Ted Kennedy

Mr. KENNEDY

Mr. KENNEDY. Madam President, there is troubling news on the education front. Yesterday, the Republican majorities on the House and Senate Appropriations Committees approved education budgets filled with harsh cuts that will hurt families, students, schools, and teachers throughout the country. Unfortunately, the pattern is all too clear. Our Republican colleagues promise strong support for education and quietly break the promise. The bills unveiled yesterday contain a litany of broken promises on education. Obviously, money is not the answer to all the problems of our schools. But the way we allocate resources in the Federal budget is a clear expression of our Nation's priorities. And the priorities on education reflected in this Republican Appropriations bill are profoundly wrong. In January 2002, President Bush promised that ``America's schools will be on a new path of reform . . . our schools will have greater resources to meet those goals.'' But yesterday, on a strict party-line vote, our Republican colleagues voted to cut funding for the No Child Left Behind Act by $200 million. We have raised standards and raised expectations on schoolchildren. We intend to hold schools accountable for better performance. Yet now the Republican majority wants to cut funding for school reform. President Bush promised that we would ``leave no child behind,'' and that became the title of the landmark school reform bill he signed into law a year and a half ago. But yesterday, behind closed doors, our Republican colleagues approved a budget that leaves 6 million children behind. It underfunds the title I program for needy children by over $6 billion. Under the Republican education budget, needy children will not get smaller classes, will not get supplemental services, and will not get special attention in reading and mathematics. In March last year, President Bush promised to support teachers, making sure they ``get the training they need to raise educational standards.'' But yesterday, Republicans on the Appropriations Committees proposed to cut 20,000 teachers from professional development programs. They proposed to eliminate training for teachers in technology. We need to upgrade teacher quality, not downgrade teacher training. The No Child Left Behind Act requires schools to give every classroom a high quality teacher. They need more resources, not fewer resources, to reach that goal. President Bush promised that his administration ``will promote policies that expand educational opportunities for Americans from all racial, ethnic, and economic backgrounds.'' But yesterday, our Republican colleagues approved a budget that cuts 32,000 children from education programs in English as a Second Language. They want to eliminate the Thurgood Marshall Scholarship program. They want a zero increase in Pell grants, a zero increase in campus-based financial aid, and a zero increase in College Work Study. President Bush promised to increase AmeriCorps by 25,000 volunteers. Two weeks ago, the Administration told us that AmeriCorps programs would be cut by 25,000 volunteers. Clearly, Federal resources are being limited unfairly because of the massive tax breaks already enacted that benefit the wealthy. If we freeze future tax breaks for the wealthy, we can obtain the resources we need for education. In the Senate and the House, Senator Byrd and Congressman Obey have shown impressive leadership on this issue. Instead of providing millionaires with an average tax cut of $88,000 each as the President proposes, they would use the savings to fund the No Child Left Behind Act, invest in teachers, and help students pay for college. But the Republican majority rejected those amendments. The Republican majority voted to give $88,000 to each millionaire and to cut funds for education. These are the wrong priorities for America, and we are going to oppose them on the Senate floor. Next week on the Fourth of July, we will all celebrate our Nation's founding values, values whose preservation depends heavily on the quality of education of each generation. As Senators go home to their States for the recess, they should ask constituents whether they give higher priority to tax breaks for millionaires or to education. They should ask their constituents if they value investing in school reform and improvement. They should ask teachers what they think of a cut in the No Child Left Behind budget. If we intend to hold schools and students accountable, Congress has to be accountable, too. On this Fourth of July, let's reflect on our history, on the need to keep our promises, and on the importance of building a better future.

Mr. KENNEDY

Mr. KENNEDY. Madam President, in considering potential nominees for a possible vacancy on the Supreme Court, I hope President Bush will consider the example of earlier Presidents who followed both the letter and the spirit of the Constitution, and fully respected the role the Framers gave the Senate to share with the President. The Framers originally rejected a proposal that the President alone appoint judges, and they seriously considered allowing the Senate to exercise that responsibility alone. In the end, they decided to make that responsibility a shared function of the President and the Senate, through the ``advice and consent'' mechanism. There is nothing ``novel'' or extra-constitutional about Presidents consulting in advance with the Senate before nominating a person to a lifetime position on the Supreme Court. George Washington wanted the Senate to be his own ``privy council'' and refused to do so, but for the past century many Presidents have taken the opposite course. They have decided not only that such consultation was fully consistent with the Framers' system of checks and balances, but also that their concern for achieving a consensus in the selection of strong and independent Justices could be best achieved by consulting in advance with the Senate. Presidents who did so often achieved broad Senate and national support for their nominees, avoided divisive and unnecessary battles, and prevented embarrassing rejections of their selections. President Theodore Roosevelt frequently consulted with Senators before making Supreme Court nominations, including the 1902 nomination of Oliver Wendell Holmes, Jr., who was confirmed the day he was nominated. In 1932, President Herbert Hoover presented his list of possible nominees to Senator William Borah, a fellow Republican. Benjamin Cardozo, a Democrat, was at the bottom of the President's list, but Senator Borah persuaded the President to nominate Cardozo, who was confirmed nine days after his nomination was sent to the Senate. President Franklin Roosevelt also shred his list of potential nominees with Senator Borah in advance. Senator Borah expressed his enthusiastic support for William O. Douglas, who was quickly confirmed by a vote of 62-4. In 1975 President Gerald Ford shared his list of 11 prospective nominees with both the Senate and the American Bar Association. Although there was support for others on the list, his choice, John Paul Stevens, was confirmed in three weeks by a vote of 98-0. President Bill Clinton consulted with Senators from both parties on each of his two Supreme Court nominees. Senator Dole, Senator Hatch, and others advised him that his favored candidate would be controversial, and supported the nomination of Ruth Bader Ginsburg. Later, Senators from both parties, including Senator Hatch, recommended Stephen Breyer. Both Ginsburg and Breyer were quickly and overwhelmingly confirmed. Nominations which generated the most controversy were those which had little or no consultation with the Senate, or where the President ignored advice of the Senate. President Richard Nixon sought little or no direct advice from Senators who were not friends and supporters of his prospective nominees. He suffered two consecutive defeats, and the opponents included members and party leaders of the President's own party. President Ronald Reagan's Chief of Staff, former Senator Howard Baker, consulted with leading Senate Democrats, and received strong advice that Robert Bork would have substantial opposition. Bork was nominated nevertheless, and was defeated by a vote of 58-42. There is no down-side to serious consultation with the Senate. If a well-known prospective nominee has significant bipartisan support, the President will know in advance that he is likely to achieve prompt confirmation of the nominee, without a divisive debate in the Senate that would also be divisive for the country. The selection of a Supreme Court Justice with broad national support would help bring the country together at a time when we are facing many difficult challenges, and I hope very much that the Members of the Senate can work closely with the President and with one another to achieve that goal.

