Bob Graham

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Medicare has served our seniors superbly. And where it has not, as in the area of prescription drugs, it has been because Congress has not allowed it to do so. I hope when this bill comes back from conference, it will be better but I doubt that will be the case.

Mr. GRAHAM of Florida. Mr. President, I will vote no today in the hopes that soon we will have an opportunity to pass a prescription drug bill that will fully meet the needs and expectations of older Americans. Exhibit 1 [From The Washington Post, June 26, 2003] For Struggling Seniors, Medicare Drug Plan's Proof Is in the Purse (By Ceci Connolly) CLEVELAND--As the Medicare drug package moving through Congress takes on an air of inevitability, Washington politicians are already jostling for credit. But in this working-class city 370 miles from Capitol Hill, prospects for the plan's eventual success may lie deep inside the handbags of women such as Marie A. Urban. Stashed in there are her monthly Social Security statement, a half-dozen prescription discount cards and insurance letters rejecting several recent medical claims. The scraps of paper--creased and scribbled on--document a life near the financial edge. After working 24 years as the secretary at St. Paul's Shrine, Urban, 72 collects $843.70 a month in Social Security. After housing and Medicare payments, she has $459 for utilities, food, car insurance, taxes and medication. ``Some months I have 87 cents to live on,'' she said. With her drug bills this year already exceeding $1,500, she said she probably will try to cobble together the money to buy the prescription coverage that lawmakers plan to offer Medicare recipients. ``I don't know,'' she said. ``My finances right now are very tight. I guess I'd have to go with it.'' In interviews at two senior centers here, Urban and other retirees expressed deeply mixed feelings about the voluntary prescription drug benefit scheduled for votes in Congress as early as today. They exhibited a visceral distrust of Washington, voicing skepticism that elected officials would deliver a package that fits their health needs and budgetary constraints--in time for them to use it. They were disappointed that in most cases, benefits would not begin until a person spent nearly $1,000 a year on prescription drugs. And they were annoyed--but not totally surprised--that the program would not begin until 2006. ``They've been kicking this ball around for a while,'' said Carrie Adams, 66. ``If they wanted to solve this, they would. The people with the ball are not relating to the people out here.'' Ruby Bogus, 83, was a bit more sanguine. ``We just have to live longer, girls,'' she said. Both the House and Senate plans would require seniors to pay about $35 in monthly premiums and an annual deductible of $250 to $275 before receiving any subsidy. The Senate plan would cover half of a person's annual drug expenditures between $276 and $4,500. The recipient would pay the next $1,300 in prescription costs. If the person's total drug costs rose above $5,800 in a year, subsidies would resume. The House bill would offer retirees an 80 percent subsidy on drug bills between $251 and $2,000 and no coverage for the next $1,500 worth of medications. The ``catastrophic coverage'' would begin when costs reached $3,501. Asked whether either plan was attractive, Emily Eckert pulled a tiny notebook from her purse. It listed her daily medications: two pills to control sugar, one for high blood pressure, another to regulate potassium. Using her People's Drug Mart discount card--also tucked in her pocketbook-- Eckert spends about $100 a month on prescriptions, plus $22 for diabetes test strips. At 79, she has outlived two husbands, but at a high cost. Caring for her first husband, who had cancer, and the second, who had diabetes, wiped out $7,000 in savings and two life insurance policies valued at $3,000. Eckert has been in bankruptcy and worries about helping her three children, 10 grandchildren and 10 great-grandchildren. ``If it wasn't for this center, I'd be starving,'' she said, referring to the Senior Citizens Resources facility in the Old Brooklyn neighborhood. She wants to buy the drug coverage proposed for Medicare but isn't certain she will be able to pay the premiums. The situations of Marie Urban and Emily Eckert may sound dire, but in many respects they are typical for the millions of senior citizens and disabled people who rely on Medicare for their health care. Not poor enough to qualify for Medicaid, yet not fortunate enough to have substantial savings or a lucrative retirement package, such people have clamored for years for help with the rising cost of medication. Assuming the House and Senate pass their spending bills and then resolve their differences, Congress hopes to answer those demands by spending nearly $400 billion on drug coverage over 10 years. The legislation would mark the largest Medicare expansion in the program's 38-year history and could provide a political boost to President Bush and fellow Republicans who campaigned on the promise of alleviating drug costs. However, as the conversations in Cleveland illustrated, many older Americans are watching with guarded optimism and could revolt if the final package fails to meet expectations. That would dash Republicans' hopes of taking away an issue that has been mostly associated with Democrats for decades. Their elderly residents' fundamental question is whether they would save money under the new plans. The answer isn't easy. Urban is torn. Most years she spends about $800 on medicine, so a benefit that does not begin paying off until after $1,000 in out-of-pocket spending looks like a money loser for her. But this year, a mysterious infection and several hospitalizations pushed her drug bills to $1,500, and the federally subsidized insurance would have saved her money. Urban drives 30 minutes to several pharmacies in the Cleveland suburbs to shop for the best deals. She gets agitated thinking about the complex math of the new proposal. Howard Bram, 77, also complained about the complexity of a program that will involve choosing a plan, tracking out-of- pocket expenses and knowing when the coverage kicks in, lapses and then resumes in severe cases, all according to a sliding scale of benefits. ``It's just gonna blow their minds,'' he said. Bram is trying to figure out whether the drug plan would put a significant dent in the cost of the eight medications he takes. Carrie Adams and Jean Nagorski are precisely the sort of customer-patients that Medicare will need--comparatively young, healthy and with some retirement income. Yet both women doubt they would buy the Medicare drug coverage because they believe they get a better bargain with the current supplemental insurance plans. Without clients such as Adams and Nagorski, policymakers worry, the new Medicare package will draw the oldest, sickest and poorest patients, leading to skyrocketing costs. Despite the plan's limits, Adams predicted many friends will sign up for any program that might lower their drug bills. ``They're gonna jump on this like white on rice,'' she said. Zev Harel, 73, agreed. ``There are always those who hope for a revolution, but what has worked in the United States is evolution,'' said Harel, a professor at Cleveland State University and board member of the Western Reserve Area Agency on Aging. Many of his friends will be disappointed with the limits of the drug coverage, he said, but he considers it ``a major improvement over the current situation.'' If analyzed in the context of other types of insurance, the Medicare drug plan is a reasonable approach, Harel said. ``This follows on the principle of purchasing protection.'' But many others said the fundamental promise of Medicare--a system they supported through payroll taxes throughout their careers--has always been health care for all, and in today's world, that should include prescriptions. ``The politicians seem to say it's better than nothing, and we should be grateful,'' Urban grumbled. To some retirees here, who chip coupons and follow the news, Washington's Medicare is just the latest example of the doings of out-of-touch elitists. Nagorski reached into her purse and retrieved a recent newspaper clipping detailing the personal riches of the United States' elected leaders. The article identified several millionaires, including Sens. Bill Frist (R-Tenn.), Edward M. Kennedy (D-Mass.) and Ohio's senators, Mike DeWine and George V. Voinovich, both Republicans. ``Do you really think they care about the average person with what they earn?'' Nagorski asked. ``I don't think any of them are ever going to have to live on $1,100 a month.''

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Mr. President, I rise today to introduce legislation that will authorize additional judgeships in the Middle and Southern Federal Judicial Districts of Florida. Additional judgeships are needed in these two districts in order to deal with a large volume of filings, heavy pending caseloads, the considerable number of senior judges, and a rapidly growing population. It is vital that we add two additional permanent and one temporary judgeship in the Middle District and four additional permanent judgeships in the Southern District of Florida. Florida's Middle District is one of the busiest Federal district courts in the Nation. In 2001 it was ranked fifth in the Nation for the number of criminal defendants charged with fraud and drug related offenses among all district courts. It handles cases filed in three of the four largest cities in the State of Florida, Jacksonville, Orlando and Tampa, which comprise 60 percent of the State's population. In 1999 four judges were added to the Middle District of Florida. The numbers of weighted filings and pending caseload both decreased in 2000. However, numbers quickly rose again in 2001. A biennial judgeship survey conducted in 2003 showed that in 2001 there were 553 weighted filings in this district versus the national average of 490. In addition, the United States Department of Justice has identified Central Florida as a High Intensity Drug Trafficking Enforcement Area. The Southern and Middle Districts are parallel in some of the challenges that they face. Despite the additional judgeships that were created in the Southern District in 2001, the amount of weighted filings continues to rise. Since 1994, civil and criminal filings per judgeship have stayed above the national average, with civil filings rising by 67 percent and criminal filings increasing by 58 percent. Many of these increases in criminal filings are linked to the increase in fraud, drugs, firearms and immigration prosecutions. The administration of justice will continue to be a challenge in Florida's Federal courts unless adequate resources are committed. It is projected that by 2015 Florida may surpass third-ranked New York in population. As the population increases, so do the number of people seeking justice from the Federal courts in our State. I ask that my colleagues join me in supporting this important legislation.

