Bob Graham

Mr. GRAHAM

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

Mr. GRAHAM. Mr. President, Congress has created an anomaly, a catch- 22 situation which occurs in one of the most traumatic areas of our society, the hospital emergency room. The anomaly is that under the Federal Emergency Medical Treatment Act, physicians in hospitals which participate in Medicare must provide ``an appropriate medical screening examination to any patient who presents himself or herself in an emergency room without regard to insurance coverage or ability to pay. If the emergency condition exists, the patient must be stabilized before transfer or release.'' So, the hospital which provides Medicare services is required to receive any persons presenting themselves to the emergency room and to provide initial stabilization and screening, without regard to the persons' ability to pay. Second, health maintenance organizations, which, today, provide Medicare services for almost 1 out of 10 Medicare beneficiaries, are not required to reimburse the emergency room if it performs the services that we have statutorily required the emergency room and its professional staff to perform. Who is affected by this anomaly? Who is caught in the catch-22 which we have created? Obviously, it is the Medicare beneficiaries, the Medicare beneficiaries who, as we have increasingly encouraged them to do, have signed a contract with a health maintenance organization and now have found that, after having gone to the emergency room, had services provided, finds that they are denied reimbursement and become financially obligated for what, in many cases, is a very substantial bill. Mr. President, I have, and I would like to offer as one of several items to appear immediately after my remarks, a letter from a health care organization in Clinton Township, MI, St. John Emergency Physicians. They outline an example of this instance in which a 46- year-old female patient presented herself to their emergency room department. The patient was traveling in a car with her husband when she experienced a sudden onset of shortness of breath and collapsed. She was rushed to the emergency department in an ambulance. Despite the best efforts of the emergency room personnel, the patient, unfortunately, did not respond to any of the emergency treatment. She was pronounced dead. The cause of death was cardio- pulmonary arrest. The patient belonged to a HMO organization. They refused coverage and have sent a bill of $1,200 to the widower of the deceased patient. That is illustrative of situations which relate to emergency rooms in HMO's. You might say this certainly is an anomaly; this is aberrant; this cannot be a recurring condition. In fact, presently 60 percent of all of the claims disputed between Medicare beneficiaries and managed care plans involve emergency services. Sixty percent of the disputes between Medicare beneficiaries and an HMO plan relate to circumstances that revolve around emergency room services. The purpose of this amendment is to resolve that dispute. We are not doing this for the first time. In November 1995, this Senate, by unanimous vote, adopted this amendment as part of the Medicare component of the Balanced Budget Act. We are not the only ones to be concerned about this. Increasingly, States are adopting provisions to resolve this dispute between HMO patients and emergency rooms. To date, Maryland, Virginia, and the State of Arkansas, have all adopted legislation that relates to this subject, and action is being taken by the leaders of the industry, of the health maintenance organizations. Washington Health Week of August 26, 1996, states that: HMO patients who make emergency room visits may benefit from the unlikely alliance of a leading HMO company and an emergency physicians group, jointly pushing for federal standards that would make it harder to deny coverage for such services. Kaiser Foundation Health Plan and the American College of Emergency Physicians are advocating standards for emergency care coverage that include the controversial ``prudent layperson'' standard. It goes on to say: The jointly developed standards would require managed care plans to cover non-emergency services provided in an emergency department if a prudent lay person would reasonably think that his or her condition needed emergency treatment. HMOs would have to cover medically necessary ER [emergency room] services without preauthorization. Emergency MDs [physicians] would have to notify the plan within 30 minutes after the enrollee's condition is stabilized to obtain authorization for promptly needed services. HMO's would have 30 minutes to respond. If the HMO and the doctor couldn't agree on a post-stabilization treatment, the plan would have to arrange alternative treatment. Mr. President, that is the essence of the amendment we have offered. It is an amendment which the Senate has already adopted. It is an amendment which is increasingly being adopted by States, not just for Medicare patients but for all patients who are members of a health maintenance organization. And it is the position that is now being advocated by one of the leading HMO's in the country and the College of Emergency Physicians. I recently had an experience, as I do on a monthly basis, taking a different job. In this case, it was working with the fire and rescue department of Palm Beach County, FL, in an area of the county which has a large number of Medicare beneficiaries in their population. I was at one of the fire and rescue stations which said they got as many as 40 calls in a 24-hour period for emergencies. I asked them, ``What would you do, for instance, if you came to the home of an older person, a home of any person, who was suffering from chest pains?'' Their answer was: ``Our instructions are to provide stabilization and immediately deliver that individual to an emergency room. We are not to make any independent attempts to assess what the cause of those chest pains may be. We rely on the reasonable judgment of this lay person that those chest pains would be symptomatic of a serious life- threatening condition. We deliver that individual into the hands of persons who are capable of making the judgment as to whether, in fact, that is the circumstance.'' Mr. President, that is the essence of this amendment. It is to use the standard of a prudent lay person who felt that their condition was such that it required emergency medical evaluation, and if that standard of a prudent lay person is met, then that individual should be eligible, or the physicians or the emergency room which provided the services, should be eligible for the reimbursement for the services which they provide. As I say, that is the standard the Senate has adopted. It is the standard increasingly States have adopted. It is the standard which the leaders in the health maintenance organization industry and the College of Emergency Physicians recommended be adopted. I urge the adoption of this amendment which will give peace of mind to millions of Americans and will help resolve the largest single source of contention between Medicare beneficiaries, for whom we have a particular responsibility, and health maintenance organizations. Mr. President, I ask unanimous consent that several articles and a letter to which I referred be printed in the Record.