Mr. KENNEDY

Mr. KENNEDY. Mr. President, do we have any time?

Mr. KENNEDY. Will the Senator yield me a minute?

Mr. KENNEDY. Mr. President, I suggest the absence of a quorum.

Mr. KENNEDY. Mr. President, the Boxer amendment provides the additional resources for the treatment of cancer. I think all of us understand the importance of the continuity of care in the treatment of disease generally. That is why I am going to continue to vigorously fight for additional resources to fill in this gap in the future for all diseases. But it is particularly important to fill this gap for people who are afflicted with the disease of cancer. They are waiting for Congress to fill in this gap. It does seem to me, because of the compelling reasons for the continuity of care in terms of diseases generally we ought to be able to find the additional resources to fill this gap. The Boxer amendment does not replace the fundamental structure of this legislation. It finds the additional resources to be able to make sure there will be continuity of care for what is, for many families, their Number 1 health concern. So that is a very compelling reason. I hope the amendment will be favorably considered. I suggest the absence of a quorum.

Mr. KENNEDY. Mr. President, we will have a chance to have greater discussion and debate on one of the important amendments that is before the Senate. But I wanted to bring to the attention of our Members as we go through the course of the day the Grassley-Baucus amendment, which has two different parts to it. I would like to address the part of the amendment which I find enormously compelling and which deserves the broad support of all the Members of this body. This amendment provides equal funding for Medicare and the private plan demonstration plans. That is effectively what will be in the Grassley-Baucus amendment. The Republicans say the private sector can do a better job providing health care for seniors and we say Medicare can do a better job. This amendment tests both. This amendment improves the coordination of care for seniors with multiple chronic conditions who remain in Medicare. Republicans have said we need to move seniors into private plans if we want to provide chronic care coordination, disease management, or enhanced preventive services. I am confident this demonstration program will show Medicare can do an even better job than private plans in providing preventive health services and ensuring care coordination. Care for patients with chronic conditions is especially critical. These patients account for 95 percent of Medicare spending, according to ``Care Coordination for People with Chronic Conditions'', an analysis published this year by Johns Hopkins University. Currently, 60 million Americans have multiple chronic conditions, and that number is expected to grow to 157 million by the year 2020. Sixty-two percent of seniors have multiple chronic conditions, but their care is often fragmented. A senior citizen may get treatment for her diabetes from one doctor, care for her arthritis from a second doctor and attention for her high blood pressure from a third. Study after study shows that improving the coordination of care for those with multiple chronic conditions can improve outcomes and reduce costs. For example, in Laconia, NH, the Home and Community Based Care program improved disease management for seniors with multiple conditions. This program saved an average of $8,100 in health care costs for each senior served and decreased admission to nursing homes. In Georgia, the Service Options Using Resources in a Community Environment--SOURCE--program improved disease management for 1,600 beneficiaries in 80 counties. The costs of caring for those seniors in the SOURCE program over two years was over $4,000 lower than for those who were not in the program. My own state of Massachusetts is part of the New England States Consortium, a multi-state effort funded by the Robert Wood Johnson Foundation to study the improvements that can be made in health care through better care coordination. Expert groups in health care have said that care coordination should be one of the highest priorities for our health care system. For example, in its recent report, Priority Areas for National Action: Transforming Health Care Quality, the Institute of Medicine identified 20 ``priority areas'' for improving health care. The Institute of Medicine has carefully examined the issue of care quality. The Institute's recent report, ``Priority Areas for National Action'' has a series of recommendations on improving the quality of health care in America. We have included in our amendment 13 of the 20 priority items that have been identified by the Institute of Medicine that will make a significant difference in quality. The amendment will have an important impact in reducing costs by improving care coordination and providing needed preventive services. A recent study funded by the Robert Wood Johnson Foundation reaches the same conclusion. The study examined the effect of care coordination on outcomes for patients with diabetes. Care coordination and simple preventive services dramatically improved the outcome for patients with diabetes in terms of their blood glucose levels. Elevated blood glucose is a major concern for patients with diabetes, and preventive services are effective in keeping blood glucose levels down. As we know, diabetes is one of the principal health concerns for our country, and is of particular concern for our seniors. A decrease of even one percentage point in the blood glucose level of a patient with diabetes can have a profound effect on health. That seemingly small decrease results in a 21 percent drop in mortality from the disease, a 12 percent decrease in strokes, a 24 percent decrease in renal failure, and a remarkable 43 percent drop in the amputations that so many patients face as a result of this cruel disease. More effective management of blood glucose levels is also effective in keeping patients out of hospitals or nursing homes and thus reducing costs. A reduction in blood glucose levels of just one percent reduces health care costs by $800 per patient. These kinds of extraordinary improvements in health care quality are what this amendment is all about. We are going to provide some $6 billion nationwide over a 5-year period to give life to these kinds of quality improvement efforts, and we are going to challenge the private sector to do it as well. We believe that the kinds of quality improvement initiatives included in this amendment will be a major factor for the support for this legislation. Health care quality and its impact on health care costs is an aspect of the health care debate that has not received sufficient attention. This amendment will give us an opportunity to take dramatic steps forward in Medicare which will strengthen and improve the quality of health care for our seniors. The amendment will also have a very positive impact in terms of cost reductions. This amendment also addresses the whole question of prevention which is equally critical to keeping people healthy. Immunizations, managing high blood pressure, cancer screening, and patient education can all have an enormous impact on keeping people healthy and reducing costs. Too often Medicare pays huge amounts to care for people who are sick but fails to invest adequately in keeping them healthy. Failure to invest adequately in preventive services is a tragic consequence of the repayment system we now have under the Medicare system. When the original Medicare system was established, we did not have the knowledge, awareness, and understanding of the importance of prevention nearly to extent we have it today. Preventive care was not reimbursed the way it should be. Under this amendment, we will have the opportunity to provide the kinds of real, effective support for prevention programs they deserve. Increased support for preventive services will mean lower costs and better quality of care for our seniors under Medicare. As I mentioned, too often we pay huge amounts to care for people who are sick, but fail to invest in keeping people healthy. This amendment gives Medicare the tools to invest in keeping people healthy. Too often the care for people with the highest cost, the most serious illnesses, such as cancer and stroke, is not optimal. This demonstration will help Medicare assure the highest quality care for the sickest patients. Medicare is a fine program. It has kept our senior citizens secure for 40 years. Today let us make Medicare even better with this amendment. I will include the selective parts of the studies I referred to previously in the Record. I ask unanimous consent that the selective parts be printed in the Record at the conclusion of my remarks.