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Mr. President, I rise today to introduce legislation that will authorize additional judgeships in the Middle and Southern Federal Judicial Districts of Florida. Additional judgeships are needed in these two districts in order to deal with a large volume of filings, heavy pending caseloads, the considerable number of senior judges, and a rapidly growing population. It is vital that we add two additional permanent and one temporary judgeship in the Middle District and four additional permanent judgeships in the Southern District of Florida. Florida's Middle District is one of the busiest Federal district courts in the Nation. In 2001 it was ranked fifth in the Nation for the number of criminal defendants charged with fraud and drug related offenses among all district courts. It handles cases filed in three of the four largest cities in the State of Florida, Jacksonville, Orlando and Tampa, which comprise 60 percent of the State's population. In 1999 four judges were added to the Middle District of Florida. The numbers of weighted filings and pending caseload both decreased in 2000. However, numbers quickly rose again in 2001. A biennial judgeship survey conducted in 2003 showed that in 2001 there were 553 weighted filings in this district versus the national average of 490. In addition, the United States Department of Justice has identified Central Florida as a High Intensity Drug Trafficking Enforcement Area. The Southern and Middle Districts are parallel in some of the challenges that they face. Despite the additional judgeships that were created in the Southern District in 2001, the amount of weighted filings continues to rise. Since 1994, civil and criminal filings per judgeship have stayed above the national average, with civil filings rising by 67 percent and criminal filings increasing by 58 percent. Many of these increases in criminal filings are linked to the increase in fraud, drugs, firearms and immigration prosecutions. The administration of justice will continue to be a challenge in Florida's Federal courts unless adequate resources are committed. It is projected that by 2015 Florida may surpass third-ranked New York in population. As the population increases, so do the number of people seeking justice from the Federal courts in our State. I ask that my colleagues join me in supporting this important legislation.

Mr. GRAHAM of Florida. Mr. President, I rise today to introduce legislation that will remove a significant and arbitrary barrier to appellate review of veterans' benefits claims. In 1988, when Congress created judicial review for veterans' claims it intended to provide ``an opportunity for those aggrieved by VA decisions to have such decisions reviewed by a court'' and found such review ``necessary in order to provide such claimants with fundamental justice.'' A veteran or survivor of a veteran seeking VA benefits must file a claim for such benefits, generally at a VA Regional Office. If the VA denies the claim for benefits, the claimant must file a ``Notice of Disagreement,'' or NOD, as defined in section 7105 of title 38 of the United States Code. This NOD initiates appellate review by the agency and begins a series of events where VA communicates the basis of the denial to the claimant and allows various levels of review of this denial at the regional office. If the claimant still disagrees with the VA decision, the claimant may file a ``Substantive Appeal'' that vests jurisdiction of the claim with the Board of Veterans' Appeals, the appellate arm of VA. Section 7105 defines what is required of a valid NOD. It must be filed within 1 year from the notice of the initial denial, in writing, and filed with the regional office that issued the decision over which there is disagreement. The NOD may be filed by the claimant or the claimant's guardian or representative. VA has promulgated regulations to implement section 7105. In Section 20.201 or title 38 of the Code of Federal Regulations, the Secretary defined a NOD to not require special wording. The regulation does require that the NOD ``must be in terms which can be reasonably construed as disagreement with the determination and a desire for appellate review.'' The second component of that sentence--``a desire for appellate review''--is not required under the statute. In 1997, Raymond Gallegos, a veteran, again filed an application for service connection for post-traumatic stress disorder that had been previously denied. The VA regional office granted his claim. However, Mr. Gallegos believed the effective date assigned to his claim was wrong and filed what was then thought to be a NOD. He appealed this issue to the Board, which reasoned that the letter expressing his disagreement was not a valid NOD because it did not express his desire for appellate review. Mr. Gallegos appealed the Board's determination to the United States Court of Appeals for Veterans Claims, or the CAVC. In 2000, the CAVC determined in Gallegos v. Gober that the VA regulation was invalid because it required more of the claimant than Congress required in statute. Last year, in Gallegos v. Principi, the United States Court of Appeals for the Federal Circuit reversed the CAVC and upheld the VA regulation, finding that the agency interpretation was entitled to deference because Congressional intent was not clear in limiting the requirements of a NOD to those in section 7105. Congress never intended to require that level of formality from veterans, in this uniquely pro-claimant system. Therefore, I offer legislation that would specify that if a claimant's filing meets the criteria defined in section 7105 of title 38 of the United States Code, the document will be deemed a Notice of Disagreements with all the rights and procedures that accompany that determination. It will also ensure that claimants whose NODs were found to be defective since the court decision will have the opportunity to have their NOD reevaluated under this new provision. This is very significant because there are two key consequences of not having a valid, timely NOD. First, if a claimant fails to file a timely, valid NOD, the VA denial becomes final. The claimant will need to submit ``new and material evidence'' that VA erred in order to reopen the case. If successful, the claimant will only be able to receive benefits dating to the beginning of the newly reopened claim, potentially losing years of retroactive benefits. This may affect a veteran's ability to receive VA health care, a dependent's ability to use educational benefits, and all the other benefits that flow from a finding of service-connection. Second, if a claimant has not been deemed to file a NOD, there can be no appeal of the VA decision. A NOD is required to initiate an appeal. It is a prerequisite to review by the Board of Veterans' Appeals and ultimately judicial review at the CAVC. This contravenes Congress's intent to remove arbitrary barriers to judicial review as it did in Public Law 107-103. We face the tragic fact that in 2002, America lost 646,264 veterans. The many aging veterans who still await justice cannot afford this debate. I ask my colleagues to support this critical measure and restore this fundamental justice to our veterans. I ask unanimous consent that the text of this bill be printed in the Record.

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Mr. President, I rise today to introduce legislation that will remove a significant and arbitrary barrier to appellate review of veterans' benefits claims. In 1988, when Congress created judicial review for veterans' claims it intended to provide ``an opportunity for those aggrieved by VA decisions to have such decisions reviewed by a court'' and found such review ``necessary in order to provide such claimants with fundamental justice.'' A veteran or survivor of a veteran seeking VA benefits must file a claim for such benefits, generally at a VA Regional Office. If the VA denies the claim for benefits, the claimant must file a ``Notice of Disagreement,'' or NOD, as defined in section 7105 of title 38 of the United States Code. This NOD initiates appellate review by the agency and begins a series of events where VA communicates the basis of the denial to the claimant and allows various levels of review of this denial at the regional office. If the claimant still disagrees with the VA decision, the claimant may file a ``Substantive Appeal'' that vests jurisdiction of the claim with the Board of Veterans' Appeals, the appellate arm of VA. Section 7105 defines what is required of a valid NOD. It must be filed within 1 year from the notice of the initial denial, in writing, and filed with the regional office that issued the decision over which there is disagreement. The NOD may be filed by the claimant or the claimant's guardian or representative. VA has promulgated regulations to implement section 7105. In Section 20.201 or title 38 of the Code of Federal Regulations, the Secretary defined a NOD to not require special wording. The regulation does require that the NOD ``must be in terms which can be reasonably construed as disagreement with the determination and a desire for appellate review.'' The second component of that sentence--``a desire for appellate review''--is not required under the statute. In 1997, Raymond Gallegos, a veteran, again filed an application for service connection for post-traumatic stress disorder that had been previously denied. The VA regional office granted his claim. However, Mr. Gallegos believed the effective date assigned to his claim was wrong and filed what was then thought to be a NOD. He appealed this issue to the Board, which reasoned that the letter expressing his disagreement was not a valid NOD because it did not express his desire for appellate review. Mr. Gallegos appealed the Board's determination to the United States Court of Appeals for Veterans Claims, or the CAVC. In 2000, the CAVC determined in Gallegos v. Gober that the VA regulation was invalid because it required more of the claimant than Congress required in statute. Last year, in Gallegos v. Principi, the United States Court of Appeals for the Federal Circuit reversed the CAVC and upheld the VA regulation, finding that the agency interpretation was entitled to deference because Congressional intent was not clear in limiting the requirements of a NOD to those in section 7105. Congress never intended to require that level of formality from veterans, in this uniquely pro-claimant system. Therefore, I offer legislation that would specify that if a claimant's filing meets the criteria defined in section 7105 of title 38 of the United States Code, the document will be deemed a Notice of Disagreements with all the rights and procedures that accompany that determination. It will also ensure that claimants whose NODs were found to be defective since the court decision will have the opportunity to have their NOD reevaluated under this new provision. This is very significant because there are two key consequences of not having a valid, timely NOD. First, if a claimant fails to file a timely, valid NOD, the VA denial becomes final. The claimant will need to submit ``new and material evidence'' that VA erred in order to reopen the case. If successful, the claimant will only be able to receive benefits dating to the beginning of the newly reopened claim, potentially losing years of retroactive benefits. This may affect a veteran's ability to receive VA health care, a dependent's ability to use educational benefits, and all the other benefits that flow from a finding of service-connection. Second, if a claimant has not been deemed to file a NOD, there can be no appeal of the VA decision. A NOD is required to initiate an appeal. It is a prerequisite to review by the Board of Veterans' Appeals and ultimately judicial review at the CAVC. This contravenes Congress's intent to remove arbitrary barriers to judicial review as it did in Public Law 107-103. We face the tragic fact that in 2002, America lost 646,264 veterans. The many aging veterans who still await justice cannot afford this debate. I ask my colleagues to support this critical measure and restore this fundamental justice to our veterans. I ask unanimous consent that the text of this bill be printed in the Record.

