Tom Harkin

Mr. HARKIN

Mr. HARKIN. As soon as the vote is over, I assume the floor would be open for further amendments and debate. Is that affirmative?

Mr. HARKIN. Return to the Ashcroft amendment?

Mr. HARKIN. So the floor would be open at that time. I thank the Chair. Thank you.

Mr. HARKIN. Is there a limited amount of time on that amendment?

Mr. HARKIN

Mr. HARKIN. Mr. President, it is not a long amendment. That is why I wanted it read. It is very straightforward. It will be my intention to just speak for a few minutes on the amendment, and then I will withdraw the amendment. After seeing how all of the amendments seem to be faring here, it seemed ridiculous to waste any more time of the Senate to be voting on these amendments. I feel strongly about this aspect of going into NATO enlargement. More than anything else, I want to explain the purpose of my amendment and lay down a marker regarding an issue that I know concerns all of us here and which could have very severe repercussions in an expanded NATO. That is the issue of the nonproliferation treaty of which the United States is a signatory and, of course, an issue that we have pushed very hard. Many of us have spoken many times about the importance of not slowing down international arms control and nonproliferation efforts. This amendment is simply a sense of the Senate regarding NATO's relationship to the Nuclear Non-Proliferation Treaty, or NPT, and urges that the President should propose that NATO examine the compatibility-- Mr. President, could I have order? I have trouble hearing myself.

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

Mr. HARKIN

Mr. HARKIN. As former U.S. Ambassador to Russia, Jack Matlock warned: We're going to have a dilemma that we either encourage them--new NATO members--to divert resources they don't have or we end up fooling the American people about what it's going to cost them. That is what this amendment is about, not fooling the American people. My amendment does two things. It requires a full accounting of all U.S. contributions, all for NATO expansion by including the U.S. contributions to the national governments when calculating the U.S. share of enlargement costs. Right now, we are limited to 25 percent for the common costs. That does not take into account the national costs. What I am saying with this amendment is, sure, we will provide our fair share, but why should we do more than 25 percent. And please do not fall for the argument that we could not have done this for Greece and others in the past. The cold war is over. Europe is rich. These countries have money. We should not just stick U.S. taxpayers with the total bill.

Mr. HARKIN. I ask for the yeas and nays.

Mr. HARKIN

Mr. HARKIN. Mr. President, I am pleased to join today with my distinguished colleague, Senator Susan Collins, in the introduction of the ``Medicare Home Health Equity Act of 1998.'' This bill tries to fix what we believe to be an unintended injustice in the Balanced Budget Act of 1997. As many of you know, home health agencies have historically been reimbursed on the basis of costs. The Health Care Financing Administration paid each agency to cover the cost of providing care. This arrangement has been widely criticized because of offers no incentive for agencies to control their costs. In order to correct this, we in Congress agreed that Medicare should move to a prospective payment system to control costs and ensure quality and access to care. The Balanced Budget Act establishes this system for home health, effective as of October 1, 1999. In the mean time, an interim payment system has been put in place. These changes were needed in order to rein in the incredible growth--some due to inappropriate payments--in the industry in the last seven years. In 1990, Medicare spent $3.7 billion on home health care. In 1996, $16.7 billion was spent. In addition, the average number of visits per beneficiary soared from 26 in 1990 to 76 in 1996. I believe the change to the prospective payment system had to be done. However, the interim payment system will reward high-cost, inefficient home health provides at the expense of those home health agencies that have historically kept their costs low. I don't believe this was the intent of Congress, and that is why I am cosponsoring Senator Collins' bill to correct this injustice. As co-chair of the Senate Rural Health Caucus, I've been working for a long time to change the big city, urban bias in Medicare's reimbursement payments. It penalizes more conservative cost-effective approaches to health care, and that hurts rural areas like Iowa. We went a long way towards fixing that bias in Balanced Budget Act by equalizing Medicare's reimbursement payments for managed care services. But unbeknownst to me and, I believe, most of my colleagues, while we provided rural equity in one area, we took it away in another. It is just common sense that we should reward those who provide quality care in a cost-effective, efficient manner. We did this when we changed the Medicare managed care rates. It doesn't seem right that in the same Act, we created an interim payment system for home health services that rewards the high cost, wasteful agencies and leaves those that have successfully kept their costs low struggling to survive. The system's reliance on a provider's historical costs in determining their reimbursement amounts has produced an uneven playing field. Many of the newer agencies, who got started during a period of high growth, now have a competitive advantage. They will now be reimbursed at a higher rate than their lower cost competitors. Senator Collins' bill does the right thing--it rewards those agencies who have done the most to save Medicare money. These include many visiting nurse associations, non-profit free standing agencies and most non-profit hospital based programs. The Home Health Equity Act will revise the current system of reimbursement based on 75 percent of agency cost blended with 25 percent of national costs. The legislation would create a 75 percent national rate blended with 25 percent regional rate to level payments to providers in a given geographic area. In addition, this bill continues the cost savings that the interim payment system was intended to achieve. Price Waterhouse has analyzed the bill and found it to be budget neutral. If we don't fix the interim payment system, I am afraid we risk a reduction in access to and quality of health care for Iowa seniors. Iowa home health care agencies have historically provided efficient, quality service and they ought to be rewarded, not punished for this. Most importantly, rural patients and their families deserve continued access to the best possible care.

