John Ensign

Mr. ENSIGN

Mr. ENSIGN. If the Senator would vote for us to go forward with the bill tomorrow when we have a cloture vote, we will have a lot of time to debate this. We can amend it and go forward with this debate. So I hope he will join us in voting for cloture because I do have a lot of evidence to justify the various provisions in the bill. The bottom line is we all know that today it costs around $900 million to bring a single new drug to the market. I am not here to defend the pharmaceutical companies or any other company.

Mr. ENSIGN. No. What I am here to say is we have a problem with our health care system today and we need to fix it. If we can go forward with this bill, if there are amendments the Senator thinks can improve this bill, let's at least move to it so that we can amend it, put the amendments forward, and have a healthy debate. We can take a week, or whatever it takes, to do that so that we can go forward and try to fix some of the glaring problems. If the Senator thinks there are some problems with the bill, let's bring forth amendments and try to fix it.

Mr. ENSIGN. Mr. President, I say to my colleague that it is a great point. I practiced veterinary medicine and I understand how professional boards work. I understand that with professional boards there is a self-policing that is assumed. It is supposed to happen with lawyers. It is supposed to happen with accountants. It is supposed to happen with veterinarians. It is supposed to happen with physicians. The big problem today with professional boards is they are afraid to do something with somebody's license because if they do, they can be held personally liable. That happens time and time again. All of the professional boards go through this; that as badly as they would love to jerk somebody's license, unless it is so clear and the evidence is so outrageous of what they have done to deserve their license being jerked, it just does not happen. Frankly, it should happen more. There are incompetent doctors. There are incompetent lawyers. There are incompetent veterinarians. More of them should have their license jerked in that case, and I wish they were empowered a little more and maybe protected a little more to do that.