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Mr. President, there has been a renewed interest in health issues, particularly the plight of the uninsured. That issue presents lawmakers with significant challenges, particularly finding the right mixes of programs to provide health care coverage to the vastly different populations that make up this group. There is an equally daunting health care issue facing our country, but it is one that has received far less attention. That issue is the increasing need for long-term care. Over 13 million people in the United States need help with basic activities of daily living such as eating, getting in and out of bed, getting around inside, dressing, bathing and using the toilet. While many Americans believe that long- term care is an issue primarily affecting seniors, the reality is that 5.2 million adults between the ages of 18 to 64 and over 450,000 children need long-term care services. These numbers are expected to double as the baby boom generation begins to retire. Most long-term is provided at home or in the community by informal caregivers. However, in situations where individuals must enter nursing homes or other institutional facilities, costs are paid largely out-of- pocket. Such a financing structure jeopardizes the retirement security of many Americans who have worked hard their entire lives. In order to help families address their long-term care needs, Senator Grassley and I are re-introducing the ``Long-Term Care and Retirement Security Act.'' This legislation provides two important tools to help Americans and their families meet their immediate and future long-term care needs--an above-the-line income tax deduction for the purchase of long-term care insurance and a caregiver tax credit. First, the bill provides an above-the-line deduction for long-term care premiums to make long-term care insurance more affordable for a greater number of Americans. Today, such premiums are deductible, but the availability of the deduction is severely limited. First, the current deduction is available only for the thirty percent of taxpayers who itemize their deductions. That leaves the remaining seventy percent of taxpayers with absolutely no benefit. Second, the deduction is limited to an amount, which in addition to other medical expenses exceeds 7.5 percent of the taxpayers adjusted gross income. This AGI limit further decreases the utilization of the current deduction. The Graham-Grassley legislation removes these restrictions and makes the deduction for long-term care premiums available to all taxpayers. In order to provide sufficient incentives for families to maintain long-term care coverage, the deduction allowed under this bill increases the longer the policy is maintained. The deduction starts at 60 percent for premiums paid during the first year of coverage and gradually increases each year thereafter until the deduction reaches 100 percent after at least 4 years of continuous coverage. This schedule is accelerated for those age 55 or older. For them, the deduction starts at 70 percent for the first year and increases to 100 percent with at least two years of continuous coverage. Second, the bill provides an income tax credit for taxpayers with long-term care needs. The credit is phased in over 4 years, starting at $1,000 for 2003 and eventually reaching $3,000. To target assistance to those most in need, the credit phases out for married couples with income above $150,000, $75,000 for single taxpayers. In addition to the deduction and tax credit, our bill allows employers to offer long-term care insurance under cafeteria plans and include long-term care services as reimbursable costs under flexible spending arrangements. The bill also updates the requirements that long-term care policies must meet in order to qualify for the income tax deduction. These updated requirements reflect the most recent model regulations and code issued by the National Association of Insurance Commissioners. I urge my colleagues to join Senator Grassley and me in cosponsoring this legislation.

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Mr. President, I am here this morning to offer an amendment to the Prescription Drug and Medicare Improvement Act of 2003. This amendment has as its goal to repeal the ``sick tax,'' which is part of the pending legislation. I send the amendment to the desk.