Mr. HARKIN

Mr. HARKIN. Mr. President, I am pleased to join today with my distinguished colleague, Senator Susan Collins, in the introduction of the ``Medicare Home Health Equity Act of 1998.'' This bill tries to fix what we believe to be an unintended injustice in the Balanced Budget Act of 1997. As many of you know, home health agencies have historically been reimbursed on the basis of costs. The Health Care Financing Administration paid each agency to cover the cost of providing care. This arrangement has been widely criticized because of offers no incentive for agencies to control their costs. In order to correct this, we in Congress agreed that Medicare should move to a prospective payment system to control costs and ensure quality and access to care. The Balanced Budget Act establishes this system for home health, effective as of October 1, 1999. In the mean time, an interim payment system has been put in place. These changes were needed in order to rein in the incredible growth--some due to inappropriate payments--in the industry in the last seven years. In 1990, Medicare spent $3.7 billion on home health care. In 1996, $16.7 billion was spent. In addition, the average number of visits per beneficiary soared from 26 in 1990 to 76 in 1996. I believe the change to the prospective payment system had to be done. However, the interim payment system will reward high-cost, inefficient home health provides at the expense of those home health agencies that have historically kept their costs low. I don't believe this was the intent of Congress, and that is why I am cosponsoring Senator Collins' bill to correct this injustice. As co-chair of the Senate Rural Health Caucus, I've been working for a long time to change the big city, urban bias in Medicare's reimbursement payments. It penalizes more conservative cost-effective approaches to health care, and that hurts rural areas like Iowa. We went a long way towards fixing that bias in Balanced Budget Act by equalizing Medicare's reimbursement payments for managed care services. But unbeknownst to me and, I believe, most of my colleagues, while we provided rural equity in one area, we took it away in another. It is just common sense that we should reward those who provide quality care in a cost-effective, efficient manner. We did this when we changed the Medicare managed care rates. It doesn't seem right that in the same Act, we created an interim payment system for home health services that rewards the high cost, wasteful agencies and leaves those that have successfully kept their costs low struggling to survive. The system's reliance on a provider's historical costs in determining their reimbursement amounts has produced an uneven playing field. Many of the newer agencies, who got started during a period of high growth, now have a competitive advantage. They will now be reimbursed at a higher rate than their lower cost competitors. Senator Collins' bill does the right thing--it rewards those agencies who have done the most to save Medicare money. These include many visiting nurse associations, non-profit free standing agencies and most non-profit hospital based programs. The Home Health Equity Act will revise the current system of reimbursement based on 75 percent of agency cost blended with 25 percent of national costs. The legislation would create a 75 percent national rate blended with 25 percent regional rate to level payments to providers in a given geographic area. In addition, this bill continues the cost savings that the interim payment system was intended to achieve. Price Waterhouse has analyzed the bill and found it to be budget neutral. If we don't fix the interim payment system, I am afraid we risk a reduction in access to and quality of health care for Iowa seniors. Iowa home health care agencies have historically provided efficient, quality service and they ought to be rewarded, not punished for this. Most importantly, rural patients and their families deserve continued access to the best possible care.