Mr. ENSIGN. Mr. President, I wish to respond to a few of the items just laid out in the Senate and try to point out what I think are glaring inaccuracies. First of all, the Weiss report we have heard so much about from the last two speakers uses numbers from the Medical Liability Monitor. The Medical Liability Monitor just provides the numbers. They are not a group that is pro tort reform or anti tort reform. This is what the editor, Barbara Dillard, says about the numbers that the other side of the aisle is using to somehow skew what the premiums are doing in those States that have enacted tort reform. Let me read some of the most salient parts: The Weiss ratings analysis of medical malpractice caps cites the Medical Liability Monitor as the source of data Weiss uses to calculate ``average'' and ``medium'' premiums for physicians during the last 12 years. While we are an independent news publication and take no position on tort reform, or other proposals to improve the medical liability climate, we feel it is necessary to comment on the use of our statistics because some readers have expressed concern. The median and averages in the Weiss report are not the numbers we report in our annual rate surveys. Weiss may have taken our numbers, the amounts and increases of premiums paid by doctors State by State, and used them to arrive at their statistics. But it is not possible from the report to say definitely how our numbers have been used. It is our view that it is impossible to calculate a valid ``average'' premium for physicians, or for physicians in a particular State or territory, and we state that clearly in the executive summary of our rate survey. But the editor of the Medical Liability Monitor goes further. She advised the leader's office that: It is misleading to use median premiums compiled with data from the Medical Liability Monitor to demonstrate the effect of noneconomic damage limits on liability rates. This is exactly what Weiss does. That is the report they have been quoting here. The report uses median annual premiums compiled with data from the Medical Liability Monitor to try to demonstrate the effect of noneconomic damage limits on liability rates. Not only is this wrong, it downright misleads the public. Let me refer to some of the other issues they were talking about. Half of the States have enacted medical liability reform. My State did that a year ago. It has caps. If you look at my State, as far as the numbers, it would look like it hasn't worked. It takes a minimum of probably 8, 10, 12, or 15 years to go through the courts to find out whether the caps are going to be upheld. If the insurance companies are unsure whether the caps are going to be upheld or not, there is no predictability there because they can reach way back--once it is held unconstitutional, they can go back and try those cases and get those awards. That is why in California it took so long--from 1975 until the mid- 1980s--to find out whether the law was going to work. Colorado and California have now had their laws in place long enough to stabilize rates. Let's look at those two States, in major cities, compared to other cities around the country. Here are Los Angeles and Denver. We will start with the general surgery. It is almost $37,000 in Los Angeles for the medical liability premiums for the year; that is for a general surgeon. In Denver, it is around $34,500. New York is about $51,000. Las Vegas was $70,000. It is a lot higher this year in Las Vegas. In Chicago, it is $68,000. In Miami, it is $174,000. The cities in the gray on the chart are States without medical liability reform. The two in the white have had medical liability reform in place long enough for them to have predictability. This whole debate isn't about hurting patients; it is about helping them to have access to quality care. In my State, we had a level I trauma center close for 10 days because of a crisis, where the specialists who were treating patients there could not afford the medical liability insurance anymore. So they had to say: We cannot come in there and practice because we cannot afford the insurance. The Governor of our State, within a week, called a special session of the legislature. They enacted, in a bipartisan way, caps. Unfortunately, like a lot of the caps in the country--and they use a lot of these statistics--they are similar to the caps in my State where they have loopholes that you can drive a truck through, which makes the legislation pretty much, as far as a court of law is concerned, ineffective. That is why there is a move in my State to close those huge loopholes down to where just the most serious cases actually have unlimited pain and suffering type of awards. In our State, the way they reopened the level I trauma center in that special session of the legislature--not only did they enact a $350,000 cap for the general population but for the level I trauma center they put it under the State. Guess what. Our State has $50,000 caps total-- economic, pain and suffering, medical, the whole thing. That is the only way they could get the level I trauma center back open. Why did they do it? They knew there was a crisis. People had died, and more would die if they didn't reopen the trauma center. Well, how bad does it have to get in the U.S. for us to say there is a crisis? When will the other side realize how bad the situation is in America? We are losing specialists. People are leaving the practice of medicine--especially those specialties and subspecialties in which we already have a shortage in many areas; and new people are not going into these areas because they see the writing on the wall. They see it is going to be too expensive for them to go out and practice. I have a good friend from Las Vegas, Dr. Spoon. We were talking a couple months ago. One of his favorite things to do in his practice--he is an obstetrician--is to deliver babies, especially those high-risk pregnancies. He got so much enjoyment from bringing them to the point where they were successful. His insurance company made him stop performing high-risk deliveries, and they also cut him down from 250 or 300 deliveries a year, and he can deliver no more than 125 babies a year. Southern Nevada is the fastest growing metropolitan area in the country. Yet we are losing OB/GYNs and new ones are not coming in. So what happens in that area is women are having serious trouble locating OB/GYNs to deliver their babies. I want to try to talk a little bit about the bill and what it really does do and try to clear up some of these issues. First, to go back to premiums. It was said that in places such as California premiums and caps on economic damages--caps on pain and suffering don't work. According to the CBO, they do work. H.R. 5, which is virtually identical to the bill we have today, would significantly lower premiums for medical malpractice insurance from what they would otherwise be under current law. Premiums for medical malpractice insurance ultimately would be an average of 25 to 30 percent below what they would be under current law. The Congressional Budget Office is nonpartisan, and everybody is supposed to respect the numbers they put out around here. They certainly don't have any pro or con as far as tort reform is concerned. There are others such as the U.S. Department of Health and Human Services that say States with limits of $250,000 or $350,000 on noneconomic damages have average combined highest premium increases of 12 to 15 percent--that is average combined highest premium increases-- compared to 44 percent in States without caps on noneconomic damages. The Joint Economic Committee of the Congress says that tort reform will reduce overall spending on health care savings by between $67 billion and $106 billion over the next 10 years. I wish to talk a little bit about what kinds of economic damages. That has been criticized. We don't cap economic damages. What can you get in economic damages under this bill? You can get all lost wages and benefits. Lost earning capacity. They say it hurts children. You get a child who gets hurt because of malpractice and you can calculate what that child would have had over the next 60, 70 years.

