William Roth

Mr. ROTH

Mr. ROTH. Yes, I can manage that.

Mr. ROTH. Mr. President, I, too, want to join the distinguished Senator from Oklahoma in thanking our friend from New Hampshire and withdrawing the amendment. I think he has articulated the reason for the change. I think there is considerable merit to the idea, but I do appreciate the fact that he has withdrawn the amendment. I don't think it is appropriate at this time. We look forward to working with him. Mr. DOMENICI addressed the Chair.

Mr. ROTH

Mr. ROTH. That is correct. We are waiting for certain figures from the Congressional Budget Office. As soon as we have those, we expect to be in a position to offer those amendments.

Mr. ROTH. I would just point out that the Senator is absolutely correct. The proposal was adopted unanimously by the committee, both Democrat and Republican. As I said, it was done in such a way as to try to make the beneficiaries be more careful in its utilization. I would point out that the question was raised, why did we use the $760 limitation? The reason for that is that under part A, many people, after being in a hospital for 3 days, will utilize home health care. They do not pay the $5 fee, but instead they pay $760. So that was the ceiling that was set under part A, and we carried that over to part B. There the beneficiary pays $5 per visit but not in excess of $760.

Mr. ROTH. Mr. President, will the Senator yield?

Mr. ROTH. I would like to make a comment or two on the question----

Mr. ROTH. Yes.

Mr. ROTH. The problem that has been faced in Medicare is the explosion of costs in home health care. It has been going up something like 30 percent a year. Obviously, that kind of increase cannot be permitted if we are going to salvage and strengthen the Medicare Program. Just let me point out that Medicare spending on home health services increased most dramatically in the last decade. In 1989-90, it went up 53 percent; 1990-91, it went up 44 percent; 1991-92, it went up 40 percent again; 1992-93, 30 percent; 1993-94, 30 percent; 1994-95, 19 percent. So, basically, it has been going up roughly 30 percent. There has been an increase in beneficiaries using home health care. There has been an increase in the number of visits per beneficiary. There has been an increase in the number of agencies providing care. So the payment system has not controlled the utilization of home care. There is the reason that we have put this $5 copayment. Let me point out that it is particularly important to understand that those who are 100 percent of poverty or less will have this $5 fee paid by Medicaid. So those who are under poverty are protected. And that is the idea of the program. We want those who are over 100 percent of poverty to be careful in their utilization. The program is there. It is a good program. In many cases, it can save money because it is better to have home health care than to put a person into a hospital. But the problem is that the costs have exploded. Somehow we have to make sure that the beneficiaries are more careful in their utilization of this program. And that is the reason for this change. Again, I want to stress the fact that those who are 100 percent of poverty or less will have this copayment of $5 paid by Medicaid. And they will not be out of pocket. So they are protected.

Mr. ROTH. I point out to the distinguished Senator from Massachusetts we have added a number of preventive services for the sick. For example, we now permit mammography testing to be made, colorectal testing or screening; we also permit diabetes home care matching. So we have added a number of things. But again, overall, we are trying to put this program in such shape that it will survive in the long term. Unfortunately, in the area of home health care, the costs have exploded. Let me mention again that home health care in 1989-90 went up 53 percent; 1990-91, it went up 44 percent; 1991-92, 40 percent; 1992- 93, 30 percent; 30 percent again in 1993 and 1994; 19 percent in 1994 and 1995. Let me point out further that other groups, such as the Commonwealth Fund, support the idea of a $5 copay. In a report issued by the Commonwealth it says that ``this is a sensible approach which would make beneficiaries sensitive to use but not form a barrier to care.'' I yield back the floor.