Mr. HARKIN

Mr. HARKIN. Mr. President, I will respond with a couple of things. First of all, I have to ask again the question: Can these three members, these three nations, can they afford membership in NATO or can they not? Can they afford to bear the burden or can they not? We have been told they can. One of the requirements for membership is they can pay the tab. These three nations have stated over and over they could afford it. Now I am hearing, wait a minute, no, maybe they can't, because now we will have to give them a lot of subsidies to buy weapons systems. Well, if that is the case, then do they have the economic strength to join NATO? It seems like we cannot have it both ways. If they have the economic strength, why do they need all the subsidies? If they don't, are they really capable of joining NATO? Secondly, yes, I am concerned about these types of giveaway programs and loans and grants. I say to my friend from Connecticut, we have--I have been on the Defense Appropriations Committee for several years now, and I have been in some aviation things going back almost 20 years, both in the House and the Senate. I say to my friend from Connecticut, we have always been faced with other countries subsidizing, in many cases more than we ever subsidized our arms manufacturers. So how do we beat them? We beat them because we make the best products. We have the best quality. No one can match our aircraft. No one can match our weapons systems. No one can match not only the quality but the kind of support infrastructure that we can provide for those weapons systems. So other countries might have to subsidize theirs a little bit more, but only because they cannot match us in those areas. So we have been quite capable of competing and winning in the world market our share of defense items in the past. I do not think that will change in the future. So in the last decade we have written off or forgiven over $10 billion in default of loans on military-related items on this. I think, again, we have to be very careful about this. We are told it will only cost us $400 million, but now what I hear is no, that is only for the common costs. This could go up and up and up and up, subsidy after subsidy after subsidy. Then we hear that is only if there is a crisis. Fine. If there is a crisis we will address it then. But even the administration has said any threat to Europe to these nations is not imminent and would take years to develop. So we are not facing something that might happen in the next few months or even in the next couple of years or so, even according to the administration's own admission. Therefore, I submit once more, Mr. President, that to keep the costs down, to be honest with the taxpayers of this country, what my amendment says is what is good for the common costs--that is, we limit our involvement to 25 percent--that we should limit the 25 percent, for subsidies for all of those national costs, also. That is all this amendment does. My friend from Oregon, my amendment does not stop NATO expansion. It simply says no longer will our taxpayers simply pick up the tab. I yield the floor and reserve the remainder of my time.

Mr. HARKIN. How much time remains?

Mr. HARKIN. The Senator talks about prices. Again, with all due respect, when a crisis happens, Congress responds. Again, just from a budgeting standpoint, from being perhaps a little tightfisted with taxpayer dollars, and not giving sort of a blank check and saying, ``Fill it in,'' I think by having a cap on these costs, a national cost that I propose equivalent to what we do in our common costs, that it precludes a kind of runaway giveaway. It is like, OK, Hungary wants to upgrade their capabilities in a certain area, so we say, ``Oh, wonderful. You need not the $1.98 version, you need the $100 version.'' But Congress says, ``We can't afford the $100 version.'' We say, ``Not to worry. We'll give it to you. That will be one of our grants. We will subsidize it, and you will get ours.'' Again, I must respectfully say to my friend from Connecticut, this is a whole new vineyard, this debate about jobs. I thought this was about democracy and markets and peacekeeping. Now we are talking about jobs. I find this debate now is veering off course a little bit. To answer the question as forthrightly as I can, yes, I am saying that if one of these three countries want the $1.98 version, we could give up a 25-percent subsidy for that. We would not come in with a $100 version and say taxpayers are going to pay for the whole thing. Yes, that is exactly what I mean.

Mr. HARKIN. If the Senator would yield further.