Mr. GRAHAM. I urge the adoption of this amendment.

Mr. GRAHAM. Mr. President, I request the yeas and nays, unless the managers of the bill are prepared to accept this amendment. If they are so prepared, I will waive the yeas and nays. If not, I will ask for them.

Mr. GRAHAM. Mr. President, I would like to ask for the yeas and nays, and if this amendment is capable of being accepted, I will ask that request be vitiated and will accept a voice vote. I ask for the yeas and nays.

Mr. GRAHAM. Mr. President, I have two unanimous-consent requests. First, that Ms. Nani Coloretti, of our office, be allowed the privilege of the floor during the consideration of the Treasury-Postal appropriations bill.

Mr. GRAHAM

Mr. GRAHAM. Mr. President, I want to begin my statement by congratulating two heroes--heroes of south Florida and heroes of our Nation--officers Joseph Alu and James O'Hara, former members of the city of Plantation police department. On October 3 of this year, these two men will be honored by the National Association of Police Organizations, when they receive the Top Cops Award--an honor given to a select group of officers who display exceptional courage and bravery in the face of danger. Mr. President, we in Florida are quite proud to have citizens like Officers Alu and O'Hara living among us, not just for the courage they displayed while in the line of duty, but also for the courage and perseverance displayed after the tragic incident which occurred on July 24, 1995. Mr. President, let me briefly recount the tragic events of July 24, 1995. While on duty, Officer Joseph Alu and Detective James O'Hara, were called to what turned out to be an emergency hostage situation. When the officers had arrived at the scene--they found that an assailant had cordoned himself off in a bedroom of a house and had taken two teenaged girls hostage. The officers broke down the bedroom door, only to discover that the assailant had doused himself, the hostages, and the entire room in gasoline. At that moment, the assailant dropped a lighter on the floor, setting the room ablaze, killing himself and the two hostages. Officers Alu and O'Hara were critically wounded--receiving severe burns over most of their bodies. Both officers remained in the hospital for the better part of a year fighting for their survival. Officer O'Hara was so badly burned that while he struggled for his life in the intensive care unit for over 6 months, his wife was told to expect and prepare for his imminent death. Miraculously, Officer Alu and Officer O'Hara survived. But, while still in the hospital, the officers were notified that since they wouldn't be physically able to return to work they and their families would lose their health insurance benefits. Imagine fighting for your life in a hospital, in excruciating pain, knowing that your family is going to be left unprotected. When these heroes returned home, that's exactly what they found: no job, disability payments of approximately $1,200 a month, prohibitively expensive COBRA insurance which would run out in 18 months, and no private health insurance for them and their families. For over 5 months, Officer Alu's wife, Sheila, stayed home to care for her husband during his rehabilitation, herself unable to work to bring in badly needed extra income. Further complicating their situation was their 5-year-old daughter, Christina, who was battling chronic asthma without health insurance. Detective O'Hara's family was in a similar situation. In fact, his wife still must care for his everyday needs almost 14 months after the incident. But instead of giving up hope, Officers Alu and O'Hara fought hard. They brought their case to the Florida Legislature. Mr. President, they won. The legislature, with a Republican senate and a Democratic house, unanimously passed this legislation at the State level--requiring that localities continue whatever health insurance benefits the officer had prior to the injury after the injury when they are no longer able to return to work. Mr. President, although they have won personal victories, Officers Alu and O'Hara have continued their fight--taking their case to Congress--and asking us to make sure that other officers not go through the same pain, uncertainty, and feelings of shame when they were unable to provide for their families. Across the Nation, unlike veterans who have risked their lives to protect our national security, those who protect our homes and streets have their insurance canceled by municipalities or States when they can no longer return to work. Mr. President, the House of Representatives has already passed the Alu-O'Hara amendment--unanimously, I might add--to the Commerce, State, Justice appropriations bill which would prevent this injustice from happening to any other officer again. I have introduced identical legislation in the Senate. It is my hope that the Senate Appropriations Committee will simply maintain the House-passed Alu-O'Hara provision in the Senate bill. Mr. President, I ask unanimous consent that at the conclusion of my remarks, the amendment that it is my hope will be maintained, which has been adopted by the House of Representatives, be printed in the Record.