Mr. ENSIGN

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

Mr. ENSIGN

Mr. ENSIGN. Mr. President, means testing and universal have been mentioned. The Senator from New Hampshire mentioned that this is a brand new benefit, and that is why we are only talking about the prescription drug part--a brand new benefit for which young people in America are going to be paying for years and years. It seems to make sense that we try to control those costs. Yes, our bill means tests. So does the underlying bill. To sit up here and say their bill does not means test is completely disingenuous. They have several levels in the low-income areas they means test. They are just means testing in a different area. If you means test one, why is calling our bill means testing when their bill means tests as well? How can they say our bill means tests and theirs does not? That is disingenuous. It is critical that we have this debate. There was a complaint that they just saw this amendment tonight. Part of the reason is that we are trying to rush this bill through what is supposed to be the most deliberative body in the world, and we have this false deadline that we must get this bill passed before the July break. I submit, this deserves more debate. The debate cannot happen when it goes to conference because most of the Senate is cut out then and there is no debate when it comes back here. With all due respect, I think we have a superior portion of the prescription drug plan, and I hope our colleagues vote for this plan. I reserve the remainder of our time.

Mr. ENSIGN. Mr. President, I will use 30 seconds and Senator Hagel will use 30 seconds on this side. The Hagel-Ensign amendment corrects several problems in the bill. Let me go over those real briefly. We have no monthly premiums. We do not make middle-class taxpayers pay for prescription drugs for wealthy seniors. We preserve the State and the private plans that are already out there, which the underlying bill does not do. We give most of our help to low- and moderate-income seniors but we still control costs in our bill. I encourage a ``yes'' vote on this amendment.

Mr. ENSIGN. Mr. President, I ask unanimous consent for whatever time I consume from Senator Hagel's time to respond.

Mr. ENSIGN. Mr. President, I want to clear up something. We don't touch any of the other Medicare reforms in your bill. The whole thing with the PPOs, we touch the prescription drug part of the underlying bill. You mentioned competition. I practiced veterinary medicine, built, owned, and operated two different animal hospitals. Why do I bring that up? It is because in veterinary medicine people pay out of their own pocket. Veterinarians are in an incredibly competitive field because we know that if somebody brings a case to you, they are going to shop about half the time based on price. So veterinarians have to be very competitive and price sensitive to that, so they work to become more efficient, to keep their costs down, because individuals shop. In our health care system today, individuals do not shop because we have low deductible policies, and a lot of times the doctors waive those deductibles. Senator Frist will be able to tell you about that. The hospitals waive the deductibles. So the person receiving the care is not accountable for the care, and so they don't shop. The doctor tells them, go get this service or this drug, and they don't think about it. They have modest, low copays, and they don't think about it. The cost control, the competition, is established by 40 million people on Medicare, 40 million people receiving drugs. If they are paying out of their own pocket or low-income people have the $500 in a pharmaceutical benefit account, they have something at stake, so they go shop. They ask the questions: Do I need the drug in the first place? Maybe I can get a generic. So they do the shopping. Also, we have pharmaceutical benefit managers in the bill. That is what the whole drug discount card is about. So those pharmaceutical benefit managers help lower the costs as well. We have several reforms in this bill that are true reforms, that introduce competition to keep the costs down. That is why our bill actually scored lower. Because of that, we were able to add a couple other things. When Senator Hagel arrives, he will modify the amendment. For instance, we will allow Medicaid, the dual eligibles that people have been talking about today, to give States help in handling those dual eligibles through Medicare because our prescription drug cost to the taxpayer was less. It is because we have more reform on the prescription drug part of it than the underlying bill. It just a difference of philosophy of how you do it. I come to this based on my experience in the private sector and how health care can be delivered by individuals shopping. I reserve the remainder of my time.