Mr. ROTH

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

Mr. ROTH. Mr. President, I am pleased by the work and cooperation that was exhibited last week in the Senate Finance Committee. It was an encouraging display of bipartisanship--both sides of the aisle working together to craft a proposal that meets the guidelines of the budget agreement and achieves needed reforms in spending programs while protecting America's vulnerable. Out of this tremendous effort that went into the Finance Committee markup of the budget came two distinct themes that we would do well to keep in mind as we take this issue up to the floor. First, that the time has come, as President Clinton expressed in an earlier State of the Union Address, to end big Government as we know it. This is no longer an objective held by one side of the aisle over the other. It is a necessity. We are blessed with the greatest Nation on Earth. We have the most productive citizens, the finest resources and materials, and we have the ingenuity and spirit of enterprise. We realize, however, that our resources are finite and Government's role is limited. Yet, we are willing, on both sides of the aisle, to make certain that Government efficiently and effectively provides for those with whom Government has a contractual or moral obligation to provide. Medicare is contractual. Medicaid, when it serves the most vulnerable, particularly America's children, is moral. And these feelings are shared mutually by Republicans on the committee as well as Democrats. This became obviously clear last week. Second, we demonstrated the power of bipartisanship. I can safely say that no one, but no one, on the Finance Committee got everything he or she wanted. No one was completely satisfied with everything, as it is a compromise between differing political philosophies and between deeply held views. So while what we have passed and addressed on the floor today is not the budget package that any of us would have drafted, it represents a major step forward, a step forward that, through balancing the budget, can help assure continued growth, jobs and opportunity. As we worked on the committee to report out this budget, I was led by two primary goals. First, to implement the budget agreement in such a manner that we not only balance the budget but that we do so in a manner that preserves and strengthens the programs impacted. As I said during the committee markup, ``It is not enough to reduce the cost of such critical programs as Medicare and Medicaid, but it must be done in a way that provides better service to beneficiaries of these programs.'' My second objective was to implement the budget agreement in a manner that assured bipartisan support for the program. I believe we have accomplished both of these. What we offer today is a workable balance, a critical balance that protects our most vulnerable populations while addressing necessary reforms in important entitlement programs. Let me give some specifics. The largest program we concerned ourselves with was, of course, Medicare. Much has been written and said about the future of this program and the need to strengthen it for the long term. We did this. We took a critical first step towards addressing the long-term solvency of the Medicare Program while at the same time making certain that the program meets the needs and expectations of its current beneficiaries. The changes we made in Medicare actually allow us to expand Medicare coverage for certain important preventive services including mammography, colorectal screening, bone mass measurement and diabetes self-management. We are able to offer this expanded coverage and protect and preserve Medicare by incorporating choice and competition into the current program, and by slowing Medicare's rate of spending growth. Our measures will save Medicare from bankruptcy for another 10 years, while still increasing Medicare spending per beneficiary from $5,450 this year to $6,950 in the year 2002. In expanding choice in the Medicare Program, we have used the highly successful Federal Employees Health Benefit Program as a model. Under our new Medicare Choice Program, seniors will have the opportunity to choose from a variety of private health plan options and select the health care plan that best suits their needs and preferences. These choices will include the whole range of health plan options available to the under-65 population--fee-for-service, varieties of managed care, and medical savings accounts. Through these options, seniors will be able to obtain important benefits, like prescription drugs, that are not covered by traditional Medicare. It is clear to see how these commonsense and, again, I want to say, these bipartisan solutions will preserve and strengthen the program. We were not content to stop there. The Finance Committee proposal calls for a National Bipartisan Commission on the Future of Medicare. This will be a 15-member commission, established for 1 year, charged with making recommendations to Congress on actions necessary to ensure the long-term fiscal health of the Medicare Program, something of great concern to the ranking member, Pat Moynihan, and myself. The Finance Committee report also creates a demonstration project within the Medicare Program for medical savings accounts. This demonstration project will allow up to 100,000 Medicare beneficiaries to opt into an MSA program, a program that will allow them to choose a high-deductible Medicare Choice plan. These changes to Medicare will result in a net savings of $115 billion, savings that will not only help us meet the budget compromise but savings and reforms that will preserve the Medicare Program while ensuring that it continues to serve those who depend on it now. Again, these important reforms were made possible only through sincere bipartisan efforts, and it is my hope that such bipartisanship will continue as we address these reforms on the floor. Such bipartisanship also marks our treatment of Medicaid. Working together, we passed reforms that will control the growth of the program, resulting in a net savings of over $13 billion. For more