Mr. GRAHAM. Mr. President, if this amendment should not be adopted by the Senate Appropriations Committee, I announce that it is my intention to offer this as an amendment when we consider the Commerce, State, Justice bill, hopefully next week. The Alu-O'Hara bill, endorsed by all major police and firefighter organizations, would create a safety net for injured officers by requiring municipalities that receive Federal crime dollars to continue to maintain the same level of benefits that an officer had prior to being injured in the line of duty. If a locality chooses not to offer health insurance to these public safety officers, it would only be able to receive 90 percent of its full complement of community-oriented policing services funding. Mr. President, the scope of this bill is extremely narrow. It would apply only to a handful of public safety officers, estimated at approximately 100 nationwide per year. And it is not costly. CBO has already stated that this bill is not an unfunded mandate. In fact, the city of Lauderhill, FL, where Officers Alu and O'Hara reside, added expanded insurance coverage to cover all of its municipal employees, not just public safety officers, at no extra cost to the city. Even though the Alu-O'Hara amendment is inexpensive, its message is unmistakably clear. We need laws which protect our valiant men and women on the frontlines. When they go down in the line of duty protecting us, we have a corresponding duty to care for them. Mr. President, this amendment would provide only the most basic package of benefits. It does not grant any enhanced or increased benefits over what the officer had at the time of the injury. The bill requires State and local governments to offer only the minimum level of health insurance necessary to maintain the health coverage the officer had prior to the disabling injury. For instance, if an officer or firefighter did not have family coverage prior to the injury, he would not be entitled to family coverage after the injury. Mr. President, I am proud of my State of Florida. But it should not take a terrible incident like this to make sure that our public safety officers are protected. We can prevent this situation from ever happening to officers like Alu and O'Hara by making sure that we maintain the Alu-O'Hara provision in the Commerce, State, Justice bill, and can do so in a proudly bipartisan fashion. Mr. President, allow me to conclude by commending both Officer Alu and Detective O'Hara and their families for their bravery, sacrifice, and dedication to public service. Without their perseverance we wouldn't be here today discussing this most critical issue. I know that police officers and firefighters across the Nation share my gratitude for their courage and selflessness. Mr. President, in passing this bill, we will honor our commitment to all of our public safety officers: to protect and care for them after they have done so much to protect and care for us. Mr. President, thank you. Exhibit 1 At the end of the bill, insert after the last section (preceding the short title) the following new section: Sec. . Of the funds appropriated in this Act under the heading ``OFFICE OF JUSTICE PROGRAMS--state and local law enforcement assistance'', not more than ninety percent of the amount to be awarded to an entity under part Q of title I of the Omnibus Crime Control and Safe Streets Act of 1968 shall be made available to such an entity when it is made known to the Federal official having authority to obligate or expend such funds that the entity that employs a public safety officer (as such term is defined in section 1204 of title I of the Omnibus Crime Control and Safe Streets Act of 1968) does not provide such a public safety officer who retires or is separated from service due to injury suffered as the direct and proximate result of a personal injury sustained in the line of duty while responding to an emergency situation or a hot pursuit (as such terms are defined by State law) with the same or better level of health insurance benefits that are paid by the entity at the time of retirement or separation.

Mr. GRAHAM

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

Mr. GRAHAM

Mr. GRAHAM. Mr. President, I am pleased that once again the Senate has chosen to continue our Nation's commitment to the future through the exploration and study of the exciting frontier of space. No one can predict the outcome of our investment in NASA, the space program, and the international space station; but we must continue to push forward in our pursuit of knowledge. Generations to come will benefit from the knowledge and experience gained from the investment we have made, and continued exploration of space will present many more opportunities to learn. First, the space program will provide significant contributions not only to Americans, but people all around the world. We have already seen results of space-related research in life sciences, and the potential for expansion and development is virtually limitless. The discovery of possible life on Mars is a very exciting development for all mankind, and highlights the possibilities that exist if we continue to encourage and support our curiosities about the universe. Second, our Nation's leadership role in high technology research and development must be maintained and enhanced. The aerospace industry is a significant area of America's international competitiveness. Support of our space program is essential to our future position as the world leader in high technology aerospace sciences. Third, projects such as the international space station help to continue and expand the cooperation among the nation's of the world. Our collaborative efforts with the Europeans, Japanese, and Russians only serve to increase stability and strengthen our relations. Our space program enables us to exchange exciting ideas with the world community, and accelerate the pace of our own technology and space exploration. Mr. President, I believe that these are very compelling reasons for continued support of our space program. NASA deserves our support. Congress and the administration should provide the appropriate resources needed for NASA to effectively and efficiently manage the space program. We must invest in our future, and invest in ourselves.

Mr. GRAHAM. Mr. President, I would join Senator Mack in commending the city of Gainesville for its diligence in funding a solution to this complex problem. The project should be considered for Federal funding because of the complexity of the problem, the difficult web of jurisdictions, and the large potential impact to the State's primary drinking water supply. I would simply add, Mr. President, that the city of Gainesville has a history of using local resources to solve local problems. In this case the city has already financed the development of this plan and would be further committed to a financial partnership on the solution. I believe such an arrangement is critical to the success of the plan and, again, I commend the city of Gainesville for its strong commitment to this most important project. I express my strong support for the efforts of the city of Gainesville and look forward to working with my colleagues on the subcommittee to secure the necessary funding in the fiscal year 1997 legislation. Restructuring the FHA-insured and assisted multifamily mortgage portfolio

