November 19, 2008 CONGRESSIONAL RECORD — SENATE S10623 

lasting economic impact. It is important to leave behind a record that you 

are proud of, but it is also maybe even 

more important to leave behind many 

fond memories of that work, fond 

memories of colleagues with whom you 

were able to spend time and, of course, 

fond memories of the friendships you 

were able to form, both with members 

of your own party and with those on 

the other side of the aisle. 

Perhaps what I am most proud of 

overall is that the pieces of legislation 

I was able to sponsor and pass, whether 

it was the Internet tax ban, civil liberties protection that we added under 

the PATRIOT Act, the Wilderness Act 

that protects 25,000 acres of the White 

Mountain National Forest, were all bipartisan pieces of legislation. That 

means a lot to me. 

I think it will serve me well in any 

future endeavors I undertake in public 

service. I thank Senator MCCONNELL, 

the Republican leader. 

Mr. MCCONNELL. Madam President, 

let me just say to my friend from New 

Hampshire, it has been a real privilege 

to serve with somebody of your intellect and ability. I know you are going 

to be a huge success. You have, as we 

discussed, a lot of your life left. I know 

you are going to be a huge success in 

the coming years, and I am looking forward to seeing more of you in the future. 

The PRESIDING OFFICER. The Senator from Maryland. 

f 

UNANIMOUS-CONSENT REQUEST— 

S. 3684 

Ms. MIKULSKI. Madam President, I 

ask unanimous consent that the Senate proceed to the immediate consideration of a bill I have at the desk which 

is the text of title VII of S. 3689 regarding the auto sales tax deduction, and 

further that the bill be read a third 

time and passed, and the motion to reconsider be laid upon the table, with no 

intervening action or debate. 

The PRESIDING OFFICER. Is there 

objection? 

Mr. SUNUNU. I object. 

The PRESIDING OFFICER. Objection is heard. 

Ms. MIKULSKI. It is my understanding I still have the floor? 

The PRESIDING OFFICER. The Senator has the floor. 

Ms. MIKULSKI. Boy, am I sorry that 

is the last act of JOHN SUNUNU in the 

Senate. I hope it is not the last thing. 

I feel so badly about people objecting 

to me bringing this up. Mine is a bipartisan bill that I thought maybe I would 

win, maybe I would lose, but at least 

we could bring it up and debate it and 

discuss it and vote on it. 

My bill was a straight-forward bill. 

My bill was to help save jobs in the 

automobile industry, from manufacturing, sales to service, to the little 

people who are the bookkeepers in our 

communities. 

My bill would give a tax deduction to 

someone who would buy a car in these 

6 weeks and they would be able to take 

a deduction of interest and sales tax. 

The total cost of my bill was $8 billion. 

But the cost of not doing my bill is 

going to be horrific. It is going to be 

absolutely horrific. I cannot get over 

how these economic conservatives have 

their ostrich heads in the quicksand of 

our economy. 

You know what is going to happen 

when our automobile industry goes 

down. Well, let them go. Well, I will 

tell you, we are going to lose $156 billion over the next 3 years in lost taxes, 

unemployment, and health care assistance. 

We are facing the possibility that 3 

million people could lose their jobs. 

But oh, no, we object. We object to debate. We object to discussion. We object to taking our ideas and putting 

them into the sunshine and being able 

to do what I thought you do in a democracy, vote ideas up or down. 

If I lose my bill in a vote, that is the 

way democracy works. But to move it 

through a parliamentary maneuver of 

something called, ‘‘I object,’’ I object 

to the objection. I have no idea why 

anyone would object to bringing up an 

idea that has bipartisan support to see 

if we could stimulate demand in the 

automobile industry. 

Well, I tell you what. Senator BARB

MIKULSKI is not the only one who objects. The American people object. And 

that is what they did when they walked 

into that voting booth on November 4 

and voted for change. They said: Yes, 

we can. They were objecting to what 

goes on in this institution and what 

has been going on in the White House 

for the last 8 years. 

They said: I object. And they voted. 

They objected and then they voted. 

And they object by their vote. There is 

a reason a political tsunami hit this institution. It is because of this continual way of throwing sand in the 

gears of democracy. So they said: I object. That is what the people said. 

So we can go through these parliamentary shenanigans. We can delay 

what we could do in the next 48 hours 

to get our economy going. But, oh, no. 

We are going to do it. The question 

is, are we going to do it today or are we 

going to do it 8 weeks from today? The 

longer we wait, the deeper and more 

prolonged the recession will be. Right 

now we could begin to not only turn 

the page but begin to turn the economy 

around. 

So those are the rules of the Senate. 

I signed up for the Senate, so I take the 

rules as they are. But I will tell you, I 

stand with the American people. I object. And I object to the objection. I am 

going to keep fighting this until we 

leave. It is my view we shouldn’t leave 

until we pass legislation to get this 

economy going. If we cannot do it this 

week, come back next week because 

the real turkeys will not be in our 

oven. The real turkeys will be close at 

hand. 

I yield the floor. 

UNANIMOUS-CONSENT REQUEST— 

S. 3656 

Mr. SCHUMER. Madam President, I 

inform the Republican leader, I had arranged to do a unanimous-consent request when the Senator from Iowa 

could be on the floor. 