Mr. HARKIN. Is the Senator then saying that the cost of this is going to escalate greatly in the future, that it is not $400 million, it is going to be something much above that because we are going to subsidize a lot of sales? Is that what the Senator is saying?

Mr. HARKIN. If the Senator will yield.

Mr. HARKIN. Mr. President, again, this amendment does not preclude increased subsidies as long as we only pay our fair share. That is the point I was making prior to the Senator's comments. But, again, is the Senator arguing that, again, this is going to cost a lot more than the $400 million that the administration has suggested--that this could really balloon in the years ahead? That is what I am concerned about. What is this going to cost? We are told it is only going to cost us $400 million. But now I hear the Senator saying maybe, if a country there decides to buy some expensive military hardware, we will want to jump in and subsidize our sales, so, therefore, we don't give it? I mean, nothing is given? It is not free; the taxpayers pay for it. And that bothers me. It doesn't preclude the sale of weapons; it just means it must be a fair share. Again, I probably agree with the Senator that my amendment would preclude the kind of giveaway programs that cost our taxpayers a lot of money in order to maybe help one of these countries modernize to the point where they may not need it. But as long as it is free to them and costs our taxpayers, why not give it to them?

Mr. HARKIN. I will respond to my friend, if he will yield.

Mr. HARKIN. I am sorry. Mr. President, I yielded the floor and reserve the remainder of my time.

Mr. HARKIN. Mr. President, I will yield the floor and let others use their own time.

Mr. HARKIN. I am sure the Senator will yield me some more off his time, because I have been so yielding to him. I think the analogy that the Senator from Delaware uses is totally wrong. Let me provide, I think, a more correct one. This amendment in no way limits how much total defense dollars we can provide to these three countries--not at all. It simply says, whatever their national budget, we will only pay 25 percent. So the Senator's analogy that we are somehow going to cap defense spending is not right. A better analogy, if I might say to my friend from Delaware, is this. We do have a defense budget in the United States. It is $260 billion. Let's say that for national emergency reasons, or whatever threat might come up, we have to increase it to $300 billion a year. But what we are going to do is tax the citizens of Delaware for half of it, and then we will spread the other half among the other 49 States of the Union. That is the more correct analogy as to what my amendment seeks to do. Now, certainly we would not say to the citizens of Delaware, ``We are going to increase the defense budget. You have to pick up 50 percent of the total.'' No. We would spread it out, make everybody pay a fair, proportionate share. That is what my amendment says. My amendment in no way limits the total amount of defense money spent on these three countries.

Mr. HARKIN. Yes, out of our taxpayer dollars, subsidies to those countries. But it has nothing to do with our military expenditures for our nation's forces stationed in Europe.

Mr. HARKIN. I didn't hear the Senator from Delaware.

Mr. HARKIN. I thank the Senator. That says it very clearly and very eloquently, and I think brings the point home again. I say to the manager of the bill that when you talk about $1.5 billion, that is one of the common costs. That is why we are trying to reach out and find out what these other costs associated with it are. These NATO's costs, as I have pointed out, we have already allocated over $1 billion ourselves of taxpayer dollars for this. I also say in response to the comments of the Senator from Delaware about what happens in the future that, if there is an emergency or something happens where you have changed circumstances, I would respond with the same enjoinder that he gave to this Senator; that is, I believe it is important now to limit our taxpayers' exposure rather than a blank check. If there is an emergency in the future, if something does happen, yes, the Appropriations Committee will respond. The Foreign Relations Committee and the authorizing committee will respond. The Armed Services Committee in their capacity as authorizing committee will respond. The appropriators will respond. It is better to address it at that point rather than giving a blank check now and just sort of letting it go. I think from a budgetary standpoint, from the standpoint of protecting our taxpayer dollars better, we limit it now, and then, if there is an emergency, fine, we can come up with the money and finance the emergency.

Mr. HARKIN. I don't believe so. I think all we are saying is that the other members of NATO have to be as fully involved financially in upgrading and modernizing their force structure as the taxpayers of this country. I basically would submit that this amendment is more inclusive. It is saying to our partners in NATO that we are in this together; don't just stick the American taxpayer with the bill.