Mr. GRAHAM

Mr. GRAHAM. Thank you, Mr. President. Mr. President, this amendment which was adopted overwhelmingly by the Senate, today being the third or fourth instance in which this amendment has been adopted, speaks to a simple principle. And that is, that the Nation's commitment to provide for the health care of its veterans is a national commitment, and that that commitment runs to individual veterans, not to them through the State in which they happen to live. These facilities that provide the services are facilities of the Federal Government, financed and administered under laws that we enact. Our responsibility is to individual veterans. The principle of this amendment is that those veterans should be treated equitably. The fundamental operative provision of the amendment which this Senate has adopted is that the Department of Veterans Affairs, among the health care networks of the department, shall allocate health care resources so as to assure that veterans who have similar economic status and eligibility priority and who are eligible for medical care have similar access to such care regardless of the region of the United States in which such veterans reside, a fundamental principle of fairness. And that, Mr. President, has been the objective of the Veterans' Administration for over a decade. Prior to 1985, the Veterans' Administration followed the principle that the Senator from Iowa is advocating we return to. And that is, that you look first at what were expenditures in the previous year, make incremental adjustments to those previous expenditures, and that becomes the funding level for the future. According to a report by the General Accounting Office, dated February 1996, the VA historically allocated funds to facilities on the basis of the facility's past expenditures with incremental increases for such factors as inflation and new programs. Beginning in 1985--I repeat, beginning in 1985--the Veterans Administration modified its allocation system because it recognized the need to more directly relate funding to the work performed, the cost to perform it, and to improve the efficiency and productivity with which medical care is delivered to veterans. We have not had the plan that the Senator from Iowa suggested for a decade. This same GAO report indicates we need to move further in order to accomplish the objective, that we still have a system which does not treat all of our veterans fairly according to their eligibility standards, their economic status, and their eligibility for and need for medical services. The GAO report states in part, ``Because of differences in facility rationing practices, veterans' access to care systemwide is uneven. We found that higher income veterans receive care at many facilities while lower income veterans were turned away at other facilities.'' That is the system that we have today. Mr. President, there are a number of reasons why this is occurring. A fundamental reason is the fact that veterans are, as a part of our population, becoming a smaller group. We have fewer veterans today than we did 5 years ago and we will have still fewer 5 years into the future, and veterans are not distributing themselves proportionately across the country. For example, in the State of Arizona, between 1980 and 1995, the number of veterans increased by 89,000 or 24 percent. There were 24 percent more veterans in Arizona in 1995 than in 1980. In the State of the proponent of this amendment, the number of veterans in the same 15- year period declined by 68,000 or almost 19 percent. Yet the Senator is advocating a proposition that says regardless of the number of veterans being served--my State happens to have a declining population while another State has an increasing population--we should, for some arbitrary reason, fix on the past and say that will be the basis on which we will distribute our Veterans' Administration funds for medical care, not taking into account what that means in terms of per patient recipient of funds or what it may mean in terms of encouraging greater efficiency and effectiveness in the use of funds available. I could give stories similar to the one that the Senator from Iowa has just given about former residents of his State who now live in my State who say, ``When I lived in my previous residence I was able to get certain prescriptions from the VA center. I cannot get them now in my new home. I was able to get treatment for a condition in my previous residence through the VA. I cannot receive it in my new home because of inadequate resources and inequitable allocation of funds.'' Mr. President, the principle of the amendment of the Senator from Arizona and myself is a simple one: The Nation's responsibility is to individual veterans wherever they live. And to fulfill that responsibility, we should pursue the goal of treating all veterans equally wherever they might live, and the responsibility is upon the Veterans Administration to reach that goal. We have outlined a plan which the Veterans' Administration supports. They support the amendment that this Senate has already adopted because they recognize that it is a road back to achieve the objective which they have been pursuing since 1985. Mr. President, I urge the Senate recommit itself to the principle of fairness that was adopted earlier in the debate on this issue and reject the amendment of the Senator from Iowa, which would return us to a period of a decade in the past and would return us to a time in which we did not accept the principle that all veterans should be treated equally, because all veterans in the same economic conditions, the same health status, have served this Nation with equal valor and commitment and deserve to be treated fairly.

Mr. GRAHAM. Two minutes.