Mr. KENNEDY. I withhold.

Mr. KENNEDY. Mr. President, as I mentioned, the New England Journal of Medicine--in a major study published just today--focuses on the issue of quality. The study demonstrates that the problem most likely to occur in our health care system is not overutilization of services, but underutilization. This point bears repeating. Patients all over America are not receiving the services they need to keep them healthy. 46 percent of patients did not receive the recommended care, while only 11 percent received care that was not recommended and was potentially harmful. That means that four times as many patients did not receive the care they needed as received care they did not need. The problem in our health care system is not overutilization of services, but underutilization. The problem of not receiving needed care is particularly acute for some of the most serious disorders that affect seniors. The New England Journal article states that less than a quarter of patients with diabetes received recommended blood tests. Fewer than two-thirds of patients with high blood pressure received the recommended care. These two diseases alone take an extraordinary toll on the lives of our citizens. Nearly 600,000 seniors die each year from heart disease, and complications of diabetes kill over 50,000 seniors. We could dramatically reduce the serious toll of these diseases--and many others--by improving access to preventive services and enhancing the quality of care. Modern medicine--and a strong Medicare program--have been effective in allowing seniors to live with chronic conditions that once were fatal. Millions of seniors are alive today because of advances in the treatment of heart disease, high cholesterol, cancer and other serious illnesses. As a result of this success, however, millions of seniors have multiple chronic conditions which put them at higher risk for illness and hospitalization. The Institute of Medicine reports that only 0.7 percent of seniors with just one chronic condition require hospitalization in any given year. 6.2 percent of seniors with 4 chronic conditions are hospitalized, and over 25 percent of those with 10 or more chronic conditions require a hospital stay. Currently, 60 million Americans have multiple chronic conditions, and that number is expected to grow to 157 million over the next two decades. Improving the coordination of care for those with multiple chronic conditions can markedly improve outcomes. Yet the average Medicare beneficiary sees more than six different doctors in a year. Clearly, we need to do more to see that seniors receive the most appropriate care for all their conditions--not just the one that any particular doctor among these six is treating individually. Study after study cited by the Institute of Medicine indicates that care is inadequately coordinated for patients with some of the most serious diseases. Our health care system also fails to provide adequate preventive services. Survival rates for many forms of cancer increase dramatically if the disease is detected early--yet far too few patients receive the type of early screening that can literally mean the difference between life and death. For example, early diagnosis of colon cancer results in a survival rate of 90 percent, but that survival rate drops precipitously if the cancer spreads or grows before it is detected. Early detection not only saves lives--it reduces costs too. Proper screening can save up to $25,000 for every patient who avoids painful and lengthy treatment through early detection of cancer. Despite this compelling evidence of the value of preventive services, only a third of patients receive the recommended form of colon cancer screening. The story is the same with adult immunization. Pneumonia and influenza are the seventh leading cause of death in the United States, and the fifth leading cause of death among seniors. Over a third of seniors with invasive pneumonia will die of the disease. Many cases of these diseases are preventable with a simple immunization--yet one- third to one-half of all seniors do not receive needed immunizations. Coverage rates for high-risk seniors are particularly poor. Tragically, only about a quarter of seniors with chronic disease receive a flu shot. This very important amendment will address these challenges which the Institute of Medicine, the Robert Wood Johnson Foundation, and the New England Journal of Medicine have all commented on as being critical if we are going to strengthen quality and begin to get a greater handle on costs. I will refer to the part of the amendment that addresses these questions. Page 13 of the amendment describes the enhanced benefits that will now be available to beneficiaries in terms of care coordination, disease management and preventive services not otherwise covered under section 18 of the Social Security Administration. I ask unanimous consent to include the section of the bill containing this provision in the Record. The amendment provides chronic care coordination services, disease management services and other benefits that the Secretary will determine to improve preventive health care for Medicare beneficiaries. These services will improve chronic disease management and management of complex life-threatening or high-cost conditions. The amendment will make a real difference in improving the health of millions of seniors. This is really a historic opportunity. I can say, having been here for some period of time, the idea that you would get $6 billion over 5 years to be able to support prevention and the coordination of care for our seniors--I didn't believe it would ever be realized. We have that chance with this amendment. I think one of the most important aspects of this legislation is its emphasis on the area of prevention, which is so important, as I have just described. Increased support for preventive health care services will improve and strengthen the quality of health care and also result in savings for the Medicare system. We have seen how these services help the intensely ill and sick and fragile elderly. And we will increase the coordination of services as well. All of this makes a great deal of sense. And we have the evidence--ample evidence--to show that action in this area can make a very important difference to the elderly. I will let others describe the other part of the amendment dealing with private plans. But we challenge them, after the 5 years in which the resources will be spent--with a GAO study that will report back how the money has been spent--we challenge them to see which will make the greatest difference in terms of quality of care for our senior population and will make a difference in terms of the savings in the Medicare system. There is no question in my mind--no question in my mind--what that GAO report will demonstrate. We have clear documentation and scientific information that talks about the various studies that have been done to date, and also the conclusions that have been reached by the thoughtful, nonpartisan groups in this very area. We welcome the opportunity to show to the American people which system is really going to work effectively. At the end of that period of time, we will have the chance to enhance and improve on that, to make sure the future generations' health care will be strengthened. So I hope this amendment, which will be before us very soon, will receive overwhelming support because I think it will have a real chance to evaluate the different approaches and see what is going to be most effective in terms of quality and cost. Blood Glucose--Reductions Pay Off Longitudinal studies demonstrate that a one percentage point reduction in Hemoglobin A1C (blood glucose) results in: 14% decrease in total mortality; 21% decrease in diabetes- related deaths; 14% decrease in myocardial infarction; 12% decrease in strokes; 43% decrease in amputations; 24% decrease in renal failure; and $800 reduction in health care costs. Problems with Quality of Care The problem with quality that is most likely to occur, is underuse: 46.3 percent of participants did not receive recommended care. With overuse, 11.3 percent of participants received care that was not recommended and was potentially harmful. Variations in Quality There is substantial variability in the quality-of-care patients receive for the 25 conditions for which at least 100 persons were eligible for analysis. Persons with senile cataracts received 78.7 percent of the recommended