Mr. ENSIGN. Mr. President, I rise to speak on behalf of the amendment on which Senator Hagel and I have been working actually for the last several years. This amendment received bipartisan support in the last Congress as a stand-alone bill. We actually made some improvements to it. We think if this amendment is adopted, it will dramatically improve what the committee has attempted to do to add a prescription drug benefit to Medicare. The only portion of the bill we are modifying in substantial form is the prescription drug part of it. Let me talk about what our amendment exactly does. It would say to a person who is below 200 percent of poverty, they would pay the first $1,500 out of pocket. After that, the Government is going to pay for the rest of their drug costs, other than a 10-percent copay the person would pay. However, if a person is up to 160 percent of poverty, we will give them, in a pharmaceutical benefit account, $500 per year, which they can use to go to a local pharmacy to buy their prescription drugs or they can use that money and negotiate the price of their prescription drugs through a pharmaceutical benefit manager and mass buy them with their drug discount card. If they want to use their local pharmacist, they can do that. And this $500, if they did not spend it that year, would be rolled over to the next year where it would cover the first part of their deductible. So if you are below 160 percent of poverty, the most you are going to pay out of pocket is less than $100 per month. There are several benefits to our plan. First of all, with the committee mark, you pay a monthly premium of $35. You also have a deductible of $275. With our bill, you have no monthly premiums, you have a one-time annual fee of $25, and for low-income people, we waive that. Our plan is completely voluntary. It also gives the most help to lower income seniors and gives progressively less help the more money you make. So between 200 percent and 400 percent of poverty, $3,500 is your out-of-pocket expenses. Above that amount, the Government pays 90 percent. And from 400 percent to 600 percent of poverty, $5,500 is your out-of-pocket expenses. Above that amount, 20 percent is your deductible before catastrophic coverage kicks in. For all of these people, though, who want to sign up for the plan, they get a drug discount card where they will save between 25 to 40 percent on their prescription drug costs. It is a completely voluntary program. And in this program, we have several benefits that we think are better than the committee's underlying bill. One is, under our bill, States that have already enacted programs will be encouraged to keep their programs. Under the committee mark, every State that has a program for low-income seniors is going to drop those. There is no debate about that. As a matter of fact, the Secretary of HHS was before us. The person who oversees Medicare was before us. Both of them said there is nothing in this bill that will say to the States: Don't drop your plans. And they agreed they will probably drop their plans. Our bill works with the States that have those programs, States such as my State of Nevada, and encourages those programs to be kept. A couple of other advantages that our bill has: I want to illustrate those with a couple of examples. These are real-life cases. This is a fictitious name, of course, to protect this woman's identity, but this is a real person. We call her Doris Jones. She is 75 years old. She has an income of about $17,000 a year. She is being treated for diabetes, hypertension, and high cholesterol. She is taking medications that are very typical of what this type of a disease management would require. Her out-of-pocket expenses right now are $3,648. Let's compare how our amendment, the Hagel-Ensign approach, would affect her out-of-pocket expenses versus the bill on the floor if our amendment is not accepted. Under our bill, she would have $1,700 out-of-pocket expenses a year. Under the committee bill that is before us today, she would have $2,383 a year. So it is a savings of almost $700 under our approach. Another person: James is 68 years old. He has an income of about $16,000 a year. He is being treated for diabetes, a pretty severe case of diabetes, and he has all these different medications--very common medications today for a diabetic. His total out-of-pocket expenses today are $5,700. How does he compare under the two provisions? Under the Hagel-Ensign approach, about $1,900 would be his out-of- pocket expenses for the year; under the bill that is before us today, a little over $4,000 in out-of-pocket expenses a year. So the difference is almost $2,200 to this senior who is sick. And we certainly would not call him a rich person. I would call this person certainly a low- to moderate-income senior. Now, Betty is another example. These are real-life examples taking real medicine, prescribed by real doctors. She is 66 years old. She has an income of $15,500. She is being treated for breast cancer and she is taking commonly prescribed medications for that. She is on low-dose radiation. She pays about $8,000 for her prescription drugs a year. What would happen to her under the two different scenarios? Under our scenario, she would pay about $2,100 out of pocket. Under the bill that is before us today, she would pay $4,300. What we have done with our amendment is we have said: Let's help the seniors who need it the most. And we put the dollars to them. Under our amendment, people who are sick, with low and moderate income, they really get help. For people above that, they are treated about the same between our amendment and the bill. The out-of-pocket expenses for people between 200 and 400 percent of poverty are about the same. When you start getting to the wealthier seniors, there is no question, the committee bill is more generous. For very low income seniors, the committee bill is slightly more generous. But for those who are really sick, our amendment is much better. Also, there are a couple of other advantages. In the future, to control costs, our amendment says: The person receiving the medication has something at stake. They are paying out of their own pocket for the first dollars, so they are going to shop. They are going to go around and see: Do I need generics? First of all, do I need the drug? Could I take a generic, which may be less expensive? Are there perhaps other alternatives for treatment that may be cheaper and just as effective? They will have that conversation with their doctor because they have something at stake. I would argue that what the committee is doing--and I applaud what they are doing, trying in a bipartisan fashion--I believe our amendment would strengthen the committee's bill dramatically because it would target the dollars, those precious taxpayers' dollars, to the people who need it the most. It will also, though, in the future, control costs and, therefore, be more responsible to the next generation. The committee mark, especially for very low income people, pays 97.5 percent of their drug costs, maybe a $1 to $2 copay. Well, there is going to be a tremendous amount of overutilization in that group. Our amendment gives that group help by putting $500 of their first costs into an account. They will use that to go shop because if they do not use it, it gets rolled over to the next year where it covers more of their deductible. So they have something to benefit by if they do not use it. So I implore our colleagues to look and compare. If you look and compare, you will see there truly is a difference. Mr. President, I reserve the remainder of my time.