Mr. GRAHAM

Mr. GRAHAM. Mr. President, I rise today to join in support of the ``Medicare Hospice Benefit Amendments of 1996'' to be introduced by Senator Breaux. The number of terminally ill patients choosing hospice care over conventional Medicare has increased from 11,000 Medicare admission in 1985 to more than 220,000 Medicare beneficiaries last year. During the current session of Congress, much has been made about the problems with the Medicare Trust Fund. Congress should act as soon as possible to reduce Medicare costs and protect the Medicare Trust Fund. However, radical cuts to the program are not the solution. Instead, we should emphasize prevention, fraud reduction, and successful programs such as hospice care--all proven efforts at reducing spending while maintaining current Medicare quality and beneficiary protections. The goal of hospice is to provide comprehensive health care at home to terminally ill patients in a manner that improves the quality of life for the patients and their families. This approach places a high value of personal choice, family support, and community involvement. Patients covered by Medicare and Medicaid waiver their eligibility for all other public program benefits when choosing hospice care. By doing so, hospice patients are cared for at home with their families and avoid costly hospitalizations. Hospice makes sense from a health care, quality of life, and economic perspective. The number of terminally ill patients choosing hospice care over conventional Medicare has increased from 11,000 Medicare admission in 1985 to more than 220,000 Medicare beneficiaries last year. Clearly, hospice is an idea that is rapidly gaining acceptance and acclaim in modern times. Florida has been a pioneer in the modern hospice movement. In 1979, while I was the Governor in Florida, my State became the first to set standards for hospices and recognize hospice as an option for the terminally ill. The Florida law served as a model for national legislation. As a result, inpatient and at-home hospice care has been covered by Medicare since 1982. The goal of hospice is to make the last months of a person's life as comfortable and meaningful as possible. Hospice does not use artificial life-support systems or surgery when there is no reasonable hope of remission. Hospice offers dignity for the dying and avoids costly-- often traumatic--acute-care hospitalization. For example, according to Lewin-VHI in their 1994 study entitled Hospice Care: An Introduction and Review of the Evidence, Medicare beneficiaries in their last year of life constituted 5 percent of beneficiaries in 1988 but more than 27 percent of Medicare payments. Lewin-VHI adds that ``during the last month of life, hospice users cost, on average, $3,069, while those using conventional care cost $4,071.'' Overall, that study indicates the use of the hospice benefit saved Medicare $1.26 for every $1.00 spent. However, an updated 1995 Lewin-VHI study shows even better results through the use of hospice. The study, entitled An Analysis of the Cost Savings of the Medicare Hospice Benefit, found that Medicare saves $1.52 for every $1.00 spent on hospice. According to Lewin-VHI, ``First, hospices effectively substitute relatively inexpensive care at home for costly inpatient hospital days during the period in which expenditures are typically the greatest and in which most hospice users enroll in the benefit, in the last month of life. Second, the financial incentives of the current Medicare Hospice Benefit reinforce the organizational incentives of most hospice programs to provide quality care at a lower cost.'' In another study entitled ``Survival of Medicare Patients After Enrollment in Hospice Programs'' in the New England Journal of Medicine on July 18, 1996, authors Nicholas Christakis and Jose Escarce establish that the benefits of hospice should be expanded. They write, ``Enrolling patients [in hospice] earlier . . . might enhance the quality of end-of-life care and also prove cost effective.'' Again, hospice has been a Medicare benefit since passage of the 1982 law and its implementation in 1983. Hospice care has grown dramatically since the benefit's inception, but few changes have been made to the 1982 law. As the bill's House sponsors--Congressmen Ben Cardin and Rob Portman--have said, ``As more and more patients choose the hospice benefit, it has become clear that certain provisions of the law need to be clarified in order to protect Medicare beneficiaries and to ensure that Medicare hospice patients can continue to receive excellent, cost- effective hospice care.'' We should do what we can to encourage hospice care in the Medicare program and through the health care system generally. This bill makes technical amendments to Medicare's hospice program. Specifically, the bill would: Restructure the benefit periods to require more frequent certifications after 180 days to facilitate appropriate discharge with no penalty to the patient; clarify that ambulances, diagnostic tests, radiation and chemotherapy are covered hospice services when included in the plan of care; amend the ``core services'' requirement to allow hospices to contract for physician services with independent contractor physicians or physician groups; allow waiver of certain staffing requirements of rural hospices; extend the expired favorable presumption of waiver of liability provisions and include waiver protection where prognosis of terminal illness is found to have been in error; and, allow the Health Care Financing Administration to set documentation requirements of physician certifications. Finally, I would like to commend Congressman Cardin from Maryland for his hard work on this legislation on the House side. The Congressman is a great thinker on the topic of how to improve Medicare and his legislation--H.R. 3714--once again serves that purpose.

Mr. GRAHAM

Mr. GRAHAM. Mr. President, I rise today to join in support of the ``Medicare Hospice Benefit Amendments of 1996'' to be introduced by Senator Breaux. The number of terminally ill patients choosing hospice care over conventional Medicare has increased from 11,000 Medicare admission in 1985 to more than 220,000 Medicare beneficiaries last year. During the current session of Congress, much has been made about the problems with the Medicare Trust Fund. Congress should act as soon as possible to reduce Medicare costs and protect the Medicare Trust Fund. However, radical cuts to the program are not the solution. Instead, we should emphasize prevention, fraud reduction, and successful programs such as hospice care--all proven efforts at reducing spending while maintaining current Medicare quality and beneficiary protections. The goal of hospice is to provide comprehensive health care at home to terminally ill patients in a manner that improves the quality of life for the patients and their families. This approach places a high value of personal choice, family support, and community involvement. Patients covered by Medicare and Medicaid waiver their eligibility for all other public program benefits when choosing hospice care. By doing so, hospice patients are cared for at home with their families and avoid costly hospitalizations. Hospice makes sense from a health care, quality of life, and economic perspective. The number of terminally ill patients choosing hospice care over conventional Medicare has increased from 11,000 Medicare admission in 1985 to more than 220,000 Medicare beneficiaries last year. Clearly, hospice is an idea that is rapidly gaining acceptance and acclaim in modern times. Florida has been a pioneer in the modern hospice movement. In 1979, while I was the Governor in Florida, my State became the first to set standards for hospices and recognize hospice as an option for the terminally ill. The Florida law served as a model for national legislation. As a result, inpatient and at-home hospice care has been covered by Medicare since 1982. The goal of hospice is to make the last months of a person's life as comfortable and meaningful as possible. Hospice does not use artificial life-support systems or surgery when there is no reasonable hope of remission. Hospice offers dignity for the dying and avoids costly-- often traumatic--acute-care hospitalization. For example, according to Lewin-VHI in their 1994 study entitled Hospice Care: An Introduction and Review of the Evidence, Medicare beneficiaries in their last year of life constituted 5 percent of beneficiaries in 1988 but more than 27 percent of Medicare payments. Lewin-VHI adds that ``during the last month of life, hospice users cost, on average, $3,069, while those using conventional care cost $4,071.'' Overall, that study indicates the use of the hospice benefit saved Medicare $1.26 for every $1.00 spent. However, an updated 1995 Lewin-VHI study shows even better results through the use of hospice. The study, entitled An Analysis of the Cost Savings of the Medicare Hospice Benefit, found that Medicare saves $1.52 for every $1.00 spent on hospice. According to Lewin-VHI, ``First, hospices effectively substitute relatively inexpensive care at home for costly inpatient hospital days during the period in which expenditures are typically the greatest and in which most hospice users enroll in the benefit, in the last month of life. Second, the financial incentives of the current Medicare Hospice Benefit reinforce the organizational incentives of most hospice programs to provide quality care at a lower cost.'' In another study entitled ``Survival of Medicare Patients After Enrollment in Hospice Programs'' in the New England Journal of Medicine on July 18, 1996, authors Nicholas Christakis and Jose Escarce establish that the benefits of hospice should be expanded. They write, ``Enrolling patients [in hospice] earlier . . . might enhance the quality of end-of-life care and also prove cost effective.'' Again, hospice has been a Medicare benefit since passage of the 1982 law and its implementation in 1983. Hospice care has grown dramatically since the benefit's inception, but few changes have been made to the 1982 law. As the bill's House sponsors--Congressmen Ben Cardin and Rob Portman--have said, ``As more and more patients choose the hospice benefit, it has become clear that certain provisions of the law need to be clarified in order to protect Medicare beneficiaries and to ensure that Medicare hospice patients can continue to receive excellent, cost- effective hospice care.'' We should do what we can to encourage hospice care in the Medicare program and through the health care system generally. This bill makes technical amendments to Medicare's hospice program. Specifically, the bill would: Restructure the benefit periods to require more frequent certifications after 180 days to facilitate appropriate discharge with no penalty to the patient; clarify that ambulances, diagnostic tests, radiation and chemotherapy are covered hospice services when included in the plan of care; amend the ``core services'' requirement to allow hospices to contract for physician services with independent contractor physicians or physician groups; allow waiver of certain staffing requirements of rural hospices; extend the expired favorable presumption of waiver of liability provisions and include waiver protection where prognosis of terminal illness is found to have been in error; and, allow the Health Care Financing Administration to set documentation requirements of physician certifications. Finally, I would like to commend Congressman Cardin from Maryland for his hard work on this legislation on the House side. The Congressman is a great thinker on the topic of how to improve Medicare and his legislation--H.R. 3714--once again serves that purpose.