care; persons with alcohol dependence received 10.5 percent of the recommended care. The aggregate scores for individual conditions were generally not sensitive to the presence or absence of any single indicator of quality. Discussion Overall, participants received about half of the recommended processes involved in care. These deficits in care have important implications for the health of the American public. For example, only 24 percent of participants in our study who had diabetes received three or more glycosylated hemoglobin tests over a two-year period. This routine monitoring is essential to the assessment of the effectiveness of treatment, to ensuring appropriate responses to poor glycemic control, and to the identification of complications of the disease at an early stage so that serious consequences may be prevented. In our study, persons with hypertension received 64.7 percent of the recommended care. We have previously demonstrated a link between blood-pressure control and adherence to process-related measures of quality of care for hypertension. Persons whose blood pressure is persistently above normal are at increased risk for heart disease, stroke, and death. Poor blood-pressure control contributes to more than 68,000 preventable deaths annually. final list of priority areas The committee's selection process yielded a final set of 20 priority areas for improvement in health care quality. Improving the delivery of care in any of these areas would enable stakeholders at the national, state, and local levels to begin setting a course for quality health care while addressing unacceptable disparities in care for all Americans. The committee made no attempt to rank order the priority areas selected. The first 2 listed--care coordination and self-management/health literacy--are cross- cutting areas in which improvements would benefit a broad array of patients. The 17 that follow represent the continuum of care across the life span and are relevant to preventive care, inpatient/surgical care, chronic conditions, end-of- life care, and behavioral health, as well as to care for children and adolescents (see boxes ES-1 to ES-6). Finally, obesity is included as an ``emerging area'' that does not at this point satisfy the selection criteria as fully as the other 19 priority areas. Recommendation 3: The committee recommends that DHHS, along with other public and private entities, focus on the following priority areas for transforming health care: Care coordination (cross-cutting); Self-management/health literacy (cross-cutting); Asthma--appropriate treatment for persons with mild/ moderate persistent asthma; Cancer screening that is evidence-based--focus on colorectal and cervical cancer; Children with special health care needs; Diabetes--focus on appropriate management of early disease; End of life with advanced organ system failure--focus on congestive heart failure and chronic obstructive pulmonary disease; Frailty associated with old age--preventing falls and pressure ulcers, maximizing function, and developing advanced care plans; Hypertension--focus on appropriate management of early disease; Immunization--children and adults; Ischemic heart disease--prevention, reduction of recurring events, and optimization of functional capacity; Major depression--screening and treatment; Medication management--preventing medication errors and overuse of antibiotics; Nosocomial infections--prevention and surveillance; Pain control in advanced cancer; Pregnancy and childbirth--appropriate prenatal and intrapartum care; Severe and persistent mental illness--focus on treatment in the public sector; Stroke--early intervention and rehabilitation; Tobacco dependence treatment in adults; and Obesity (emerging area). Care Coordination--Rationale for Selection Impact Nearly half of the population--125 million Americans--lives with some type of chronic condition. About 60 million live with multiple such conditions. And more than 3 million--2.5 million women and 750,000 men--live with five such conditions (Partnership for Solutions, 2001). For those afflicted by one or more chronic conditions, coordination of care over time and across multiple health care providers and settings is crucial. Yet in a survey of over 1,200 physicians conducted in 2001, two-thirds of respondents reported that their training was not adequate to coordinate care or education for patients with chronic conditions (Partnership for Solutions, 2001). More than 50 percent of patients with hypertension (Joint National Committee on Prevention, 1997), diabetes (Clark et al., 2000), tobacco addition (Perez-Stable and Fuentes- Afflick, 1998), hyperlipidemia (McBride et al., 1998), congestive heart failure (Ni et al., 1998), chronic atrial fibrillation (Samsa et al., 2000), asthma (Legorreta et al., 2000), and depression (Young et al., 2001) are currently managed inadequately. Among the Medicare-eligible population, the average beneficiary sees 6.4 different physicians in a year, 4.6 of those being in the outpatient setting (Anderson, 2002a). Cancer Screening That is Evidence-Based--Rationale for Selection Impact Colorectal cancer is the third most common cancer among men and women in the United States, with an estimated incidence of 148,300 cases annually. In 2002, 56,600 Americans died from colorectal cancer, making it the nation's second leading cause of cancer-related death. Lifetime risk for developing colorectal cancer is approximately 6 percent with over 90 percent of cases occurring after age 50 (American Cancer Society, 2002). The estimated long-term cost of treating stage II colon cancer is approximately $60,000 (Brown et al., 2002). Cervical cancer is the ninth most common cancer among women in the United States, with an estimated incidence of 13,000 cases annually. Cervical cancer ranks thirteenth among all causes of cancer death, with about 4,100 women dying of the disease each year (American Cancer Society, 2002). The incidence of cervical cancer has steadily declined, dropping 46 percent between 1975 and 1999 from a rate of 14.8 per 100,000 women to 8.0 per 100,000 women (Ries et al., 2002). Despite these gains, cervical cancer continues to be a significant public health issue. It has been estimated that 60 percent of cases of cervical cancer are due to a lack of or deficiencies in screening (Sawaya and Grimes, 1999). Prevention--Cancer Screening Improvability Early diagnosis of colorectal cancer while it is still at a localized state results in a 90 percent survival rate at 5 years (Ries et al., 2002). The American Cancer Society's (ACS) guidelines recommend screening for colorectal cancer beginning at age 50 for adults at average risk using one of the following five screening regimens: fecal occult blood test (FOBT) annually; flexible sigmoidoscopy every 5 years; annual FOBT plus flexible sigmoidoscopy every 5 years; double contrast barium enema every 5 years; or colonoscopy every 10 years (American Cancer Society, 2001). The United States Preventive Services Task Force strongly recommends screening for men and women 50 years of age and or older for colorectal cancer. Screening has been found to be cost-effective in saving lives, with estimates ranging from $10,000 and $25,000 life-year saved. immunization (adult)--rationale for selection Impact Pneumonia and influenza are the seventh leading cause of death in the United States (The Commonwealth Fund, 2002). Pneumococcal disease causes 10,000 to 14,000 deaths annually; influenza causes an average of 110,000 hospitalizations and 20,000 deaths annually (United States Department of Health and Human Services, 2000). Approximately 30-43 percent of elderly people who have invasive pneumonia will die from the disease (United States Preventive Services Task Force, 1996). The elderly are also at increased risk for complications associated with influenza, and approximately 90 percent of the deaths attributed to the disease are among those aged 65 and older (Vishnu-Priya et al., 2000). To decrease the burden of these diseases, including incapacitating malaise, doctor visits, hospitalizations, and premature deaths, experts recommend vaccination. Yet one- third to one-half of older adults (aged 65 and over) do not receive these vaccinations (The Commonwealth Fund, 2002). Coverage rates for high-risk adults who suffer from chronic disease are especially poor, with only 26 percent receiving an influenza vaccination and 13 percent a pneumococcal vaccination (Institute of Medicine, 2000).