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

Mr. GRAHAM of Florida. Mr. President, I have many concerns with this legislation. Probably at its core is the fact that we are about to adopt a prescription drug benefit for 39 million older and disabled Americans, of which there is no current model. Virtually every question about this legislation has to be answered at a theoretical level because we cannot say the Federal health insurance plan that covers Federal employees, or a Blue Cross/Blue Shield plan, or any other plan has provisions to dispense prescription drugs through a prescription drug-only insurance policy. In my judgment, that is a very fundamental concern that we should share. Understand that we are about to conduct a gigantic social experiment on 39 million Americans, many of whom are the sickest, most frail, most vulnerable of our citizens. I am here today to talk about a specific troubling aspect of this legislation, and that is what has been referred to as the ``sick tax.'' What do we mean by that? This bill includes what has come to be known as either the donut hole or the benefit shutdown. I think it is more like a black hole. Here is how that hole would develop. Seniors who sign up for this new benefit will face a gap in those benefits. Once a senior has reached $4,500 in drug spending, the Medicare prescription drug benefit evaporates, the senior falls into the black hole and gets no help with his or her prescriptions for the next $1,312.50. I know of no insurance plan that has such a gap in coverage. The Federal Employees Health Benefits Plan, which has often been touted as the model we should use for Medicare, does not have such a gap in its benefit structure. If it is not bad enough that Medicare beneficiaries will get no help from Medicare during this gap, any contributions from the senior's former employer would not count to closing that gap. In many instances, individuals were members of unions and they negotiated a collective bargaining agreement under which they understood they were going to reduce their current income in order to get other benefits that would be paid at the point of their retirement. Frequently, one of those benefits was some assistance in the payment of their prescription drugs. So they have already paid once for that benefit by not getting that raise that they had anticipated or not getting as much of a raise as they anticipated, and now they are going to be penalized a second time by not allowing those employer payments that contribute to covering the cost of prescription drugs to count toward narrowing the hole; that is, if a senior has a retiree prescription benefit, that benefit cannot be used to reach the catastrophic limit. The final insult is that during this gap--when the senior is paying 100 percent of the cost--every penny of prescription drugs purchased during this period in the black hole will be paid by the senior beneficiary. But the senior will still have to keep paying the monthly premium. This legislation suggests that is going to be $35 a month. Most people believe that number is likely to be exceeded in 2006. It certainly will be exceeded as medical and particularly prescription drug inflation takes hold in future years. The senior will have to continue to write that check every month, although they get absolutely no benefit. Let me be perfectly clear. During months in which seniors are not getting any assistance whatsoever, they will continue to pay the monthly premium. Collecting monthly premiums, while a senior has fallen into this black hole, is the equivalent of levying a tax on the sick. They are asked to pay into the program without receiving any benefit. The average Medicare beneficiary today spends a little over $2,000 a year on prescription drugs. We are talking about people who have already spent well over twice that to get to the $4,500 level. So we are talking about seniors who have significantly poorer health and, therefore, higher prescription drug costs, and that is a group of seniors we are going to discontinue from benefits until they have paid out of their pocket another $1,300-plus of prescription drug costs. Why would there be this gap in prescription drug coverage? Why do we do what no other insurance policy in America does today? Surely, none of my colleagues can believe this gap is a good insurance policy or good medicine for seniors. So let's call this gap what it is: a gimmick that is designed to lower the cost of this legislation at the expense of seniors who are most in need of the drugs. What does the gap in coverage mean for a senior? I would like to take a few minutes to spell it out so that we will know exactly what we are voting for if we approve this legislation. The gap with the black hole begins at $4,500 in total drug spending. Beneficiaries have to reach a point where their total spending--the spending of the beneficiary, the Federal Government, and any other source--reaches a level of $4,500, over twice the average Medicare beneficiary's annual prescription drug cost. Once you reach that point, you receive no assistance for your prescription drugs until you have spent out of your own pocket--not counting any contribution made by your former employer--until you have spent $3,700. How does the math work? To get to the $4,500 level, the out-of-pocket expenditures by the beneficiary will be, first, a $275 deductible. You have to pay that before you get any assistance. Incidentally, you are also paying the monthly premium during the time you are meeting that deductible requirement. Then between $275 and $4,500, you pay half, the Federal Government pays half. You would pay $2,112.50, and the Federal Government would pay $2,112.50. By the time the combined expenditures reached $4,500, you would have paid $2,387.50 out of your pocket. That is the deductible plus your coshare of prescriptions purchased. At this point, you would fall into the gap. You would receive no assistance. In order to get out of this black hole, you have to have total expenditures out of your pocket of an additional $1,312.50 beyond the $2,387.50 you have already paid. So you will have to pay a total of $3,700 before you can escape. While you are in the black hole, you are continuing every month to pay the premium for a policy for which you are getting no benefit. The sponsors of this legislation say the monthly premium is $35. However, look through the hundreds of pages of this legislation and you will not find a $35 number. It is going to be up to the private drug- only insurers to actually decide whether the premium will be $35. It could certainly be higher. Again, we have no example of this type of prescription-drug-only insurance we can point to and say: Here is how we as Federal employees have been treated, or here is how a group of public or private employees under another standard plan have been treated. The reason is that there is no example of what we are about to impose on America's older citizens. All of this talk of math and gaps may sound theoretical, but the gap will affect the lives of real human beings. Let me give one real example. There are nearly 3 million Medicare beneficiaries in my State of Florida. One of those is an 89-year-old woman by the name of Virginia. Virginia, a widow of 11 years, is nearly blind. She lives in an assisted living facility. Her income is significantly below the median income. Her monthly income is $1,535, or $18,420 on an annual basis. Virginia recently moved in with a roommate because she could no longer afford her own apartment. She could not afford last Christmas to buy her grandchildren presents. During her working years, Virginia was an editor and columnist for a smalltown newspaper. She was also a poet. Virginia is one of the many Medicare beneficiaries in dire need of a Medicare prescription drug benefit. She suffers from high blood pressure, stomach irritation, pains in her joints, anxiety disorder, osteoporosis, hypothyroidism, trouble sleeping, and difficulty with her vision. This chart lists her conditions. These are the medications that have been prescribed. This is the cost per month based on today's cost inflated by 3.6 percent per year to reach an estimated cost in the year 2006 when this plan will commence. She is spending $489.22 a month, or $5,870.64 a year, to get the drugs she needs. Each day, she needs three medicines for her blood pressure and seven others to treat her other conditions. These medicines are necessary to reduce her pain and to prevent further health complications. I would like to be able to tell Virginia the Senate is considering a bill that will give her a comprehensive, affordable Medicare prescription drug benefit. But I cannot do that. No Member of this Senate can tell its citizens, such as Virginia, that we are providing them with a comprehensive, affordable Medicare prescription drug benefit. Why? Because if this bill is approved, I will have to tell Virginia that after she has spent $275 before she gets any help to meet the deductible, then beginning on January 18, when her deductible has been met, until October 7, 2006, Virginia would expect to pay 50 percent of the cost of each prescription. This chart shows the $35 estimated monthly premium and the out-of- pocket costs Virginia would have to pay. After spending $275, she will spend another $2,112.50 for her 10 medications. Those are the blue bars on this graph. Then what happens? If this bill is approved, I would have to tell Virginia that after October 7, while the $35 premium continues at the same level, she would receive no benefit. All of these black bars are what Virginia would have to pay, 100 percent out of her pocket. She still needs all the medications on October 8 and 9, throughout the rest of the year. Her needs have not diminished. On October 7, she falls into the black hole. She would stay there until December 27. I am guessing she will not be sending any Christmas presents to her grandchildren in 2006, either. To make matters worse, I would have to tell Virginia that in addition to paying 100 percent of the cost of her prescriptions, she would still have to pay the $35 every month and get nothing in return. How do I explain to this senior in my State that she would be getting no help from the drug benefit but would still be paying the premium? She would get no help for nearly 3 months but would pay the premium anyway. Between the premiums, which are getting her nothing, and the full cost of her medicines, Virginia would have to spend 34 percent of her income to get the medications that she needs. Let me repeat that. Between the $35 a month premiums and the full cost of medicines that she would have to pay while she is in the black hole, Virginia would be spending 34 percent of her annual income on prescription drugs. I do not think Virginia will believe this is a very adequate prescription drug benefit. It is neither comprehensive nor affordable. At an absolute minimum, Virginia should not be asked to pay a monthly premium during the time that she is getting no benefit. This gap is bad medicine. The gap is a gimmick that lowers the cost of the plan but at the expense of our seniors. One of the many pieces of information we need from the Congressional Budget Office in order to make an informed judgment on this bill is the number of Medicare beneficiaries who would fall into this gap. However, like so many other aspects of this legislation, we not only do not have any practical experience, we do not have the theoretical estimates of the Congressional Budget Office. According to the administrator of the Medicare Program, CMS, 12 percent of the almost 40 million beneficiaries would fall into this black hole. I believe that number reflects the number of beneficiaries who would fall into the gap today, in June of 2003. By the time we get to 2006, however, when the bill would actually become effective, data from the Kaiser Family Foundation suggests that more than 20 percent of the beneficiaries would fall into this gap. This debate would certainly be informed by more information from the Congressional Budget Office, but in the absence of CBO numbers I will use the CMS and Kaiser numbers. If CMS is correct, nearly 5 million Medicare beneficiaries would fall into the benefit gap if the benefits were available today. If the Kaiser projections for 2006 are correct, nearly 8 million Medicare beneficiaries would fall into the black hole in the first year of this program. Eight million seniors and people with disabilities would be forced to pay a premium when they are getting absolutely no benefit in return. I do not believe we should tax those 8 million Medicare beneficiaries whose prescription drugs are high enough to place them in this black hole. In my own State of Florida, it is estimated that there will be 600,000 Medicare beneficiaries who would fall into this black hole. I do not want to go home and tell 600,000 of my constituents that instead of getting a comprehensive, affordable Medicare prescription drug benefit, they are going to get a meager benefit run by private insurance, and to top it off they will have to pay the ``sick tax'' imposed upon them when they need the benefit the most. One goal of a Medicare prescription drug benefit, which I believe is commonly shared, is that seniors will find it in their best interest to voluntarily enroll in this new program. Last week, we debated a provision that would have given greater choice to seniors. They could have elected either to stay in the plan that is now being imposed, albeit a plan that has no history of a drug-only insurance policy, or they could make an election to stay with standard Medicare fee for service. That proposal was rejected. In my judgment, that is going to suppress voluntary participation in this prescription drug program. Surely, the success of any program depends on a high participation rate. The ``sick tax'' would be an even further discouragement and could doom the program to failure. We know seniors will reject a plan that does not provide them the benefits they need. We have already seen that with the passage and then the quick rejection of catastrophic Medicare benefits in the late 1980s. People like Virginia will not enroll in a program that requires them to make a monthly payment while they get nothing in return. This amendment to suspend the payment of premiums once a beneficiary's drug utilization is within the gap in coverage would eliminate the unfair provision under which beneficiaries with high drug costs would continue to pay premiums while receiving no benefit. In summary, the amendment that is before us would say if a beneficiary is in the black hole, if they are not receiving any benefits, they would not have to pay the monthly premium. I bring to the attention of my colleagues that there has been some defense given of this legislation which says we cannot vote for any amendment which would change the basic structure of the bill; that would change, in my judgment, the unwise reliance on an unproven, drug- only insurance benefit. I want to emphasize, this does not change the structure. Rather, this removes a clear inequity but maintains the fundamentally flawed structure of this legislation. Yes, it has a cost. Again, we do not know what the cost is from CBO, but I am going to suggest an offset which will be more than adequate to pay the cost. There are some who say we cannot afford any amendments which would increase the benefits of this program. That reminds me of the old story about the child who shot his mother and his father and then threw himself at the mercy of the court because he was an orphan. The fact is, we shot a legitimate prescription drug benefit for Medicare by passing a reckless tax cut that has absorbed the resources that would have enabled us to provide a legitimate benefit. The offset that I am offering is an amendment which would secure the savings attributable to a clarification of the Medicare secondary payment provisions. For most of the history of Medicare, the assumption has been that if a person had double coverage, the primary payer would be that payer other than Medicare, and Medicare would wrap around that primary payer. A recent court opinion has reversed that assumption. There is a provision, which is included in Chairman Tauzin's House Energy and Commerce Committee mark, supported by the Justice Department, that would clarify the circumstances in which Medicare is the secondary payer. I ask unanimous consent to have printed in the Record a letter dated January 17 from the Assistant Attorney General, William E. Moschella, outlining the Department of Justice support for this offset.

Mr. GRAHAM of Florida. This amendment is endorsed by the National Committee to Preserve Social Security and Medicare. I ask unanimous consent that their letter of endorsement be printed in the Record.

Mr. GRAHAM of Florida. I urge my colleagues to join me in amending this legislation and repeal the ``sick tax.''