Mr. ENSIGN. Mr. President, the prescription drug bill, Medicare reform bill combination that we have before us today, as we all know, is a freight train coming through this place and there is no stopping it. What is very unfortunate is that we have a very legitimate amendment on the floor today that is getting 20, 30 minutes' worth of debate. I put up some examples on the chart here of how this amendment we are offering is superior. I have tried to be objective, to say that above 200 percent of poverty, between 200 and 400 percent of poverty they are pretty equal plans. For the very low income, our amendment is slightly less generous, but it keeps the low-income people with something at stake so they will shop. We have heard nothing about that from the other side. There has been no debate, in other words. It is because there is an agreement to defeat any substantive amendment. It is unfortunate. This is probably the most important vote, as far as an entitlement program, that any of us in our careers will ever take, and this bill is being rushed through so that we can get a ``bill'' to conference, where all of the improvements are going to be made. We have an amendment before us that I believe should be debated. If you disagree, fine, but let's debate it and vote on it up or down. But I don't think this kind of a process is healthy for the Senate. I reserve the remainder of my time.

Mr. ENSIGN

Mr. ENSIGN. I appreciate the Chairman's leadership on this issue and I thank my colleague for agreeing, at a minimum, to work toward another moratorium on implementation of the therapy cap. I would also like to thank the Senator from Arkansas for her words of support. Mr. President, I yield the floor. I ask unanimous consent that this full statement be included in the Record as if read.

Mr. ENSIGN. Mr. President, I will withdraw my amendment to repeal the arbitrary beneficiary caps on therapy. However, I would urge my colleague from Iowa, the Chairman of the Finance Committee, to work in conference to find a way to delay this law. As you know, the beneficiary caps will have one of three results--beneficiaries will either: (1) pay 100 percent out-of-their own pocket once the caps are exceeded; (2) self-ration therapy care; or (3) forgo medically necessary care altogether. Mr. President, I recognize that the Chairman has been a voice to eliminate these caps and hope that a final Medicare bill further delays implementation of them.

Mr. ENSIGN

Mr. ENSIGN. Okay.

Mr. ENSIGN. Reserving the right to object, we have been waiting about an hour and a half to speak and all I can say is we have been waiting quite a long time.

Mr. ENSIGN. I ask unanimous consent that the pending amendment be laid aside.

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

Mr. ENSIGN. Madam President, there is a cap on the amount of therapy that can be given to seniors for physical therapy, occupational therapy and speech therapy, that is set to go into effect in July. There is a $1,590 cap that is set to go into effect. What we need to do is to repeal that cap and we need to do it for very good reasons. First, the oldest and the sickest seniors will be in a situation where they have to pay 100 percent of the costs over the cap. MedPAC and independent analyses have found that one out of seven beneficiaries needing such therapies will exceed the cap. This arbitrary limitation would cause the greatest harm to the sickest and the most vulnerable of our beneficiaries. It would be those seniors who suffer from stroke, from Parkinson's disease or a similar condition that would likely exceed the therapy cap. It would be the older, more vulnerable beneficiaries who will be most affected by this therapy cap. As beneficiaries continue to age and encounter multiple health problems, they are more likely to be the ones to exceed the cap. Unlike other requests for Medicare monies, this provision is truly a provision for the beneficiaries. It is the beneficiaries who will either bear the cost of the cap or not get care. It is a beneficiary cap on services. In 1999, as part of the Balanced Budget Reconciliation Act, Congress passed a 2-year moratorium to prevent implementation of the caps. A year later, Congress passed an extension of that moratorium for 1 more year through 2002, and CMS has delayed implementation until July 1 of this year. So we need to act. From a personal story, several years ago my grandmother had a total knee replacement. I visited her in the hospital when she was going through rehabilitation. Anybody who has had a total knee replacement understands it is one of the most painful surgeries you can have, as well as rehabilitation is painful. If the cap would have been in place at the time, she could have ended up being in a situation--at her income level, if she was a senior who could not afford to pay additional money--of not getting the care and rehabilitation needed for independent living. She is about 85 years old and lives on her own today because of the physical therapy. There are many other people we will institutionalize if we do not repeal the cap. It is very important that truly needy seniors who are very sick get the rehabilitation they need for the occupational therapy, speech therapy, as well as physical therapy. I urge our colleagues to look at this. I have talked to the chairman of the Finance Committee, and he is committed to making sure this cap does not go into effect this year. It truly would be harmful to many seniors in our population. I yield the floor.