Mr. KENNEDY

Mr. KENNEDY. Mr. President, I will just take a moment to address the amendment of the Senator from California, Mrs. Feinstein, and her colleagues, in terms of means testing the Medicare system. That is what we would be doing, changing what is effectively an insurance system into a welfare system. There is, really, no question about that. The fact is, the Part B of the Medicare system is basically a progressive system as it is at the present time. Wealthy people are paying a great deal more into that system than they are taking out. My concern is, if this passes, it is only a question of time before the healthiest individuals who can qualify under the Part B premium are going to leave the Medicare system and it is going to deteriorate into a general welfare system. The kind of Medicare system seniors relied on, day in and day out, would be destroyed. Make no mistake about it. That is why the AARP is strongly opposed to it, as well as the National Committee to Preserve Social Security. I hope this amendment is not accepted. I suggest the absence of a quorum.

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

Mr. KENNEDY

Mr. KENNEDY. One of the great strengths of Medicare is that it is for everyone. Rich and poor alike contribute to the system. Rich and poor alike benefit from it. At bottom, Medicare is a commitment to every senior citizen and every disabled American that we will not have two-class medicine in America. When a senior citizen enters a hospital, Medicare pays the same amount for their care whether they are a pauper or a millionaire. When a senior citizen goes to a doctor, she has the peace of mind of knowing that Medicare has the same obligation to pay for her treatment no matter what her financial circumstances--and the doctor has no financial interest in rationing her care according to the contents of her bank account. Through the Medicaid Program, we do try to provide extra help for those who are poor. But the fact that Medicaid provides extra assistance for the poor does not reduce Medicare's obligation to provide equal treatment for all. Medicare always has primary payment responsibilities for the service it covers. Medicaid is always supplementary. Medicaid provides critical help to the poor and elderly, but it does not provide the same reliable guarantees of equal treatment that Medicare does. Under Medicaid, States have limited the number of days of hospital care they would provide or the number of doctor visits they will support. States have placed arbitrary limits on the number of prescriptions. This legislation sets an undesirable precedent for treatment of poor senior citizens who are eligible for both Medicare and Medicaid. For every other benefit, these senior citizens enroll in Medicare, and Medicaid supplements Medicare's coverage. But for this benefit, the bill says that the poor are excluded from Medicare. The only benefits they get are from the Medicaid Program. Medicare is for all senior citizens who paid into the program during their working years--not just some senior citizens. And it should stay that way. This amendment rights this wrong. It says we will not take away the Medicare that the poor have earned by a lifetime of hard work.