than a decade, there has been a constant tug of war between the Federal Government and the States over Medicaid, as each side has asserted its will over the other. From the mid-1980's through the early 1990's, the Federal Government imposed mandates on the States and, in turn, the States shifted costs to the Federal Government. The result was devastating to all of our budgets as Medicaid routinely grew at a double-digit pace, reaching as high as a 29-percent increase in 1992. This Finance Committee proposal signals an important change in the program. Having said this, let me be clear. We are not cutting Medicaid. Under this proposal, Medicaid spending will continue to grow. The Federal commitment to Medicaid will grow from $99 billion in fiscal year 1997 to $140 billion in 2002. The President originally proposed $22 billion in savings in the Medicaid Program. We achieved approximately $14 billion in savings. The first part of our Medicaid reform is to give the Governors the tools they need to control this program. This will be able to move more individuals into managed care without waiting years for waivers from the Federal Government. They will be able to contract with selected providers for service. The States will be able to ask families to take some responsibility for the decisions they make when seeking health care services. In short, our plan gives the States many of the same tools that the private sector has in stretching health care dollars. The fact is, health care as a whole has changed, and the Medicaid Program needs to catch up. Our proposal gives the States the tools necessary to act as many large employers do, to get the greatest value for Medicaid dollars. So we are taking the important next step to move both the States and the Federal Government out of the waiver process. But we also want to ensure that as the old program requirements are replaced, quality is still assured. As I have said, in addressing the Medicaid Program, we also provided many of the reforms requested by the bipartisan National Governors' Association. These include repealing the Boren amendment provision. The history of the Boren amendment is a classic example of unintended consequences as it has been used to increase the costs of the program, rather than control costs. The Governors and the administration agree on the repeal of this provision. It will take the providers and the States out of the Federal courts and put them back at the contract negotiating table. As we repeal the Boren amendment, we must be very careful that we do not simply create a new round of lawsuits over what Congress means in terms of Medicaid payments to facilities. Another major provision of our plan to control the growth of Medicaid is the reduction in spending on the Disproportionate Share Hospital Program. This DSH Program provides funding for indigent individuals who are not enrolled in Medicaid. Under current law, DSH spending is projected to increase from $10.3 billion in fiscal year 1998, to $13.6 billion in 2002. In 1990, Federal and State DSH spending combined totaled less than $1 billion, and in 1995, Federal and State DSH payments totaled nearly $19 billion. Without reform, Federal DSH payments alone will total nearly $60 billion over the next 5 years, and we need to exert some discipline in this program. This bill reforms the DSH Program through a combination of controls. First, a State which spends less than 3 percent of its Medicaid Program on DSH will be frozen at its 1995 level. For these States, there will be no reduction, but also no growth. Second, beginning in 1999, high-DSH States and low-DSH States will be reduced from their 1995 actual spending levels. A high-DSH State or a State that spends more than 12 percent of its Medicaid dollars on indigent hospital costs will be reduced from its 1995 spending levels for inpatient hospitals only. It will not be allowed to count spending on institutes for mental diseases. These high-DSH States will be reduced from 1995 spending by 14 percent in 1999 and by 20 percent in the years thereafter. Low-DSH States are those that spend less than 12 percent, but more than 3 percent of the Medicaid dollars will be reduced from their 1995 spending by 2 percent in 1999. In the year 2000, they will be reduced 5 percent from the 1995 level. In 2001, the reduction will be 10 percent, and in 2002, it will be 15 percent. As I mentioned, our proposal places restrictions on the States' ability to fund their State mental health facilities with Federal funds. Over the past few years, the States have shifted the cost of these facilities to the Federal Government. As you check with your State, many will find huge increases in Federal costs associated with these facilities. It is time to close this loophole. Let me say that the President proposed $22 billion in savings from the Medicaid Program. Two-thirds of these savings were to be realized out of the DSH Program and one-third from per capita caps. The savings target has been reduced, but the potential reforms for achieving these savings are also limited. I believe there is general agreement that through the DSH Program, the use of DSH payments had been expanded well beyond the original intent. The DSH formula has been developed with consultation and in bipartisan cooperation. The formula has been carefully designed, based on past problems in this program and with input from Members. Concerning the steps which we take in this package to address children's health, let me begin by saying that we all share the same goal of increasing access to health care for as many children as we can. And it is clear that Members on both sides of the aisle are committed to finding an answer to the problem of uninsured children in this country. Of the 71 million children in the United States, more than 86 percent are covered by some type of health insurance; two-thirds are covered by insurance through the private sector; 23 percent of all children in the United States under age 18 are covered by Medicaid, and another 3 percent are covered by other public insurance programs. Of the 9.8 million children who are not insured, 