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Madam President, I rise in strong support of the amendment offered by the Senator from Michigan. We are about to undertake a massive social experiment. We are about to do it with the 39 million older Americans, including some of the most vulnerable and frail of our fellow citizens. Why do I say this is a massive social experiment? Because there is no example in America of a freestanding drug-only insurance policy as the means to gain access to prescription drugs. There are some very fundamental reasons why we don't do that in the Federal Employees Health Benefit Program, and why even the pharmaceutical industry doesn't do it in distributing drugs to its employees. There are two basic reasons why this is a first-of-a-kind social experiment. One is this is not an insurable risk. The example that has been frequently used is the one of fire insurance. If you are going to purchase fire insurance, you buy it on the whole house, from the bedroom to the living room, to the garage, to the kitchen. If you were to go to your insurance company and say I don't want to insure the whole house, I only want to insure the kitchen, the answer would be we won't sell you such a policy because the kitchen is the most vulnerable part of the house to actually have a fire. This is a similar proposition. Prescription drugs are the fastest growing part of the health care budget. Insurance companies don't want to sell a prescription-drug-only freestanding policy. That is seen in the structure of this bill. Essentially, although the statement is made that we are going to get better prices because of competition and the willingness of insurance agencies to assume the risk, the Federal Government is assuming virtually all the risk under this plan. Therefore, all of the expectations and representations that we are going to have competition through that lower cost is a mirage. The second reason is the fact that within health care, there are tradeoffs. As an example, just a few years ago the standard way of dealing with ulcers was surgery. Today there is almost no ulcer surgery; the standard treatment is through prescription drugs. What is the relevance of that? If you are only providing prescription drugs, if you had a freestanding prescription drug only policy, all you would have is the additional cost of prescription drugs. If you are insuring the whole body, you get the savings of avoiding surgery while you get the additional cost of providing the prescription drugs. Those are just two of the reasons there is no other example of what we are about to impose on 39 million old, many very sick, many very frail, Americans as a social experiment. If we were going to do this, I think what we ought to do is say we are going to change the Federal health insurance policy starting now and let us all be the experiment to find out whether such a freestanding prescription drug policy will work. We represent a much more diverse population--Federal employees. Many of us are younger, healthier than the Medicare population. We would be a more appropriate guinea pig for this experimentation than to focus this on the oldest and, in many cases, the most vulnerable of our people. A second concern I have about this approach is that it denies choice. Under the structure of this bill, once the elderly have made two choices, then they will not have any choice at all as it relates to prescription drugs. The first choice they make is the choice that they are making today and have made for many years in the past: Will I get my total health care coverage through traditional Medicare, the fee-for-service plan, or will I get it through some form of a managed care plan? The jury has come in and rendered its verdict on that issue. Over 85 percent of America's elderly have decided they want to get their health care through the traditional fee for service. The basic reason they want fee for service is that is the true access to choice. Under fee for service, they can decide what doctor, what hospital they wish to use. Under the various managed care plans, they frequently are restricted in their choice, and they have to use a gatekeeper in order to get to what choices are available. We have had a big debate in this Chamber, a debate I anticipate we will return to, and that is over the standards of managed care. That debate was sparked because so many people have had a negative experience with managed care, where services were denied or where they did not have access to the physician they wanted for their particular needs. This whole debate about whether there should be some Federal standards for HMOs is because of the actual real-life human experience of many Americans, including older Americans, as to how these managed care systems work. After the Americans have made the judgment as to which plan they wish to be in, then they will make a second judgment, and that is, under this prescription drug plan, do they want to take advantage of it? It is yes or no as to whether they will participate in the prescription drug plan. Once they have decided, yes, I wish to participate, then they lose their choices. If they are in the traditional care plan and if there are not two or more standalone prescription drug plans, then they will be forced to get their prescription drugs through the social experiment with a freestanding prescription drug plan. If there is only one plan where they live, they will be denied access to that single plan and they will have to get their drugs through traditional Medicare. I think that is a denial of the fundamental option and choice which has been a key part of the success of Medicare. I also think denial of choice could well be the torpedo which will sink prescription drugs. We learned a lesson about 15 years ago when we passed something called catastrophic care which the Congress thought would be received by the elderly with roses and flowers and applause. In fact, it ended up being received by the chairman of the House Ways and Means Committee having his car turned upside down, there was so much objection to that plan. I think we had better keep our cars in the garage after we pass this because we may experience the same thing, and this issue will be one of the reasons, in my judgment, that there will be less elderly participation in the prescription drugs and an increased likelihood that there will be a sufficient revolt that we will be forced, as were our predecessors, to repeal what we thought was going to be a very popular plan. This prescription drug architecture only works if a very high percentage of the elderly sign up to participate. If the only ones who sign up are those who are already sick and using high levels of prescription drugs, this plan will crater as being actuarially unsustainable. If it is to attract enough of the elderly who are not sick and do not have high drug bills, who will see this as a true insurance policy--that is, that they are purchasing this plan not just based on their current prescription drug costs but because they believe they may someday become ill, sicker than they are today, and get into this category of high cost--we must be able to attract that group of the elderly in order to make this plan sustainable. I think one of the reasons the relatively healthy elderly will resist joining this is precisely this issue of the denial of choice. If I am an elderly person and I live in a rural area of Florida where only one prescription drug plan is available, why shouldn't I be able to elect that one prescription drug plan or traditional Medicare? If, on the other hand, I am in an urban area where there are 20 freestanding plans, although I think this is a highly unlikely prospect, why shouldn't I be allowed to elect one of the prescription drug plans or traditional Medicare? Why? What is the rationale of us denying the elderly that important choice when there is no evidence that the standalone plans are going to actually save money? This bill itself is the best evidence of its unlikelihood of doing so since the Federal Government is picking up most of the risk that the standalone plans will, of their necessity, entail and while we are denying choice to elderly as to which of the various options they want to utilize. I cannot conceive of why we are saying to America's elderly that they will be denied the choice how they want to get their prescription drugs, particularly when they have spoken so overwhelmingly of their desire to stay in traditional fee-for-service Medicare for the rest of their benefits. So for those who favor the approach we are taking, they ought to be the strongest voices for the Stabenow amendment because it is one of the key steps in assuring that this plan will be positively received by Medicare beneficiaries and will actually work once it is in place. I urge all of my colleagues, those who favor the basic principles of this plan and those who have reservations, to vote for this amendment because it is fundamental to achieving the results that are being sought, a broadly participated in prescription drug plan which is sufficiently attractive, including attractive through choice, for America's older citizens.

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Madam President, today I introduce legislation that would take one more step toward finding answers for veterans who may have been exposed to radiation, Agent Orange, or other hazards during their military service. The last century saw the nature of war change forever. When mustard gas drifted across the trenches of World War I, troops learned that dangers less tangible, but no less deadly, than bullets might fill the air. Since then, many veterans have questioned whether health effects of the environmental hazards that they faced on and off the battlefield might appear years or even decades later. Congress, VA, the military, and scores of independent researchers have struggled to answer those questions. Many veterans still wait for scientific evidence to fill the gaps. However, research in some areas has linked specific exposures to a risk of later disease, and we must respond to those new findings and encourage further investigation. Peer-reviewed studies published in recent years suggest that veterans held prisoner during World War II, the Korean War, and in Vietnam suffer from some chronic diseases at a higher rate than expected. Scientists now report that the toll taken by malnutrition, long periods of forced confinement, and untreated infections appears to pose a lifelong risk. Based on these findings, I have introduced legislation that would add heart disease, strokes, and chronic liver diseases to the list of diseases that can be presumptively connected to service for certain former prisoners of war. This would allow eligible veterans with these conditions to seek VA benefits without having to prove that their illnesses resulted from deprivations suffered during captivity. Other veterans who were exposed to large doses of ionizing radiation in post-war Japan or during nuclear tests, and who suffer from illnesses thought to be caused by radiation, can currently claim eligibility for VA benefits. However, some veterans who believe they received high doses of radiation have been frustrated to find that their military records do not reflect the same assumptions. Congress mandated nearly 20 years ago that veterans who suffer from diseases that they suspect might be linked to radiation exposure during service could request a dose reconstruction, or a scientific estimate of past exposure levels, to remedy this. Many veterans felt that this method fell short of expectations, and Congress responded in 1998 by requiring an independent review of the Dose Reconstruction Program conducted by the Department of Defense. A panel of experts convened by the National Academy of Sciences reported recently that this contractor-operated program suffered from a shockingly cavalier approach to quality assurance, resulting in data that failed to meet the standards assumed by VA and veterans. This is not acceptable. Provisions introduced here would require the Secretaries of VA and Defense to establish permanent independent oversight of the Dose Reconstruction Program, and to create an advisory board to improve the program as necessary. Our understanding of the consequences of exposure to the herbicides and dioxin in Agent Orange remains far from complete. It has been almost 25 years since Congress required the Air Force to conduct an epidemiologic study of the veterans of Operation Ranch Hand, the unit responsible for aerial spraying of herbicides during the Vietnam War. The last scheduled round of physical examinations took place just last month, and the fate of the millions of medical records and specimens remains undecided. Experts agree that both samples and data should be preserved for further research, but do not share an opinion on the best way to do so. The bill that I have introduced would task the National Academy of Sciences to develop research recommendations for extending the Air Force Health Study, or for preserving the samples and making them accessible to independent researchers as requested by many veterans' organizations. Finally, the legislation that I have introduced would ensure that the scientific body charged with tracking veterans' and military health can continue its mission. The Medical Follow-Up Agency, MFUA, a board of the Institute of Medicine--the health agency of the National Academy of Sciences--was created at the end of World War II at the urging of the Army Surgeon General. For many years, it received funding only sporadically. In 1988, the now-defunct Office of Technology Assessment reported that MFUA's critical contribution to understanding military health issues was limited by a lack of consistent funding, which caused high staff turnover, incohesiveness in the research portfolio, and failure to maintain records. Congress responded with Public Law 102-585, which required that VA and the military each contribute $250,000 in annual core funding to MFUA for 10 years. MFUA's staff uses this funding to update, maintain, and improve long-term epidemiological studies of military and veterans populations. Congress, VA, the military, and independent scientists have relied on these studies to evaluate whether specific exposures might have long-term health effects that suggest a need for benefits, new treatments, or further research. The legislation that I have introduced would extend MFUA's core funding for 10 more years. This legislation would demonstrate to those who serve their nation now that our commitment to them will not end with the wars that they fight. We must continue to seek remedies for the sometimes invisible wounds of the new battlefield, and ensure that those who have borne them receive the support that they need. I urge my colleagues in the Senate to join me in supporting this legislation. I ask unanimous consent that the text of the bill be printed in the Record.

