. Congress' goal in reforming Medicare's graduate medical education program was to slow down our nation's overall production of physicians, while still protecting the training of physicians who are in short supply and needed to meet local and national health care demands. While the BBA's provisions will indeed curb growth in the overall physician supply, they do so indiscriminately and are thwarting efforts in Maine and elsewhere to increase the supply of primary care physicians in underserved rural areas. Because Maine has only one medical school--the University of New England, which trains osteopathic physicians--we depend on a number of small family practice residency programs to introduce physicians to the practice opportunities in the state. Most of the graduates of these residency programs go on to establish practices in Maine, many in rural and underserved areas of the state. The new caps on residency slots included in the BBA penalize these programs in a number of ways. For instance, the current cap is based on the number of interns and residents who were ``in the hospital'' in FY 1996. Having a cap that is institution-specific rather than program-specific has caused several problems. For example, the Maine-Dartmouth Family Practice Residency Program had two residents out on leave in 1996--one on sick leave for chemotherapy treatments and one on maternity leave. Therefore, the program's cap was reduced by two, because it was based on the number of actual residents in the hospital in 1996 as opposed to the number of residents in the program. Moreover, residents in this program have spent one to two months training in obstetrics at Dartmouth's Mary Hitchcock's Medical Center in Lebanon, New Hampshire. Because the cap is based on a hospital's cost report, these residents are counted toward Dartmouth Medical School's cap instead of the Maine-Dartmouth Family Practice Residency Program's. Last year, the Maine program was informed that Dartmouth would be cutting back the amount of time their residents are there. But the Maine- Dartmouth Family Practice Residency Program has no way of recouping the resident count from them in order to have the funds to support obstetrical training for their residents elsewhere. Moreover, the cap does not include residents who continue to be part of the residency program, but who have been sent outside of the hospital for training. This penalizes all primary care specialties, but especially family medicine, where ambulatory training has historically been the hallmark of the specialty. This is particularly ironic since other specialty programs that now begin training in settings outside the hospital will, under the new rules, have those costs included in their Medicare graduate medical education funding. All told, the Maine Dartmouth Family Practice Residency Program will see its graduate medical education funding reduced by over half a million dollars a year as a result of the cap established by the BBA. The example I have just used is from Maine, but the problems created by the BBA's graduate medical education changes are national in scope. It has created disproportionately harmful effects on family practice residencies from Maine to Alaska. A recent survey of all family practice residency program directors has found that: 56 percent of respondents who were in the process of developing new rural training sites have indicated that they will either not implement those plans or are unsure about their sponsoring institutions' continued support. 21 percent of respondents report planning to decrease their family practice residency slots in the immediate future. The majority of those who are planning to decrease their slots are the sole residency program in a teaching hospital. This means that, under current law, they have no alternative way of achieving growth, such as through a reduction of other specialty slots in order to stay within the cap. And finally, the vast majority of family practice residencies did not have their full residency FTEs captured in the 1996 cost reports upon which the cap is based. In addition to this survey, we have anecdotal information from residencies across the country detailing how they have lost funding either because of where they trained their residents or because their residents had been extended sick or maternity leave. For example, one family practice residency in Washington State last year had an equivalent of 14 residents training outside of the hospital and four in the hospital. Under the BBA, their cap would be four. By contrast, had all of their residents been trained in the hospital up to this point, their payment base would have been capped at 18, even if they trained residents in non-hospital settings in the future. The Medicare Graduate Medical Education Technical Amendments Act we are introducing today will address these problems by basing the cap on the number of residents ``who were appointed by the approved medical residency training programs for the hospital'' in 1996, rather than on the number of residents who were ``in the hospital.'' I am also concerned that the Balanced Budget Act and its accompanying regulations will severely hamper primary care residency programs that are expanding to meet local needs. Specifically, a new residency program that had not met its full complement of accredited residency positions until after the cutoff date of August 5, 1997, is precluded from increasing its number of residents unless the hospital decreases the number of residents in one of its other specialty programs. However, over forty percent of the nation's family practice residency programs are the only program sponsored by the hospital. This provision therefore completely precludes such a hospital from expanding its residency program to meet emerging primary care needs. To address this problem, the legislation we are introducing today would allow the small number of programs at hospitals that sponsor just one residency program to increase their cap by one residency slot a year up to a maximum of three. In addition, to enable a number of family practice residency programs that are already in the pipeline to get accredited and grow to completion, the bill extends the cutoff date to September 1999. And finally, the Balanced Budget Act gave the Secretary of Health and Human Services the authority to give ``special consideration'' to new facilities that ``meet the needs of underserved rural areas.'' The Health Care Financing Administration has interpreted this to mean facilities that are actually in underserved rural areas. There have been several recent expansions in family practice residency programs that include a rural training track, with residents located in outlying hospitals, or with satellite programs designed specifically to train residents to work with underserved populations. Even though these new programs or satellites required accrediting body approval, they are still part of the ``mother'' residencies, which may not be physically located in an underserved rural area. While these are not technically new programs, I believe that the definition should be expanded to include such endeavors, given the value of these programs in addressing the needs of underserved populations. Therefore, the Medicare Graduate Medical Education Technical Amendments Act would expand the definition to include ``facilities which are not located in an underserved rural area, but which have established separately accredited rural training tracks.'' Mr. President, while the changes we are proposing today are relatively minor and technical in nature, they are critical to the survival of the small family practice residency programs that are so important to our ability to meet health manpower needs in rural and underserved areas. I urge all of my colleagues to join us in cosponsoring the Medicare Graduate Medical Education Technical Amendments and ask unanimous consent that the text of the bill be printed in the Record.