2.9 million children live in families with incomes above 200 percent of the Federal poverty level. Half of these children live in families with incomes of about 300 percent of the Federal poverty level. Mr. President, 300 percent of the poverty level is over $48,000 for a family of four. This tells us that insurance coverage is more than an issue of family income. It is, in fact, a complex issue which does not yield easy to Washington-knows- best solutions. The proposal we offer today provides the States with a choice concerning how they will expand coverage to more children. They can expand their Medicaid coverage, or they can offer a package of benefits which is actuarially equivalent to the Federal Employees Health Benefits Program. Our intention is to build on the successes the States have been realizing. This year, the States will be increasing coverage to more than 800,000 children through initiatives proposed by the Governors. We should learn from these initiatives and encourage the States to develop them. This proposal will allow the States to choose how best to extend coverage to children. Expanding Medicaid is certainly a choice States have made. Thirty- nine States have expanded Medicaid eligibility for pregnant women and children beyond the Federal requirement, but States are also developing other strategies for increasing coverage of children as well. There are already public-private partnerships in more than half the States. There are successful programs, such as New York's Child Health Plus and Florida's Healthy Kids. These innovative programs, and programs like them, can grow with additional resources. The Children's Health Initiative that we include in our committee proposal is a bold new approach to support the States in the drive to provide coverage for more of our Nation's children. As I have said, the States will be given a choice to expand coverage through the existing Medicaid Program or through a new initiative in which they can subsidize private programs for children or provide a new benefit package which is actuarially equivalent to what Federal employees receive. Under either choice, the Federal Government will provide the same matching rates to the States. A State would pay the same rate as it does currently in the Medicaid Program. We recognize this may not be enough to encourage States to participate. Therefore, under this proposal, the Federal Government would send to the States an additional incentive bonus for each child who is covered in this new initiative. We call this an enhanced match. The State will receive a 10-percent bonus for each new child they cover and 5 percent for a child who is already covered under a State health program for children. These bonuses will be provided for children who are receiving health care coverage from the State that is beyond Federal Government requirements for Medicaid. A critical component of this agreement is what type of health insurance coverage is provided. Let me stress that this truly is insurance. A State would be required to provide either its current Medicaid benefits package or one which is equal to what the children of Federal employees receive. The Secretary of Health and Human Services will review these plans to ensure that they meet this test. The welfare of our children was a critical component in the bipartisan plan we achieved in the Finance Committee. The result of our work will be to cover more children and to provide them with real health insurance. Again, this children's health care initiative will build upon the leadership in the States. It passed the Senate Finance Committee with strong bipartisan support, and I thank all the Members who made a contribution to this special effort. As you see, Mr. President, each of these reforms is necessary. Together they meet the requirements and responsibilities that were given to us. During the next 5 years, we reduce deficit spending by $100 billion, including Medicare reductions of $115 billion, and net Medicaid reductions by $13.6 billion. At the same time, we increase spending for children's health care in this bill by $16 billion, SSI support for elderly and disabled immigrants by $10.4 billion and welfare to work by $3 billion. We extend the solvency of the part A trust fund for Medicare for at least 10 years, while introducing structural reform to give beneficiaries more choice among competing health plans. Our goal is to give the Medicare beneficiary the same choices that Federal employees have within our Federal health program, including the traditional fee-for-service, and this is an excellent beginning. We were able to produce such a strong bipartisan package because of the spirit of cooperation shared by members of the Finance Committee. Views were solicited actively, from all members of the Finance Committee. They were asked to submit in writing the recommendations as to how the budget agreement should be implemented, and their ideas were incorporated in the initial chairman's mark. Informal meetings were then held to seek the further advice and recommendations from Members. These, in turn, were incorporated into the proposal we address today. As chairman of the Finance Committee, I say with certainty that this proposal has substantial support on both sides of the political aisle and it is, again, my sincere hope that the spirit of bipartisanship that existed within our committee will prevail as we move forward. I hope the objectives that guided us will remain those that carry us through the next few days as we consider this budget. I particularly express my sincere appreciation to Senator Moynihan for his leadership in this monumental effort, as well as my appreciation to all the members of the committee who reported this proposal out of the Finance Committee unanimously. Senator Gramm provided invaluable leadership on the Medicare Subcommittee, and I thank all the committee staff members who worked around the clock day after day to ensure that the objectives we were given to meet would be met in the most efficient and effective way possible. Mr. President, I yield the floor. Mr. MOYNIHAN addressed the Chair.