Mr. ENSIGN. I do not need any additional time. I just wanted to speak if I could.

Mr. ENSIGN. Madam President, what is the pending business?

Mr. ENSIGN. I call up amendment No. 1024.

Mr. ENSIGN

Mr. ENSIGN. Madam President, I will speak on the pending amendment that Senator Hagel and I have offered. This amendment is similar to the bill we offered in last year's Medicare prescription drug debate. We offered it as a complete substitute last year. I will describe this legislation. What we are proposing to do is substitute our piece of legislation for the prescription drug portion of the pending legislation. It is very important to have a prescription drug benefit for those seniors, especially those who are low or middle income, who have serious diseases and sometimes have to choose between prescription drugs and rent or prescription drugs and maybe even the type of food they eat. I have heard story after story around my State of seniors who literally sometimes do not take their medications or maybe take half a dose because they cannot afford the prescriptions their doctor has recommended. The Hagel-Ensign amendment has several advantages over the current portion of the committee bill. First, it takes effect one full year earlier than the committee bill. Second, we do not have monthly premiums for our prescription drug benefit. Under the committee's mark, seniors pay $35 a month; under ours, it is a one-time annual fee of $25, that is all. They pay that once a year, unless they are low- income, and then we waive that annual fee. Under the committee's mark, it is $35 a month. We have several other differences in the bill. In the committee's mark, low- income seniors have a very generous benefit for those above Medicaid income but who are below 160 percent of poverty. We recognize it is very generous. As a matter of fact, I submit it is overly generous and we will see an overutilization by those senior citizens because they do not have anything at stake. One to two dollar co-pays when you are paying 97.5 percent of their out-of-pocket expenses is not enough to discourage overutilization. We are going to see an explosion of utilization of drugs, especially in the low-income market. Let me explain the amendment. We offer a prescription drug benefit with the seniors paying up to a certain percent depending on income, up to a certain dollar figure, and after that the Government will pick up 90 percent of the cost. For people who are below 200 percent of poverty, which is around $18,000 a year for an individual or $24,000 for a couple, they would be capped at an out-of-pocket expense of $1,500, and after that the Government picks up 90 percent. Between 200 and 400 percent of poverty, incomes for an individual up to nearly $36,000, and for a couple a little over $45,000, they would be capped at an out-of-pocket expense once again of $3,500 a year, and the Government pays 90 percent above that. Between 400 and 600 percent they are capped at $5,500 out-of-pocket a year. For people above that, the wealthier seniors, 20 percent of their income is their deductible under this plan. All of these people get a prescription drug discount card. That prescription drug discount card can provide a discount of 25 to 40 percent on the drugs they purchase. Before these ever kick in they have already saved money for every senior. This is a completely voluntary plan. If seniors like the coverage they have today, they can stay in the coverage they have today. If they want to try something guaranteed to cap their out-of-pocket expenses, this is the plan for them. We have several real-life examples to compare with the committee mark. First, James Johnson is 68 years old with an income of around $16,000. He is above 160 percent of poverty. He is being treated for diabetes. These are typical medications of someone being treated for diabetes: glucophage, glyburide, neurontin, lescol, zoloft. This totals $5,736 a year that this person pays for prescription drugs. Let's compare under the committee mark versus the Hagel-Ensign approach. Under the committee mark, this person would have a total out- of-pocket expense of $4,000. Under the Hagel-Ensign, this person would have about $1,900. This person would do a little over $2,000 better under Hagel-Ensign than under the committee mark. For those low-to- middle income seniors who have a serious disease, they do better under our approach. Everyone wants to help the most those who need it the most. Under our approach that is exactly what happens. Those people who are sick, who need the most help, get the most help under our plan. Here is another real life example. Doris Jones is 75 years old with an income of around $17,000 per year and is being treated for diabetes, hypertension, and high cholesterol. She takes lipitor, glucophage, insulin, coumadin, with total drug costs around $3,600. To compare the committee mark, the bill before us compared to Hagel-Ensign would spend around $2,380 a year under the committee bill; under the Hagel-Ensign approach she spends about $1,700. Although she did not have as much out-of-pocket drug costs for the year, she saves almost $700 a year under the Hagel-Ensign approach. And the last real-life example, Betty Smith is 66 years old. She has an income of around a little over $15,000 per year and is being treated for breast cancer. She is still receiving low-dose radiation therapy with nolvadex. Her medication profile is as follows: morphine, paxil, dexamethasone, aciphex, and nolvadex, with total costs for drugs around $8,000 a year. To compare Betty's costs between the Hagel-Ensign approach and the committee mark: her total out-of-pocket expenses will be $4,340 with the committee mark; under our bill, she will spend around $2,100, which would be a savings to her of almost $2,200 a year. Once again, comparing the two approaches, those middle- to low-income seniors who have serious diseases are going to get much more help under the Hagel-Ensign plan. Our bill actually costs less money than the committee approach and because of that we are going to be offering an amendment, which subsidizes the costs for people with incomes 160 percent of poverty and under; I will talk about that in just a minute. But the reason our bill comes in at less money is because the seniors are paying the first dollars