Mr. KENNEDY

Mr. KENNEDY. Mr. President, on Monday, in a landmark decision, the Supreme Court made clear that colleges and universities can adopt admissions policies that take students' racial and ethnic background into account to achieve a diverse student body. The Court's decision is a resounding vindication for the fundamental principle that affirmative action can be used in education to promote opportunity for all, and encourage interaction among students of diverse backgrounds. Our diversity is our greatest strength, and this decision recognizes the broad benefits of diversity in higher education. A diverse student body benefits all students at our colleges and universities and helps prepare students for our increasingly diverse workforce and our diverse society. As the opinion of Justice O'Connor states, ``Major American businesses have made clear that the skills needed in today's increasingly global marketplace can only be developed through exposure to widely diverse people, cultures, ideas and viewpoints.'' High- ranking military leaders, too, have stated that affirmative action is necessary for promoting a ``qualified, racially diverse officer corps,'' to enable the Armed Forces to protect national security. The Court's decision supports the paramount importance of education as a gateway to equal opportunity, reaffirming once again the Court's historic decision nearly 50 years ago in Brown v. Board of Education. Few areas are as vital to sustaining our democracy that education. Our institutions of higher education, like our public schools, are indispensable in broadening the minds of young adults, and training them for leadership. As the Court stated in Brown, and emphasized again in Monday's opinion, ``Education is the very foundation of good citizenship.'' The Nation is becoming increasingly diverse, and it is important for all our institutions to reflect that rich diversity. The Court stated: ``In order to cultivate a set of leaders with legitimacy in the eyes of the citizenry, it is necessary that the path to leadership be visibly open to talented and qualified individuals of every race and ethnicity. Access to education must be inclusive of talented and qualified individuals of every race and ethnicity, so that all members of our heterogeneous society may participate in the education institutions that provide the training and education necessary to succeed in America.'' The Supreme Court has made clear that a well-crafted affirmative action admissions program like that of the University of Michigan Law School is constitutional. It is flexible and allows for individualized review of each applicant, and it is not a quota. The Court also made clear that States do not have to promote diversity only by relying on percentage plan programs which guarantee college admission to all students above a certain class-rank in every high school graduating class in the State. As the Court recognized, such programs do not work for graduate and professional schools. In fact, percentage plans can prevent colleges and universities from making the individualized assessment of applicants that is necessary to assemble a diverse student body. Our country has made extraordinary progress over the past half century toward equality of opportunity in all aspects of our society, and affirmative action has been an indispensable part of that success. But we all know that we have to do more to make the promise of Brown a reality. Even with affirmative action, vast inequities remain in access to higher education especially for African-Americans and Latinos. We know that civil rights is still the unfinished business in America. Half a century after Brown, our schools remain starkly divided along racial and ethnic lines, and minority children are too often relegated to inadequate schools. We have to do more to see that minority children are not forced to think of an institution like the University of Michigan as an impossible dream. This decision by the Supreme Court is another major step by the Court to make that dream possible, and it is difficult to believe that either this Congress or this President would approve a Supreme Court nominee who would reverse that decision.

Mr. KENNEDY

Mr. KENNEDY. Mr. President, I strongly support S. 1157, the National Museum of African American History and Culture Act. The story of African Americans is a major part of the story of the United States. From the dark times of slavery, civil war, and reconstruction, to the extraordinary accomplishments of the civil rights movement of the past half century, it is essential for all Americans to know and understand that story in all its aspects, and this new museum in the Nation's Capital will be an especially valuable resource in achieving that goal. It will be a valuable cultural and educational experience for every visitor to Washington and for every student of American history in communities across the country. Our Nation was founded on a promise of equality and opportunity for all, and for more than two centuries, we have struggled to fulfill that great promise. The struggle goes on today, on critical issues, such as guaranteeing that all our citizens are free from hate crimes and racial profiling, and are free to go to the polls and vote without intimidation or attempts to suppress their votes. We know that civil rights is still the great unfinished business of America. As Robert Kennedy told the students at the University of Cape Town, at a time when the specter of apartheid hung heavily over South Africa: We must recognize the full human equality of all our people--before God, before the law, and in the councils of governments. We must do this, not because it is economically advantageous--although it is; not because the laws of God and man command it--although they do command it; not because people in other lands wish it to. We must do it for the single and fundamental reason that it is the right thing to do. It is especially appropriate that this new museum dedicated to African-American history and culture will be part of the Smithsonian Institution in Washington. It is long overdue, and this legislation will help advance the cause. This museum will be renowned as a source of African-American history throughout the United States. In cooperation with other museums, with historically black colleges, and with many other historical, cultural, and educational institutions, it will make this part of the Nation's history as widely available as possible. And millions of visitors who come here from throughout the world will be inspired by what they see and learn. It is an honor to be a sponsor of this legislation, and I urge my colleagues to support it.