Mr. ROTH. I yield to the distinguished Senator 10 minutes.

Mr. ROTH

Mr. ROTH. I now ask for its second reading, and I object to my own request on behalf of Senators on the Democratic side of the aisle.

Mr. ROTH. Mr. President, I understand that S. 950, introduced today by Senator McConnell, is at the desk. I ask for its first reading.

Mr. ROTH

Mr. ROTH. Mr. President, if there is no further business to come before the Senate, I now ask unanimous consent that the Senate stand in adjournment under the previous order.

Mr. ROTH

Mr. ROTH. Mr. President, for the information of all Senators, tomorrow morning the Senate will resume consideration of the reconciliation bill, and at 9:45 a.m., the Senate will proceed to a rollcall vote on, or in relation to, Senator Gregg's amendment No. 426. There are several other amendments that need to be disposed of; therefore, votes will occur throughout Tuesday's session of the Senate.

Mr. ROTH

Mr. ROTH. I further ask unanimous consent that immediately following the 9:45 a.m. vote, Senator Roth be recognized to offer an amendment.

Mr. ROTH. Mr. President, I further ask unanimous consent that there be 15 minutes equally divided prior to a vote in relation to Gregg amendment No. 426.

Mr. ROTH. Mr. President, I ask unanimous consent that when the Senate completes its business today, it stand in adjournment until the hour of 9:30 a.m. on Tuesday, June 24. I further ask unanimous consent that on Tuesday, immediately following the prayer, the routine requests through the morning hour be granted and the Senate then resume consideration of the budget reconciliation bill, with 10 hours of debate equally divided remaining under the statutory time limitation.

Mr. ROTH

Mr. ROTH. Mr. President, I ask unanimous consent that the resolution be agreed to, the preamble be agreed to, the motion to reconsider be laid upon the table, and that any statements relating to the resolution appear at the appropriate place in the Record.

Mr. ROTH. Mr. President, I ask unanimous consent that the Senate proceed to the immediate consideration of Calendar No. 81, Senate Resolution 92.

Mr. ROTH

Mr. ROTH. Mr. President, I ask unanimous consent there now be a period for the transaction of morning business with Senators permitted to speak for up to 5 minutes each.

Mr. ROTH

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

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

Mr. ROTH. Mr. President, pursuant to section 904 (c) of the Congressional Budget Act of 1974, I move to waive the point of order, and ask that debate on the waiver be postponed until tomorrow following any votes ordered for tomorrow morning.