Mr. GRAHAM of Florida. Madam President, the Department of Veterans Affairs, VA, is in the midst of determining how best to serve the millions of veterans who turn to the VA health care system for their care. This process--known as CARES or Capital Asset Realignment for Enhanced Services--will likely bring significant change to the VA system. Recommendations stemming from this process could lead to billions of dollars in new facilities construction, on the one hand, and possible closure of facilities and thousands of beds, on the other. Despite the magnitude of these possible changes, Congress has virtually no formal role in the process. I introduce legislation today that would allow for Congressional review of the CARES recommendations that the Secretary of VA will begin to implement at the end of this year. The CARES initiative has been ongoing since the Fall of 2002, tasking VA facilities with developing recommendations based on a review of population data; the conduct of market analyses of veterans' health care needs; the identification of planning initiatives for each market area; and most important, the significant involvement of stakeholders, including myriad public meetings. These so-called planning initiatives are ultimately slated to be passed on to the Secretary, who will then make the final decisions. While an independent review led by a national CARES Commission is already planned, in addition to public hearings--which I fully support--I must reiterate that Congress has little, if any, role in the CARES effort outside of construction authorization and appropriation activities. Yet, all states and most health care facilities will be affected by the results. The legislation I introduce today would give Congress a 60-day period to review the CARES recommendations submitted by the Secretary of Veterans Affairs. During that time, VA would be prohibited from moving forward with any bed or facility closures. This oversight is absolutely essential--particularly in light of recent events. Just last month, all VA health care networks submitted their plans to VA headquarters. These plans were developed following substantial analysis and thorough stakeholder involvement. While abiding by the criteria and process set forth by VA, facilities made their recommendations to the Under Secretary for Health. In a surprise move and an apparent manipulation of the process, VA instructed the network directors to re-evaluate the plans they had already submitted for 20 different VA facilities. They were told to ``evaluate a strategy to convert from a 24-hour operation to an 8 hour a day operation. This includes any inpatient care, including long term care.'' One of these hospitals is in Lake City, in my home State of Florida. Network 8, which has responsibility for Lake City, had previously recommended that no long-term care beds be deactivated at this facility, yet they were told to go back to the drawing board to develop a strategy to close nursing home beds there. Another facility tasked with re-examining their plan is Bedford, Massachusetts. In their network's plan, submitted to the Under Secretary, officials stated that they had in fact considered ``alternatives to consolidate Long Term Care, LTC, including the Alzheimer's and SCI Units, and Psychiatry inpatient beds from the Bedford to Brockton facilities'' yet, ``as final projections are not available for LTC inpatient beds and earlier projections indicated a substantial increase in LTC beds, it was determined to utilize current capacities.'' Despite these assessments to the contrary, VA has asked that they instead plan to convert these facilities to outpatient operations only. Yet one more example of this apparent manipulation involves another facility now slated for bed closures, the Leavenworth VA Medical Center in Kansas. The network plan concluded that ``[r]ealignment of workload from Leavenworth to Kansas City would exceed current capacity. . . . Elimination of inpatient and outpatient primary care capabilities at Leavenworth would seriously undermine continuity of care for the remaining long-term care patients, reduce timely access to care, hinder its ability to provide ongoing support to the DoD facility located at Ft. Leavenworth . . . '' . Again, analysis conducted at the regional level resulted in a recommendation that VA is now directing be reconsidered. The VA facility in Knoxville, IA, is being targeted for significant changes as well. The current proposal is to move all of the beds from Knoxville to Des Moines. The Knoxville facility has more than 226 long- term care beds, 40 domiciliary beds, and 34 inpatient psychiatric beds. We need to take a look at this proposal and the many others that will affect veterans all across the country. Other facilities asked to re-evaluate are: Batavia, Lyons, St. Albans, Montrose, Pittsburgh at Highland Drive, Augusta, Dublin, Lexington, Brecksville, Gulfport, Marlin/Waco, Vancouver, Livermore, and Hot Springs. While VA intends to present a five-year capital plan to Congress, there is nothing that requires VA to inform Members about possible reductions, closures, and other decisions that would have a deleterious effect on VA health care services and our veterans. This is unacceptable. Congress' role should not be limited to merely funding the implementation of these decisions; rather, we should be involved in a process that could result in the significant loss of inpatient, long- term care, and domiciliary capacity at VA health care facilities nationwide. We can rectify this problem very easily, however, by enacting the legislation I propose today. In an internal VA memo, Secretary Principi stated that ``the CARES process may be one of the most important activities undertaken by VA this decade. The outcome of this process will construct the foundation for, and set the course of, our health care system for the first half of the 21st century.'' In light of the great impact of this initiative on VA health care services, as well as recent actions that threaten the integrity of the process, it is imperative that Congress be granted a mere 60 days to review VA's proposals. I urge my colleagues to join me in this effort to secure the future of health care for our nation's veterans. I ask unanimous consent that the text of the bill be printed in the Record.

Mr. GRAHAM of Florida. Madam President, I rise today to introduce legislation that will ensure that America's veterans and their families have access to the funeral honors they have earned. The brave men and women who fought for our Nation are a population that is aging rapidly. In 2002, America lost 646,264 veterans. Projections show that this rate will continue to climb through the year 2008, when the annual death of the World War II and Korea-era veterans will peak at 700,000. By the end of 2004, only 64 of the 124 veterans national cemeteries will be available for both casketed and cremated remains. As cemetery service capabilities decrease, veterans in areas near those cemeteries that are at capacity may lose access to burial options located within a reasonable distance of their homes. In order to ensure that burial options are provided for veterans and their family members, we must develop new cemeteries and expand existing cemeteries. This process must start as soon as possible because the construction of a new cemetery takes an average of 7 years. That is why I offer this bill today, which would authorize the construction of ten new national cemeteries and ensure that the burial needs of veterans and their family members will be met in the future. In anticipation of veterans' future needs, the Department of Veterans Affairs conducted a study that identifies veteran population centers not served by an open national or state veterans cemetery. The report, ``Future Burial Needs,'' was initially released in May 2002 and has been recently revised using veteran population estimates from the 2000 census. My legislation would direct the Department of Veterans Affairs to establish ten new national veterans cemeteries in the top ten areas identified to be in the greatest need. These areas would include Sarasota, FL, Salem, OR, Birmingham, AL, St. Louis, MO, San Antonio, TX, Chesapeake, VA, Sumter, FL, Bakersfield, CA, Jacksonville, FL, and Philadelphia, PA. We can not afford to wait any longer if we are to fulfill this commitment to our nation's veterans. Mr. President, I am proud to sponsor this important bill, and look forward to the support of my colleagues as we provide for our veterans who have given so much for our country. Thank you. I ask unanimous consent that the text of this bill be printed in the Record.