out of pocket. After that, the Government kicks in to subsidize their costs. So, by them paying the first dollars out of pocket, we encourage people to be accountable in the system. The person who is receiving the drugs is responsible for paying those first dollars. Guess what: that causes them to go out and shop. They call the various pharmacies and find out what the best price is. They ask their doctor, Is there a generic drug available that is just as effective? If it is something maybe not life-threatening and they want to take the generic version of the drug, the doctor can say, Yes, I have had good experience with patients with this. They can take the generic drug, saving themselves money and saving the whole system money. That is why our bill overall would cost less money. What Senator Hagel and I have decided to do is, because there is $400 billion available to spend under the budget, we have taken around $60 billion, spread over 10 years, to put toward those people who are truly poor, below 160 percent of poverty. Our plan would give them, in a pharmaceutical benefit account, $700 to spend on prescription drugs. If they do not use it, it rolls over to the next year. By the way, if it rolls over 2 years in a row, and the third year they get another $700, at the end of the year they get to keep anything above $1,500. So there is an incentive; they have something at stake, so they will still shop around for the best price for their drugs. So it keeps market forces at play within our Medicare prescription drug system. That is one of the strong points, we feel, about our plan. There are several other advantages that we think are in our bill that are not included in the committee mark. I asked this question yesterday; I asked the administration, I asked Secretary Thompson, and I asked the director who oversees Medicare, What will happen under the committee's mark to the State plans? My State of Nevada and many other States, New York, Massachusetts, West Virginia--have State plans that help senior citizens with prescription drugs. What will happen to those state low-income plans--above Medicaid level but below around 160 percent of poverty--if the committee mark is enacted? The simple answer is: all of those plans will go away because, for those seniors under this plan, there is no reason for the States to pick them up anymore. The committee mark will pick them up completely. Our plan works with the States, instead of substituting for the States. Those plans in the States that are already working, and working well, will continue. As a matter of fact, each State can learn from the other. If they want to be a little more generous, a little less generous, they can do that. But it doesn't supplant the States, like the committee mark does. The other big problem I have heard articulated with the committee's prescription drug benefit is that private companies that currently have plans are going to start dropping their plans left and right. Under our bill, because we offer a higher deductible than most of the plans offer, there is not going to be the incentive for them to drop their plans. So it is not going to be a transfer from the private sector onto the public sector. And when I say public sector, I mean the taxpayer-- younger people paying the taxes for older citizens. There are many benefits to our plan, we think, over the committee mark. Let me just quickly repeat those. First, we help those seniors, especially in the middle- to low- income, much more than the committee mark does, those who have serious diseases. Second, we have no monthly premiums. The committee mark has a $35-a- month monthly premium. Third, our plan does not replace State plans, it works with State plans. Fourth, our plan also does not encourage the replacement of private plans that companies have set up for their retirees. Fifth, I believe our bill will control drug costs into the future. I applaud the committee. They have gotten together in a bipartisan way, trying to come up with a fix to a serious problem. But the problem I see is that it is right now scored by the Congressional Budget Office at around $400 billion. I think there is going to be so much overutilization in that, that it is going to end up being more like $800 billion or a $1 trillion plan. Young people are going to have to pay that. That is just how much it is going to cost in the next 8 to 10 years. When you start extending that out into the 10 years beyond that, you start doubling and tripling those costs as we get the new, more expensive drugs into the marketplace. So I think we should do the responsible thing. That is why we are encouraging our colleagues to take a look at this. We had the same bill voted on last year. We got a bipartisan vote. We had 51 Senators vote for this plan. If we got that for this amendment, this amendment would be adopted as part of the bill. I know there have been deals made: Let's just defeat all amendments. I encourage people to say, If we can improve this bill, let's improve this bill. Let's make it responsible to the next generation. But let's also do what we say we all want to do, and that is to help those seniors who truly need the help. Let's help those who are the sickest and those who are in the lower-income categories, who end up having to make those decisions I talked about: choosing between prescription drugs and rent, between prescription drugs and food, or maybe only taking one of their prescriptions or a half dose of their prescription because they cannot afford the full dose. In conclusion, I plead with my colleagues to study this issue. I know this bill is being rushed through, so people have not had a chance to take a look at all the options. This is so serious. This is the biggest entitlement program that any Senator who is currently serving will ever vote on. This has incredible implications for generations to come. We'd better do it right the first time because coming back for a fix a couple of years from now--we have seen how difficult it was to get to this point--is going to be virtually impossible. So we'd better do it right the first time--at least get as close to right as we can. That is why we are encouraging our colleagues to take a serious look at the Hagel-Ensign amendment and do something right for the country. I yield the floor.