Mr. KENNEDY

Mr. KENNEDY. Mr. President, I see my friend from North Dakota is eager to address the Senate. I will just be a few minutes on this particular amendment. Amendment No. 1001 Mr. President, I rise to commend the Senator from California, Senator Boxer, for her amendment. I will support this amendment for the very sound reasons she has outlined here on the floor of the Senate. Just going back very quickly, in 1965 we passed Medicare and we said to our seniors: Pay into the fund, play by the rules, and your health benefits will be attended to. Therefore, we provided the hospitalization and the physician fees. At that time, only 3 percent of all private companies provided any kind of prescription drug protection. We have made extraordinary progress in recent years with the development of prescription drugs to tend the needs of all of our citizens and particularly the elderly. Now prescription drugs are as important as hospitalization and physician fees. What this overall debate has generally been about, in terms of the prescription drug program, is how and when are we going to pass a prescription drug program that will be worthy of our senior citizens and do for our senior citizens what the hospitalization program and the physician programs, which are under Medicare, Part A and Part B, do for our seniors. This particular proposal we have before the Senate now has two very important gaps. The Senator from California has pointed out one very important gap, a failure to provide services to many of our elderly. There is a second important gap and that is how we treat our retirees. Senator Boxer has outlined the benefit gap that exists under this proposal. What we are talking about is seniors are going to be spending $1.8 trillion over the next 10 years. This bill only provides for $400 billion. It is only really about 22 percent of all that is going to be necessary for our seniors over the period of the next 10 years. The issue before us is, first, whether seniors will be able to get the prescription drug program through their Medicare program. I believe the way this bill is constructed they will be. Second, what will the amount available to them be. Clearly, this bill is short. What the Senator is reminding us about, with her excellent presentation, is that if the Senate itself had the will we could be providing the complete amount necessary to meet all the needs of our senior citizens. I believe that is what we should do. We have had this debate before in the Senate under the Graham-Miller proposal last year, which I was proud to support. That would have cost close to $600 billion over a period of 8 years. The House Democrats had a different proposal that would have been, actually, close to $1 trillion. But it would have made all the difference and would have attended to the needs of our elderly people. The Senate has made a different judgment. They have decided they were going to provide $3 trillion in tax cuts for the wealthiest individuals, and give short shrift to our seniors with a $400 billion proposal. That is what we have here in the Senate. We have had opportunities, even while we were debating the tax proposal. A number of us offered amendments and said let's just take the reduction in the top three rates and perhaps the dividend tax reduction and, instead of going ahead with those additional deductions, use those resources and put them onto a prescription drug program. We got 49 votes here in the Senate. We got 49 votes here. This body is evenly divided, effectively, on the concept that the Senator from California has provided. Virtually half of this Senate wants to provide the full benefits which would be included in the Boxer amendment. That is what I think needs to be done if we are going to provide a meaningful benefit to seniors. As this chart points out and as the Senator has explained, after paying the $275 dollar deductible, for expenditures up to $4,500, we are finding 50 percent of all the expenditures effectively are paid for. Then we have the benefit gap in here, which is sometimes known as the donut hole. And then we find the expenditures for our seniors up at 90 percent in the high-cost areas. It is this area the Senator from California is addressing. I imagine she would like, as well, to try to do something about reducing this deductible or even the premiums as well. Her amendment certainly would do that. We are back to the real choice of what is important. Are we as a Nation going to say it is more important to have a prescription drug program worthy of its name and support the Boxer amendment? Or, are we going to fail to do that? I, as one Senator, as long as I am in the Senate, am going to continue to fight to be sure we provide the resources to do for prescription drugs what we are doing for our seniors under hospitalization and also with physician fees. I think that is what is fair. That is what is necessary. That is what we mean when we talk about having a good prescription drug program. That is what is really called for if we are going to be true to our senior citizens. I thank the Senator for raising this issue again. It is really a question of choices. It is a question of priorities. This Senate has made a judgment, a decision previously that what we ought to do is provide tax reductions of $3 trillion, and therefore there are those who say we cannot afford to do what we should be doing for the senior citizens of this country. I regret it. It does seem to me the amendment, which says let's go ahead and pass the Boxer amendment and then we will sort through the pressures we are going to have on our budget in the future and perhaps review some of those excessive tax reductions--it seems to me that is in the Nation's interest. This is a question of priorities. It is a question of choice. It is a question of value. The Senator from California has made what I think is a compelling case about what is needed to do the job. Mr. President, 22 percent is what this downpayment is. I consider it a downpayment. As I mentioned on all occasions, I think the downpayment is out there. I am going to do everything I can--I am sure the Senator from California is as well--to make sure there is not just a downpayment, but there is going to be a continuing effort on our part to make sure the senior citizens are going to be treated fairly.

Mr. KENNEDY. Well, the complication is costly. We know for a fact we spend $5,000 on health care for every man, woman, and child. We are spending $1.4 trillion a year for every man, woman, and child in America at the present time. That is even before we get into this. Forty percent out of every health care dollar is nonclinical. It is nonclinical. There is not an industry in the world that has that kind of, effectively, overhead. If we reduce that from 40 cents to 35 cents, it would be $70 billion a year. If we took it down to 30 cents, which is not unreasonable, that would be $140 billion a year. It gives you some idea of what is in the health care system that is not really being translated into good kinds of services. And that is a very important issue and question. I think the Senator is right, that there is a very high administrative cost generally in terms of our health care system, and there are things that can be done about it. I hope we will have the chance to address those. We have some ideas. But I must say, now the question really has to do with the questions of priorities, about how we are going to act. The fact is, we have the amount that is in the budget which is only the $400 billion, and you stretch it and stretch it, and pull it and pull it, and you get this kind of result. It isn't the kind of result that would be there if the Senator from California drafted the bill or if I drafted the bill, but this is where we are. I am going to do everything I possibly can to make sure we are going to have a complete system. I thank the Senator. Amendment No. 976 Mr. President, I know we are going to go to a vote at 11 o'clock. I would like to take just a minute on the amendment we are going to be voting on. As I understand it, it is the Rockefeller amendment that will be directed toward the retiree issue. One of the great strengths of Medicare is that it is for everyone. Rich and poor alike contribute to the system. Rich and poor alike benefit from it. At bottom, Medicare is a commitment to every senior citizen and every disabled American that we will not have two-class medicine in America. When a senior citizen enters a hospital, Medicare pays the same amount for their care whether they are a pauper and a millionaire. When a senior citizen goes to a doctor, she has the peace of mind of knowing that Medicare has the same obligation to pay for her treatment no matter what her financial circumstances and the doctor has no financial interest in rationing her care according to the contents of her bank account. Through the Medicaid program, we do try to provide extra help for those who are poor. But the fact that Medicaid provides extra assistance for the poor does not reduce Medicare's obligation to provide equal treatment for all. Medicare always has primary payment responsibilities for the services it covers. Medicaid is always supplementary. Medicaid provides critical help to the poor and the elderly, but it does not provide the same reliable guarantees of equal treatment that Medicare does. Under Medicaid, States have limited the number of days of hospital care they would provide or the number of doctors' visits they will support. States have placed arbitrary limits on the number of prescriptions. This legislation sets an undesirable precedent for treatment of poor senior citizens who are eligible for both Medicare and Medicaid. For every other benefit, these senior citizens enroll in Medicare, and Medicaid supplements Medicare's coverage. But for this benefit, the bill says that the poor are excluded from Medicare. The only benefits they get are from the Medicaid program. Medicare is for all senior citizens who paid into the program during their working years not just some senior citizens. And it should stay that way. This amendment rights this wrong. It says we will not take away the Medicare that the poor have earned by a lifetime of hard work. It deserves the support of the Members. I hope it is adopted.

Mr. KENNEDY. I am happy to yield.