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Madam President, today I introduce legislation that would take one more step toward finding answers for veterans who may have been exposed to radiation, Agent Orange, or other hazards during their military service. The last century saw the nature of war change forever. When mustard gas drifted across the trenches of World War I, troops learned that dangers less tangible, but no less deadly, than bullets might fill the air. Since then, many veterans have questioned whether health effects of the environmental hazards that they faced on and off the battlefield might appear years or even decades later. Congress, VA, the military, and scores of independent researchers have struggled to answer those questions. Many veterans still wait for scientific evidence to fill the gaps. However, research in some areas has linked specific exposures to a risk of later disease, and we must respond to those new findings and encourage further investigation. Peer-reviewed studies published in recent years suggest that veterans held prisoner during World War II, the Korean War, and in Vietnam suffer from some chronic diseases at a higher rate than expected. Scientists now report that the toll taken by malnutrition, long periods of forced confinement, and untreated infections appears to pose a lifelong risk. Based on these findings, I have introduced legislation that would add heart disease, strokes, and chronic liver diseases to the list of diseases that can be presumptively connected to service for certain former prisoners of war. This would allow eligible veterans with these conditions to seek VA benefits without having to prove that their illnesses resulted from deprivations suffered during captivity. Other veterans who were exposed to large doses of ionizing radiation in post-war Japan or during nuclear tests, and who suffer from illnesses thought to be caused by radiation, can currently claim eligibility for VA benefits. However, some veterans who believe they received high doses of radiation have been frustrated to find that their military records do not reflect the same assumptions. Congress mandated nearly 20 years ago that veterans who suffer from diseases that they suspect might be linked to radiation exposure during service could request a dose reconstruction, or a scientific estimate of past exposure levels, to remedy this. Many veterans felt that this method fell short of expectations, and Congress responded in 1998 by requiring an independent review of the Dose Reconstruction Program conducted by the Department of Defense. A panel of experts convened by the National Academy of Sciences reported recently that this contractor-operated program suffered from a shockingly cavalier approach to quality assurance, resulting in data that failed to meet the standards assumed by VA and veterans. This is not acceptable. Provisions introduced here would require the Secretaries of VA and Defense to establish permanent independent oversight of the Dose Reconstruction Program, and to create an advisory board to improve the program as necessary. Our understanding of the consequences of exposure to the herbicides and dioxin in Agent Orange remains far from complete. It has been almost 25 years since Congress required the Air Force to conduct an epidemiologic study of the veterans of Operation Ranch Hand, the unit responsible for aerial spraying of herbicides during the Vietnam War. The last scheduled round of physical examinations took place just last month, and the fate of the millions of medical records and specimens remains undecided. Experts agree that both samples and data should be preserved for further research, but do not share an opinion on the best way to do so. The bill that I have introduced would task the National Academy of Sciences to develop research recommendations for extending the Air Force Health Study, or for preserving the samples and making them accessible to independent researchers as requested by many veterans' organizations. Finally, the legislation that I have introduced would ensure that the scientific body charged with tracking veterans' and military health can continue its mission. The Medical Follow-Up Agency, MFUA, a board of the Institute of Medicine--the health agency of the National Academy of Sciences--was created at the end of World War II at the urging of the Army Surgeon General. For many years, it received funding only sporadically. In 1988, the now-defunct Office of Technology Assessment reported that MFUA's critical contribution to understanding military health issues was limited by a lack of consistent funding, which caused high staff turnover, incohesiveness in the research portfolio, and failure to maintain records. Congress responded with Public Law 102-585, which required that VA and the military each contribute $250,000 in annual core funding to MFUA for 10 years. MFUA's staff uses this funding to update, maintain, and improve long-term epidemiological studies of military and veterans populations. Congress, VA, the military, and independent scientists have relied on these studies to evaluate whether specific exposures might have long-term health effects that suggest a need for benefits, new treatments, or further research. The legislation that I have introduced would extend MFUA's core funding for 10 more years. This legislation would demonstrate to those who serve their nation now that our commitment to them will not end with the wars that they fight. We must continue to seek remedies for the sometimes invisible wounds of the new battlefield, and ensure that those who have borne them receive the support that they need. I urge my colleagues in the Senate to join me in supporting this legislation. I ask unanimous consent that the text of the bill be printed in the Record.

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Madam President, the Department of Veterans Affairs, VA, is in the midst of determining how best to serve the millions of veterans who turn to the VA health care system for their care. This process--known as CARES or Capital Asset Realignment for Enhanced Services--will likely bring significant change to the VA system. Recommendations stemming from this process could lead to billions of dollars in new facilities construction, on the one hand, and possible closure of facilities and thousands of beds, on the other. Despite the magnitude of these possible changes, Congress has virtually no formal role in the process. I introduce legislation today that would allow for Congressional review of the CARES recommendations that the Secretary of VA will begin to implement at the end of this year. The CARES initiative has been ongoing since the Fall of 2002, tasking VA facilities with developing recommendations based on a review of population data; the conduct of market analyses of veterans' health care needs; the identification of planning initiatives for each market area; and most important, the significant involvement of stakeholders, including myriad public meetings. These so-called planning initiatives are ultimately slated to be passed on to the Secretary, who will then make the final decisions. While an independent review led by a national CARES Commission is already planned, in addition to public hearings--which I fully support--I must reiterate that Congress has little, if any, role in the CARES effort outside of construction authorization and appropriation activities. Yet, all states and most health care facilities will be affected by the results. The legislation I introduce today would give Congress a 60-day period to review the CARES recommendations submitted by the Secretary of Veterans Affairs. During that time, VA would be prohibited from moving forward with any bed or facility closures. This oversight is absolutely essential--particularly in light of recent events. Just last month, all VA health care networks submitted their plans to VA headquarters. These plans were developed following substantial analysis and thorough stakeholder involvement. While abiding by the criteria and process set forth by VA, facilities made their recommendations to the Under Secretary for Health. In a surprise move and an apparent manipulation of the process, VA instructed the network directors to re-evaluate the plans they had already submitted for 20 different VA facilities. They were told to ``evaluate a strategy to convert from a 24-hour operation to an 8 hour a day operation. This includes any inpatient care, including long term care.'' One of these hospitals is in Lake City, in my home State of Florida. Network 8, which has responsibility for Lake City, had previously recommended that no long-term care beds be deactivated at this facility, yet they were told to go back to the drawing board to develop a strategy to close nursing home beds there. Another facility tasked with re-examining their plan is Bedford, Massachusetts. In their network's plan, submitted to the Under Secretary, officials stated that they had in fact considered ``alternatives to consolidate Long Term Care, LTC, including the Alzheimer's and SCI Units, and Psychiatry inpatient beds from the Bedford to Brockton facilities'' yet, ``as final projections are not available for LTC inpatient beds and earlier projections indicated a substantial increase in LTC beds, it was determined to utilize current capacities.'' Despite these assessments to the contrary, VA has asked that they instead plan to convert these facilities to outpatient operations only. Yet one more example of this apparent manipulation involves another facility now slated for bed closures, the Leavenworth VA Medical Center in Kansas. The network plan concluded that ``[r]ealignment of workload from Leavenworth to Kansas City would exceed current capacity. . . . Elimination of inpatient and outpatient primary care capabilities at Leavenworth would seriously undermine continuity of care for the remaining long-term care patients, reduce timely access to care, hinder its ability to provide ongoing support to the DoD facility located at Ft. Leavenworth . . . '' . Again, analysis conducted at the regional level resulted in a recommendation that VA is now directing be reconsidered. The VA facility in Knoxville, IA, is being targeted for significant changes as well. The current proposal is to move all of the beds from Knoxville to Des Moines. The Knoxville facility has more than 226 long- term care beds, 40 domiciliary beds, and 34 inpatient psychiatric beds. We need to take a look at this proposal and the many others that will affect veterans all across the country. Other facilities asked to re-evaluate are: Batavia, Lyons, St. Albans, Montrose, Pittsburgh at Highland Drive, Augusta, Dublin, Lexington, Brecksville, Gulfport, Marlin/Waco, Vancouver, Livermore, and Hot Springs. While VA intends to present a five-year capital plan to Congress, there is nothing that requires VA to inform Members about possible reductions, closures, and other decisions that would have a deleterious effect on VA health care services and our veterans. This is unacceptable. Congress' role should not be limited to merely funding the implementation of these decisions; rather, we should be involved in a process that could result in the significant loss of inpatient, long- term care, and domiciliary capacity at VA health care facilities nationwide. We can rectify this problem very easily, however, by enacting the legislation I propose today. In an internal VA memo, Secretary Principi stated that ``the CARES process may be one of the most important activities undertaken by VA this decade. The outcome of this process will construct the foundation for, and set the course of, our health care system for the first half of the 21st century.'' In light of the great impact of this initiative on VA health care services, as well as recent actions that threaten the integrity of the process, it is imperative that Congress be granted a mere 60 days to review VA's proposals. I urge my colleagues to join me in this effort to secure the future of health care for our nation's veterans. I ask unanimous consent that the text of the bill be printed in the Record.