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

Mr. ENSIGN

Mr. ENSIGN. Mr. President, I ask unanimous consent that the text of ``The TRICARE Retirees Opportunity Act of 2003'' be printed in the Record.

Mr. ENSIGN

Mr. ENSIGN. Mr. President, I just want to make a couple points and keep it fairly brief. The nuclear power industry has been around for a long time. We hear about other new sources of energy that this country is trying to develop, and it seems to make sense we would subsidize some of that new research. It is basic research that the Government is involved in. Whether it is health care, whether it is energy, that seems to be an appropriate role for the Federal Government. But nuclear energy has been around for a long time, and it is commercially viable in many other countries in the world. To this Senator, it does not seem to be the right thing to do to be subsidizing nuclear power because it should have already proven its merit in the marketplace and been able to stand on its own. Unfortunately, we have a situation where we had a vote last year on the Yucca Mountain project, which is the Nation's nuclear waste repository, and this Senate decided to continue to build Yucca Mountain. What that indicates is that the Senate is already subsidizing nuclear power. People say, no, Yucca Mountain is being built by the ratepayers, the people who receive the benefits of nuclear energy. They pay a tax on that or a rate on that and, therefore, they pay into the nuclear fund that will build on Yucca Mountain. According to the General Accounting Office, that is not going to be enough. So we are going to be subsidizing nuclear power as it is. To add another subsidy would be wrong at this time. Whether you look at Japan or Germany, these other countries, they are building them commercially; they are operating them viably. If nuclear power is so good commercially, then it should stand on its own. We have several other provisions in the bill that Senators Sununu and Wyden have not touched on nuclear power. But to actually have Federal loan guarantees that will leave the taxpayer holding the bill would be wrong at this time. If nuclear power is going to stand, let it stand on its own. I yield the floor.