Mr. KENNEDY

Mr. KENNEDY. I commend Senator Dodd for offering this important amendment today. This amendment will address one of the gaping holes in this plan--its failure to treat retirees and retiree health plans fairly. Today, we have the opportunity--and the obligation--to correct that unfairness. Ten million senior citizens depend on retiree health plans to fill the gaps in Medicare. Especially given the limitations of the drug benefit we are debating, supplemental coverage from retiree health plans is crucial. But retiree health plans are being abandoned or cut back all over the country--and prescription drug costs are a key part of the problem. For retirees who are over 65, prescription drugs make up about half of all plan costs--and as much as 80 percent of recent cost increases. But the prescription drug plan before us treats those plans unfairly, by taking the unprecedented step of making senior citizens with retiree health plans second class citizens under Medicare. The Congressional Budget Office has concluded that even with the new assistance provided under this plan, one-third of all retirees--4 million senior citizens-- could lose their supplemental drug coverage. That should be unacceptable to every Senator. The issue is not one of providing a bail-out or a windfall to retiree health plans. It is one of simple fairness. Currently, whenever Medicare covers a benefit or service, Medicare is the primary payer for that service. If a retiree health plan covers the service, it pays only for what Medicare does not cover. The reason for that is straightforward. Employers pay taxes to support the Medicare Program. So do retirees. So do active workers who accept lower wages during their working years in order to have supplemental retirement health care in their retirement years. But under this legislation, these workers and these employers do not get the full benefit of their contribution to the drug benefit. Because of the ``true out-of-pocket'' concept included in the bill, Medicare does not pay for catastrophic expenses of these workers, even though the cost of covering these expenses accounts for more than one-third the cost of the current bill. And the higher the costs the retiree faces, the more the discrepancy between what Medicare pays for the retiree with employer-sponsored insurance and what Medicare pays for all other senior citizens grows. If the individual's drug costs are $6,000, Medicare pays $2,113 for the retiree with insurance but $2,281 for all other senior citizens. If the individual's drug costs are $8,000, Medicare still pays $2,113 for the retiree with employer-sponsored insurance, but $4,081 for all other senior citizens. And if the individual's drug costs are $10,000, Medicare still pays just $2,113 for the retiree, but pays $5,881 for all other senior citizens. This is double taxation at its worst. These retired workers and companies are taxed twice. They pay once to support the Mecicare program. Then they are forced to pay again by being denied the Medicare benefits their contributions have earned. During the debate on the tax bill we heard a lot about the injustice of double taxation of dividends from the other side of the aisle. Apparently, for them, double taxation of the unearned income of millionaires and billionaires is wrong, but double taxation of moderate income retired senior citizens is just fine. The fact is that it is not fine. The American people understand that it is wrong. American companies struggling to provide for their retired workers in this sour economy understand that is wrong. The Senate should understand that it is wrong, too, and right this injustice.

Mr. KENNEDY

Mr. KENNEDY. Mr. President, could I ask the floor manager, if Senator Bingaman is not here, could I have the remaining minute?

Mr. KENNEDY. Mr. President, we are not talking about individuals who have $1 million homesteads. We are talking about seniors who have $10,000 in income. We are talking about poorest of the poor of our senior citizens. This idea people are going to be able to circumvent it because they have $1 million and $10,000 in income is ridiculous on its face. Perhaps that individual is saving $5,000 in order to fix the roof in 2 or 3 years. They will not be eligible to be able to qualify under the program here. This is really the poorest of the poor, and we are talking about incomes of $10,000 or less. That is what this amendment is about. At least I hope it would not be tabled. And if there is some kind of condition in terms of the value of their home, as the Senator from Pennsylvania has outlined, we can work that out. But we are talking about the poorest of the poor. If that is the kind of protection the Senator from Pennsylvania is interested in, Senator Bingaman is interested in, we are interested in, let's work it out, but let's not table the amendment.

Mr. KENNEDY. Can I have a minute and a half? I see others who want to address this issue.

Mr. KENNEDY. Mr. President, could I ask, now do we have 3 minutes or so on each side?

Mr. KENNEDY. Could I have one of the 3 minutes?

Mr. KENNEDY. Mr. President, I hope this amendment will not be tabled. First, I commend the chairman of the committee and the ranking minority member of the committee. They have made a major step forward in reducing what we call the asset test. Under the assets test, any senior who managed to scrape together more than $4,000 in a savings account wouldn't qualify for the most generous benefit. Those elderly persons with a minimum amount of possessions, even if they are just above the very minimum wouldn't qualify. We are even talking about limits to the amounts that can be set aside for a burial plot or the value of personal items like jewelry or a car. This bill we have before us has reduced the asset test in a very significant and dramatic way for seniors who have income above 135 percent of poverty. But it still remains for those who are poorest of the poor. The Bingaman amendment costs only about $3 billion, but would substantially benefit the neediest of our seniors. In addition, the paperwork for the assets test is demeaning and an additional burden on senior citizens. I looked over the form in Georgia, for example, and it is about 10 pages long. In another State it is 16 pages long. We are talking about a test which will effectively reduce the availability of absolutely needed prescription drugs for the seniors who are the poorest of the poor. The bill before us has made very substantial progress in helping our neediest seniors. The Bingaman amendment would just finalize it and effectively say we are not going to use an asset test as a condition to be able to participate in the prescription drug program. I do not see my friend and colleague, the Senator from New Mexico, here on the floor. But I want the Senator to know that it is a thoughtful amendment and it will assure that low income seniors have access to the special assistance they need without pauperizing themselves or undergoing this demeaning procedure. A senior with income below the poverty line and who didn't pass the assets test under the current bill would pay 10 percent of the cost of the drugs, whereas under the Bingaman amendment she will have to pay only 5 percent. That doesn't sound like a lot of money around here but it is a lot of money for some of the most needy senior citizens. I commend the committee for what they have done. I hope we will continue to make progress in this area and not table the Bingaman amendment.

Mr. KENNEDY. Mr. President, if there is no one else on our side I would like to speak for another minute, if I could. Do we have the time?