Mr. GRAHAM

Mr. GRAHAM. Is this consistent with the understanding of the Senator from Nebraska as well?

Mr. GRAHAM. Would the Senator agree that the version of the bill recommended in this conference report is consistent with this understanding?

Mr. GRAHAM. I wonder if my colleague could address one point on this bill. I notice that the term ``Federal means-tested public benefit'' was defined in previous versions of the bill. However, in this conference report, no definition is provided.

Mr. GRAHAM. I thank the Senator for clarifying that point.

Mr. GRAHAM. Mr. President, during consideration of the Senate reconciliation bill, two definitions regarding immigrants, section 2403(c)(1), and in section 2423, section 213(A)(f)(2), were stricken because they contained material that was not under the jurisdiction of the Finance Committee. Specifically the definitions denied all means- tested benefits to immigrants including benefits subject to appropriations. The Parliamentarian also agreed that the provisions violated another section of the Byrd rule, section 313(b)(1)(D). Section 313(b)(1)(D) prohibits language in a reconciliation bill or conference report if the deficit reduction is merely incidental to the larger policy changes contained within the provision. The Parliamentarian agreed that since the reconciliation process is confined to mandatory spending, expanding the scope of provisions to include benefits provided by discretionary spending was a violation of the Byrd rule. The conferees were certainly notified about these rulings and the offending provisions were not included in the conference report. Moreover, would the Senator agree that, when the Senate struck these sections as violating the Byrd rule, the Senate's intent was to prevent the denial of services in appropriated programs such as those that provide services to victims of domestic violence and child abuse, the maternal and child health block grant, social services block grant, community health centers and migrant health centers? Does the Senator agree that recipients of appropriated funds are not forced to conduct checks on citizenship and immigration status when providing community services?

Mr. GRAHAM

Mr. GRAHAM. Mr. President, I conclude by saying it is with a leap of faith that we undertake this initiative. I think we are doing it at a time which gives us the greatest hope and expectation that faith will be justified.