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Madam President, I rise today to introduce legislation that will ensure that America's veterans and their families have access to the funeral honors they have earned. The brave men and women who fought for our Nation are a population that is aging rapidly. In 2002, America lost 646,264 veterans. Projections show that this rate will continue to climb through the year 2008, when the annual death of the World War II and Korea-era veterans will peak at 700,000. By the end of 2004, only 64 of the 124 veterans national cemeteries will be available for both casketed and cremated remains. As cemetery service capabilities decrease, veterans in areas near those cemeteries that are at capacity may lose access to burial options located within a reasonable distance of their homes. In order to ensure that burial options are provided for veterans and their family members, we must develop new cemeteries and expand existing cemeteries. This process must start as soon as possible because the construction of a new cemetery takes an average of 7 years. That is why I offer this bill today, which would authorize the construction of ten new national cemeteries and ensure that the burial needs of veterans and their family members will be met in the future. In anticipation of veterans' future needs, the Department of Veterans Affairs conducted a study that identifies veteran population centers not served by an open national or state veterans cemetery. The report, ``Future Burial Needs,'' was initially released in May 2002 and has been recently revised using veteran population estimates from the 2000 census. My legislation would direct the Department of Veterans Affairs to establish ten new national veterans cemeteries in the top ten areas identified to be in the greatest need. These areas would include Sarasota, FL, Salem, OR, Birmingham, AL, St. Louis, MO, San Antonio, TX, Chesapeake, VA, Sumter, FL, Bakersfield, CA, Jacksonville, FL, and Philadelphia, PA. We can not afford to wait any longer if we are to fulfill this commitment to our nation's veterans. Mr. President, I am proud to sponsor this important bill, and look forward to the support of my colleagues as we provide for our veterans who have given so much for our country. Thank you. I ask unanimous consent that the text of this bill be printed in the Record.

Mr. GRAHAM of Florida

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

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

Mr. GRAHAM of Florida. Mr. President, the amendment I have just offered will strike section 105 from the legislation we are currently considering. This amendment is cosponsored by a long and diverse list of Senators: Senators Feinstein, Dole, Cantwell, Wyden, Nelson of Florida, Boxer, Lautenberg, Edwards, Kerry, Murray, Lieberman, Akaka, Leahy, Snowe, Dodd, Chafee, Kennedy, Corzine, and Collins. In this legislation, section 105 appears to be benign. It calls for an inventory of Outer Continental Shelf oil and gas resources that may be in the ownership of the Federal Government. However, there are some insidious objectives and means to achieve those objectives in this legislation. In my judgment, section 105 is nothing more than a prelude to a direct attack on the moratorium which currently exists in the Gulf of Mexico, off New England, the Pacific Northwest, and California, and to do so in a way that will avoid a full and public debate. The OCS inventory, which is suggested in section 105, is neither benign nor innocuous. It will provide for a totally duplicative survey to one that is already conducted by the same office that would be directed to do the study under section 105, which is the U.S. Department of the Interior Minerals Management Service. This is the front page of the latest of the 5-year reports, which the Mineral Management Service does on U.S. resources and reserves in the Outer Continental Shelf. As you will see, this latest assessment was done in the year 2000. So it has been only 3 years since we had a comprehensive analysis. In light of that, why would we oppose this new study? We would oppose the new study because we think it is duplicative and redundant. We oppose it because it would allow certain techniques, which have previously not been used but which have been shown to be detrimental to the resources of the Outer Continental Shelf, including the fish resources, to be utilized. But, in my judgment, the most insidious aspect is a provision in section 105 which states that after the inventory is completed it should be used as the purpose of analysis of the Outer Continental Shelf. Let me read to you subparagraph 5 under section 105: The inventory and analysis shall identify and explain how legislative, regulatory, and administrative programs or processes restrict or impede the development of identified resources and the extent that they may affect domestic supply, such as moratoria, lease terms and conditions, operational stipulations and requirements, approval delays by the Federal Government and coastal States, and local zoning restrictions on onshore processing facilities, and pipeline landings. I think that language is clearly intended to take the results of this newly mandated inventory and use them as the basis, focusing exclusively on the issue of affecting domestic supply, to build the case that the moratoria, which California and other coastal States have had now for 20 years, would be undermined. That moratoria has been voted on by Congress on many occasions in recognition of the fact that, first, there are other interests involved beyond maximizing the exploitation of our Continental Shelf oil and gas resources. There are issues of the environment and there are issues of the economy, which are dependent upon the environment--particularly, the purity of the water and the security of the coastal areas. Second is the fact that it does not take into consideration the question of we want to have a domestic supply of oil and gas, but for what time period? If we were to initiate a policy that says we will drain America first, we can rest assured that our grandchildren, if not our children, will live in an America that will be totally dependent upon foreign petroleum sources. The estimate is that, as of today, we have known reserves of petroleum which, at current levels of utilization, will last approximately 50 years. We have much longer reserves of natural gas, stretching into the 200-year-plus estimate. I think it is eminently wise public policy to say we will try to husband our domestic resources as long as possible to delay the date when we will be fully dependent upon foreign resources. This practice of providing moratoria on certain of our resources plays a significant positive role in that policy of attempting to stretch our domestic resources. As the list of cosponsors indicates, this is by no means a partisan issue. The moratoria have broad bipartisan support, and have had it for over 20 years. This is also not an issue that is bicameral. The House of Representatives has already adopted an Energy bill, stripping out language that was virtually verbatim to that which is in 105 of the Senate bill. Our desire is to have the Senate take the same position that our House colleagues have already taken, so when this issue is taken up in conference, the issue of an inventory that has as its objective undermining the moratoria will not be a conferenceable item. I believe our colleagues in the House have shown wisdom in the course of action they have taken, and I ask my Senate colleagues to show the same wisdom by eliminating section 105. I urge my colleagues to vote in favor of this amendment, which will adopt or reinforce a policy where we look at multiple issues in the management of our coastal areas, including the issue of exploitation of the resources but also the potential effect of that exploitation on other economic and environmental considerations; that we also recognize the valid function of those adjacent State and local communities and how this issue would be resolved, and the legitimacy of the Federal Government's Coastal Zone Management Act as the means by which those interests would be expressed. For all those reasons, I urge my colleagues to adopt this amendment and strike section 105 from this bill, and then with the joy that we will know that we have taken a step to protect some of our most critical ocean resources, move on to the consideration of other provisions in this legislation.

Mr. GRAHAM of Florida. The Senator from New Mexico said ``in relation to.'' That would not preclude the possibility of an up-or-down vote as opposed to a tabling motion?

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Mr. President, I ask unanimous consent that Mindy Yergin, an intern in my office, be granted floor privileges for the remainder of the consideration of this legislation.

Mr. GRAHAM of Florida

Mr. GRAHAM of Florida. Mr. President, I rise to observe the significance of Memorial Day--and to pay tribute to the Americans we honor on this day. Three days from now, we will, as a nation, remember those who lost their lives in service to our country. They secured our freedom with the most precious gifts they could offer--their love for this country and their lives. America has honored its fallen soldiers with a Memorial Day, sometimes called Decoration Day, since the Civil War. Though we are grateful to these heroes every day of the year, we recognized that we ought to set aside one day in particular, the last Monday in May, to be especially mindful of the brave men and women who paid the ultimate price for our freedom. At a time when our Nation mourns more sons and daughters than it did just a year ago, many of whom came from my State of Florida, this Memorial Day takes on additional poignancy. My heart is full of solemn gratitude to each new generation willing to risk their lives for the security of strangers. We cannot merely make promises on this earnest occasion. We must reaffirm our commitment to the veteran soldiers still with us. We must provide full funding for veterans health care. At this moment in our Nation's history, how can we possibly justify anything but a significant increase in VA's health care budget? Not only have we been engaged in a war overseas, but, just this year, VA cut off enrollment to an entire category of veterans. During a time when 240,000 veterans nationwide--44,000 in my home State of Florida alone--are being told they have to wait 6 months or longer just to see a doctor, how can we possibly turn our backs on these men and women? These veterans have come to VA seeking care--care we promised them they would get--and we owe it to them to fulfill that promise. Memorial Day has a duality--at once provoking feelings of both somber meditation for those we have lost in battle and the joyous anticipation of celebrating with family and friends during a holiday weekend. Both reactions are fitting to the memories of those who are no longer with us--we remember and revere their service, and we honor what their sacrifice has brought us--the freedom to be with the people we love and hold dear. As we and other citizens of this country prepare to enjoy the long weekend, let us take a moment to thank those who gave us a future, at the expense of their own.