Ms. COLLINS

Ms. COLLINS. Mr. President, I am pleased to be joining my colleague from Alaska, Senator Murkowski, in introducing the Graduate Medical Education Technical Amendments Act of 1999, which is intended to address some of the problems that small family practice residency programs in Maine and elsewhere are experiencing as a result of provisions in the Balanced Budget Act (BBA) of 1997 that were intended to control the growth in Medicare graduate medical education spending. Of specific concern are the provisions in the BBA that cap the total number of residents in a program at the level included in the 1996 Medicare cost reports. Congress' goal in reforming Medicare's graduate medical education program was to slow down our nation's overall production of physicians, while still protecting the training of physicians who are in short supply and needed to meet local and national health care demands. While the BBA's provisions will indeed curb growth in the overall physician supply, they do so indiscriminately and are thwarting efforts in Maine and elsewhere to increase the supply of primary care physicians in underserved rural areas. Because Maine has only one medical school--the University of New England, which trains osteopathic physicians--we depend on a number of small family practice residency programs to introduce physicians to the practice opportunities in the state. Most of the graduates of these residency programs go on to establish practices in Maine, many in rural and underserved areas of the state. The new caps on residency slots included in the BBA penalize these programs in a number of ways. For instance, the current cap is based on the number of interns and residents who were ``in the hospital'' in FY 1996. Having a cap that is institution-specific rather than program-specific has caused several problems. For example, the Maine-Dartmouth Family Practice Residency Program had two residents out on leave in 1996--one on sick leave for chemotherapy treatments and one on maternity leave. Therefore, the program's cap was reduced by two, because it was based on the number of actual residents in the hospital in 1996 as opposed to the number of residents in the program. Moreover, residents in this program have spent one to two months training in obstetrics at Dartmouth's Mary Hitchcock's Medical Center in Lebanon, New Hampshire. Because the cap is based on a hospital's cost report, these residents are counted toward Dartmouth Medical School's cap instead of the Maine-Dartmouth Family Practice Residency Program's. Last year, the Maine program was informed that Dartmouth would be cutting back the amount of time their residents are there. But the Maine- Dartmouth Family Practice Residency Program has no way of recouping the resident count from them in order to have the funds to support obstetrical training for their residents elsewhere. Moreover, the cap does not include residents who continue to be part of the residency program, but who have been sent outside of the hospital for training. This penalizes all primary care specialties, but especially family medicine, where ambulatory training has historically been the hallmark of the specialty. This is particularly ironic since other specialty programs that now begin training in settings outside the hospital will, under the new rules, have those costs included in their Medicare graduate medical education funding. All told, the Maine Dartmouth Family Practice Residency Program will see its graduate medical education funding reduced by over half a million dollars a year as a result of the cap established by the BBA. The example I have just used is from Maine, but the problems created by the BBA's graduate medical education changes are national in scope. It has created disproportionately harmful effects on family practice residencies from Maine to Alaska. A recent survey of all family practice residency program directors has found that: 56 percent of respondents who were in the process of developing new rural training sites have indicated that they will either not implement those plans or are unsure about their sponsoring institutions' continued support. 