Mr. GRAHAM. Mr. President, when we voted on this matter a few days ago, I voted ``no.'' Today, I am going to vote for the conference report, and I wish to explain why I am taking that position. As I assessed the conference report, it seemed to me that we had basically two options. One option was to wait until there was a better point at which to commence and continue our effort at welfare reform and be prepared to accept the status quo until that second opportunity presented itself. I felt that was likely to be a long time from tonight. The second option is to accept a clearly less than perfect bill, I would say, accept a flawed bill, but one which represents a step in a multistep process leading toward a fundamental transition from a welfare system that has focused on providing for the needs of a dependent population to a welfare system that provides the ladder by which people can move from dependence to independence. I believe it is more appropriate to take that second road. I believe this is the time to take that leap of faith. To use some statistics from my State of Florida, 3 years ago, in 1993, we had an unemployment rate of 7 percent. We had 254,000 persons who were on the AFDC caseload. That is 254,000 families that were on AFDC. Today, in 1996, we have a 200,000 AFDC caseload, a reduction of 54,000 in 3 years. That says that we are in a period of a strong economy, creating jobs, providing people with the opportunity within the current system to get off welfare and to get a job. I think that is the ideal environment in which, now, to have this new system which will be giving to the 200,000 who are still on welfare the means by which they can get a job and end dependence. If we cannot make this transition work under the economic conditions that exist in my State and most of the States of America in the summer of 1996, then I doubt we will see a time in the foreseeable future when we could make this system work. It is for that reason that our Governor has announced his support for this program. It is for that reason our legislature has passed its own version of welfare reform, building on important demonstration projects in our State which have tested out what is going to be required in order to make this new system achieve its objective. I stated candidly that this is a bill which is far from perfect, and which has some flaws. That presents, as I believe the Senator from Pennsylvania just stated, the agenda for our action in the future. I suggest two areas in which I think that attention should be focused. One of those is on the basic financial arrangement between the Federal Government and the States. We start this in a period of prosperity. We know the business cycle has not yet been repealed. There will be times when we will return to the circumstances of the early 1990's, when we had unemployment rates ranging from 7.4 to 8.3 percent. We need to relook at our financial relationships to assure that we have the flexibility, the elasticity in order to protect States during those downturns. We need to also look at the issue of fairness of allocation. I continue to be distressed at the fact that we are using the old method of allocating Federal funds, the formula that we developed for the system we are now rejecting as we move into the new system. I suggest that is inappropriate, an inappropriate bit of baggage we are carrying with us and it is going to be a heavy piece of baggage, in terms of achieving the objectives of moving people from welfare to work, particularly in States such as Arkansas, which start this process as very low beneficiary States and are therefore restricted in the amount of funds they will have available. The second area in which I believe we need to focus our attention is on the issue of legal aliens. It confounds me as to why legal aliens were brought into this bill, which has, as its title, welfare reform. That has very little relationship with the severe cutbacks in benefits for legal aliens. These are our parents and grandparents of just a generation or two ago, who came to this country seeking the freedom of America. Now, those who have followed them in that 200-year quest for those values of America, we are now putting into a second-class status. There is no relationship to the goals we are trying to achieve in welfare reform. It has a lot to do with the fact this is a voiceless, vulnerable population, from which we can seek some additional resources in order to meet our budgetary goals. Let us be clear, this is a budget issue, not a welfare reform issue as we speak of legal aliens. And it is going to be a major budget issue for those communities which have sizable numbers of legal aliens who will now become an unpaid charge to the local public hospital. So that area will also require our attention.

Mr. GRAHAM

Mr. GRAHAM. Mr. President, almost 1 year ago today, Officer Joseph Alu and Detective James O'Hara responded to an emergency hostage situation. When the officers had arrived at the scene--they found that the assailant had cordoned himself off in a bedroom of a house and had taken two teenaged girls for hostages. The officers broke down the bedroom door, only to discover that the assailant had doused himself, the hostages, and the entire house in gasoline. At that moment, the assailant dropped a lighter on the floor, setting the room ablaze, killing himself and the two hostages. Officers Alu and O'Hara were critically wounded--receiving severe burns over most of their bodies. Both officers remained in the hospital for the better part of a year fighting for their lives. Officer O'Hara was so badly burned that while he struggled for his life in the intensive care unit for over 6 months, his wife was told to expect and prepare for his imminent death. Miraculously, Officer Alu and Officer O'Hara survived. But, while still in the hospital, the city of Plantation Police Department notified the officers that since they would not be physically able to return to work--they and their families would lose their health insurance benefits. Imagine fighting for your life in a hospital, in excruciating pain, knowing that your family is going to be left unprotected. When these heroes returned home--that is exactly what they found: no job, disability payments of approximately $1,200 a month, prohibitively expensive COBRA insurance which would run out in 18 months, and no private health insurance for them and their families. For over 5 months, Officer Alu's wife, Sheila, stayed home to care for her husband during his rehabilitation--herself unable to work to bring in badly needed extra income. Further complicating their situation was their 5-year-old daughter Christina, who was battling chronic asthma without health insurance. Detective O'Hara's family was in a similar situation. In fact, his wife still must care for his everyday needs almost 1 year later. But instead of giving up hope, officers Alu and O'Hara fought hard. They brought their case to the Florida Legislature--and won. The legislature, with a Republican Senate and a Democratic House, unanimously passed this legislation at the State level--requiring that localities continue whatever health insurance benefits the officer had prior to the injury. Mr. President, although they have won personal victories, officers Alu and O'Hara have continued their fight--taking their case to Congress--asking us to make sure that other officers not go through the same pain, uncertainty, and feelings of shame as they did when they were unable to provide for their families. Across the Nation, unlike veterans who have risked their lives to protect our national security, those who protect our homes and streets have their insurance canceled by municipalities or States when they can no longer do the job. Mr. President, my legislation, endorsed by all major police and firefighter organizations, would create a safety net for injured officers by requiring municipalities that receive Federal crime dollars to continue to maintain the same level of benefits that an officer had prior to being injured in the line of duty. If a locality chooses not to offer health insurance to these public safety officers, it would only be able to receive 90 percent of its full complement of community-oriented policing services funding. Mr. President, the scope of this bill is extremely narrow. It would apply only to a handful of public safety officers, estimated at approximately 100 nationwide per year. And it is not costly. CBO has already stated that this bill is not an unfunded mandate. But its message is unmistakeably clear. We need laws which protect our valiant men and women on the front lines. When they go down in the line of duty protecting us, we have a corresponding duty to care for them. Mr. President, this bill would provide only the most basic package of benefits. It does not grant any enhanced or increased benefits over what the officer had at the time of the injury. The bill requires State and local governments to offer only the minimum level of health insurance necessary to maintain the health coverage the officer had prior to the disabling injury. For instance, if an officer or firefighter did not have family coverage prior to the injury, he would not be entitled to family coverage after the injury. Mr. President, I am proud of my State of Florida. But it should not take a terrible incident like this to make sure that our public safety officers are protected. We can prevent this situation from ever happening to officers like Alu and O'Hara by passing this legislation this year, in a bipartisan fashion. Mr. President, allow me to conclude by commending both Officer Alu and Detective O'Hara and their families for their bravery, sacrifice, and dedication to public service. Without their perseverance we would not be here today discussing this most critical issue. I know that police officers and firefighters across the Nation share my gratitude for their courage and selflessness. Mr. President, in passing this bill, we will honor our commitment to all of our public safety officers: to protect and care for them after they have done so much to protect and care for us.