21 percent of respondents report planning to decrease their family practice residency slots in the immediate future. The majority of those who are planning to decrease their slots are the sole residency program in a teaching hospital. This means that, under current law, they have no alternative way of achieving growth, such as through a reduction of other specialty slots in order to stay within the cap. And finally, the vast majority of family practice residencies did not have their full residency FTEs captured in the 1996 cost reports upon which the cap is based. In addition to this survey, we have anecdotal information from residencies across the country detailing how they have lost funding either because of where they trained their residents or because their residents had been extended sick or maternity leave. For example, one family practice residency in Washington State last year had an equivalent of 14 residents training outside of the hospital and four in the hospital. Under the BBA, their cap would be four. By contrast, had all of their residents been trained in the hospital up to this point, their payment base would have been capped at 18, even if they trained residents in non-hospital settings in the future. The Medicare Graduate Medical Education Technical Amendments Act we are introducing today will address these problems by basing the cap on the number of residents ``who were appointed by the approved medical residency training programs for the hospital'' in 1996, rather than on the number of residents who were ``in the hospital.'' I am also concerned that the Balanced Budget Act and its accompanying regulations will severely hamper primary care residency programs that are expanding to meet local needs. Specifically, a new residency program that had not met its full complement of accredited residency positions until after the cutoff date of August 5, 1997, is precluded from increasing its number of residents unless the hospital decreases the number of residents in one of its other specialty programs. However, over forty percent of the nation's family practice residency programs are the only program sponsored by the hospital. This provision therefore completely precludes such a hospital from expanding its residency program to meet emerging primary care needs. To address this problem, the legislation we are introducing today would allow the small number of programs at hospitals that sponsor just one residency program to increase their cap by one residency slot a year up to a maximum of three. In addition, to enable a number of family practice residency programs that are already in the pipeline to get accredited and grow to completion, the bill extends the cutoff date to September 1999. And finally, the Balanced Budget Act gave the Secretary of Health and Human Services the authority to give ``special consideration'' to new facilities that ``meet the needs of underserved rural areas.'' The Health Care Financing Administration has interpreted this to mean facilities that are actually in underserved rural areas. There have been several recent expansions in family practice residency programs that include a rural training track, with residents located in outlying hospitals, or with satellite programs designed specifically to train residents to work with underserved populations. Even though these new programs or satellites required accrediting body approval, they are still part of the ``mother'' residencies, which may not be physically located in an underserved rural area. While these are not technically new programs, I believe that the definition should be expanded to include such endeavors, given the value of these programs in addressing the needs of underserved populations. Therefore, the Medicare Graduate Medical Education Technical Amendments Act would expand the definition to include ``facilities which are not located in an underserved rural area, but which have established separately accredited rural training tracks.'' Mr. President, while the changes we are proposing today are relatively minor and technical in nature, they are critical to the survival of the small family practice residency programs that are so important to our ability to meet health manpower needs in rural and underserved areas. I urge all of my colleagues to join us in cosponsoring the Medicare Graduate Medical Education Technical Amendments and ask unanimous consent that the text of the bill be printed in the Record.

Ms. COLLINS

Ms. COLLINS. Mr. President, I would like to announce for the information of the Senate and the public that the Permanent Subcommittee on Investigations of the Committee on Governmental Affairs, will hold hearings entitled ``Deceptive Mailings and Sweepstakes Promotions.'' These hearings are the first of an anticipated series of hearings the subcommittee plans to hold regarding deceptive mailings. The focus of these first hearings will be an examination of the use of sweepstakes by mass marketers and how these mailings impact consumers. The hearings will take place on Monday, March 8th and Tuesday, March 9th, at 9:30 a.m. each day, in room 342 of the Dirksen Senate Office Building. For further information, please contact Timothy J. Shea of the subcommittee staff at 224-3721.

Ms. COLLINS

Ms. COLLINS. I thank the Senator.