Mr. GRAHAM

Mr. GRAHAM. Mr. President, almost 1 year ago today, Officer Joseph Alu and Detective James O'Hara responded to an emergency hostage situation. When the officers had arrived at the scene--they found that the assailant had cordoned himself off in a bedroom of a house and had taken two teenaged girls for hostages. The officers broke down the bedroom door, only to discover that the assailant had doused himself, the hostages, and the entire house in gasoline. At that moment, the assailant dropped a lighter on the floor, setting the room ablaze, killing himself and the two hostages. Officers Alu and O'Hara were critically wounded--receiving severe burns over most of their bodies. Both officers remained in the hospital for the better part of a year fighting for their lives. Officer O'Hara was so badly burned that while he struggled for his life in the intensive care unit for over 6 months, his wife was told to expect and prepare for his imminent death. Miraculously, Officer Alu and Officer O'Hara survived. But, while still in the hospital, the city of Plantation Police Department notified the officers that since they would not be physically able to return to work--they and their families would lose their health insurance benefits. Imagine fighting for your life in a hospital, in excruciating pain, knowing that your family is going to be left unprotected. When these heroes returned home--that is exactly what they found: no job, disability payments of approximately $1,200 a month, prohibitively expensive COBRA insurance which would run out in 18 months, and no private health insurance for them and their families. For over 5 months, Officer Alu's wife, Sheila, stayed home to care for her husband during his rehabilitation--herself unable to work to bring in badly needed extra income. Further complicating their situation was their 5-year-old daughter Christina, who was battling chronic asthma without health insurance. Detective O'Hara's family was in a similar situation. In fact, his wife still must care for his everyday needs almost 1 year later. But instead of giving up hope, officers Alu and O'Hara fought hard. They brought their case to the Florida Legislature--and won. The legislature, with a Republican Senate and a Democratic House, unanimously passed this legislation at the State level--requiring that localities continue whatever health insurance benefits the officer had prior to the injury. Mr. President, although they have won personal victories, officers Alu and O'Hara have continued their fight--taking their case to Congress--asking us to make sure that other officers not go through the same pain, uncertainty, and feelings of shame as they did when they were unable to provide for their families. Across the Nation, unlike veterans who have risked their lives to protect our national security, those who protect our homes and streets have their insurance canceled by municipalities or States when they can no longer do the job. Mr. President, my legislation, endorsed by all major police and firefighter organizations, would create a safety net for injured officers by requiring municipalities that receive Federal crime dollars to continue to maintain the same level of benefits that an officer had prior to being injured in the line of duty. If a locality chooses not to offer health insurance to these public safety officers, it would only be able to receive 90 percent of its full complement of community-oriented policing services funding. Mr. President, the scope of this bill is extremely narrow. It would apply only to a handful of public safety officers, estimated at approximately 100 nationwide per year. And it is not costly. CBO has already stated that this bill is not an unfunded mandate. But its message is unmistakeably clear. We need laws which protect our valiant men and women on the front lines. When they go down in the line of duty protecting us, we have a corresponding duty to care for them. Mr. President, this bill would provide only the most basic package of benefits. It does not grant any enhanced or increased benefits over what the officer had at the time of the injury. The bill requires State and local governments to offer only the minimum level of health insurance necessary to maintain the health coverage the officer had prior to the disabling injury. For instance, if an officer or firefighter did not have family coverage prior to the injury, he would not be entitled to family coverage after the injury. Mr. President, I am proud of my State of Florida. But it should not take a terrible incident like this to make sure that our public safety officers are protected. We can prevent this situation from ever happening to officers like Alu and O'Hara by passing this legislation this year, in a bipartisan fashion. Mr. President, allow me to conclude by commending both Officer Alu and Detective O'Hara and their families for their bravery, sacrifice, and dedication to public service. Without their perseverance we would not be here today discussing this most critical issue. I know that police officers and firefighters across the Nation share my gratitude for their courage and selflessness. Mr. President, in passing this bill, we will honor our commitment to all of our public safety officers: to protect and care for them after they have done so much to protect and care for us.

Mr. GRAHAM

Mr. GRAHAM. Mr. President, the amendment I offer strikes an amendment which was adopted in the Senate Finance Committee. The current bill as it was submitted to the committee contains a sanction against the States in the hands of the Secretary of HHS. The Secretary, at the Secretary's discretion, can levy up to a 5- percent withholding of a State's welfare funds if the State fails to meet the work requirements. The amendment offered in the committee provides that if a State fails to meet that standard for 2 straight years, then it shall be penalized, without discretion in the hands of the Secretary, by a mandatory 5 percent. And although there is some confusion, it is assumed that this is a cumulative 5 percent, up to a total of 25 percent of the State's welfare payments. This is strongly opposed by the State and local organizations, from the National Governors' Association, the National Conference of State Legislators, the National Association of Counties, all of whom feel it denies to the Secretary the necessary discretion. This also will severely penalize those low-benefit States which are the most likely to be unable to meet the work requirements.