I ask unanimous consent the Finance 

Committee be discharged from further 

consideration of S. 3656, the Senate 

proceed to its immediate consideration, the bill be read a third time and 

passed, and the motion to reconsider be 

laid upon the table, with no intervening action or debate. 

The PRESIDING OFFICER. Is there 

objection? 

Mr. GRASSLEY. Madam President, I 

reserve the right to object. 

The PRESIDING OFFICER. The Senator is recognized. 

Mr. GRASSLEY. Madam President, 

throughout the years, the Committee 

on Finance has worked to safeguard 

and improve the programs under its jurisdiction, including the Medicare and 

Medicaid Programs. The Finance Committee has a unique expertise on these 

programs and is the only committee in 

a position to assess the possible effects 

of individual changes on all Social Security programs as a whole. Accordingly, it is essential that any legislative proposals impacting these programs be considered by the full Senate 

only after the Finance Committee conducts a thorough analysis of the issues 

involved and the potential solutions. 

I would like to bring up one example 

of how this bill needs scrutiny. There is 

a provision buried in here that would 

allow California to escape its responsibilities to ensure that illegal aliens 

are not getting Medicaid benefits to 

which they are not entitled. Do the 

American people support giving Medicaid to illegal aliens? I don’t think so. 

Simply bypassing the committee process with legislation on complex issues 

runs contrary to how this body should 

function. In fact, as my friend from 

New York is aware, Congress already 

had extensive debate and enacted a 

Medicare bill already earlier this year. 

That bill was authored by the chairman of the Finance Committee. So the 

Senate and the full Congress have already had extensive Medicare debate 

this year. The Senator from New York, 

as a member of the Finance Committee, had ample opportunity to raise 

the issues earlier this year that he now 

raises in a bill he wants to bring up 

right now. So regardless of the merits 

of the Senator’s proposal, I believe that 

ship has set sail. 

I have a more extensive statement on 

the provisions themselves. Some of 

them, I want the Senator from New 

York to understand, I actually support, 

and I oppose some, obviously. Perhaps 

we can work together on some of these 

issues where we agree, if the Senator is 

interested. Today, however, I am forced 

to object to the Senator’s consent request. 

Notwithstanding the significant jurisdictional and process issues I just 


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S10624 CONGRESSIONAL RECORD — SENATE November 19, 2008 

raised, I would also like to note that 

there are several provisions in the bill 

I strongly support. However, there are 

several provisions in this bill that I oppose at this time and do not believe the 

Finance Committee has given proper 

consideration through hearings and investigations. 

One of the provisions in S. 3656 that 

I support would delay implementing 

provisions of a proposed CMS rule that 

would change conditions of participation for rural health clinics and decertify rural health clinics that are no 

longer in nonurbanized areas. It would 

also delay proposed changes to the existing payment methodology for rural 

health clinics and federally qualified 

health centers. While I am very concerned about the proposed CMS rule 

and its impact on rural health centers, 

RHCs, unfortunately I cannot support 

this legislation which is within the jurisdiction of the Finance Committee 

but which has not been given any consideration by the committee. 

The CMS proposed rule would impose 

new location requirements for RHCs 

and require that clinics be located in a 

nonurbanized area, as defined by the 

U.S. Census Bureau, as well as meet 

shortage area designation requirements. Only new RHCs applying for the 

program are currently required to meet 

these criteria but the CMS proposal 

would extend these requirements to already certified RHCs. According to 

CMS, about 500 of the approximately 

3,700 RHCs operating today may not 

meet these requirements. 

Iowa is currently in the throes of a 

growing shortage of physicians, especially in the more rural areas of the 

State, due to inequitable geographic 

adjustments in physician payment that 

result in Iowa physicians receiving 

some of the lowest Medicare reimbursement in the country even though 

they provide some of the highest quality care. These geographic payment 

disparities, which discriminate against 

rural areas, have further exacerbated 

the problems of rural access to care. 

The CMS proposed rule could have a 

severe adverse impact on a number of 

rural health clinics in Iowa, including 

many located in counties that have 

been declared disaster areas from the 

severe flooding Iowa suffered earlier 

this year. Rural clinics in Iowa also 

could be severely impacted by the CMS 

proposed payment changes since RHC 

costs in Iowa and other States are already higher than the existing Medicare reimbursement cap. If the CMS 

rule is finalized as proposed, rural 

health clinics in Iowa and elsewhere 

may be forced to close their doors, even 

though they have served rural populations very well for many years, leaving Iowa with fewer physicians and 

some patients with little access to primary care and other critical medical 

services. 

This bill would prevent the application of a CMS policy to phase-out a 

payment adjustment for indirect medical education, IME, under the Medicare capital Inpatient Prospective Payment System, IPPS. Currently, teaching hospitals receive this upward payment adjustment under the capital 

IPPS. CMS announced in the fiscal 

year 2008, Medicare Hospital IPPS 

Final Rule that they would begin to 

phase out the IME adjustment for capital IPPS in fiscal year 2009. 

As the former chair and currently 

the ranking member of the Senate Finance Committee, it has long been one 

of my priorities to ensure Medicare 

payments are both accurate and equitable. I question whether this bill 

would further this goal, which many of 

us share. 

The appropriateness of the IME capital IPPS adjustment has been analyzed not only by CMS, but also the 

Medicare Payment Advisory Commission, MedPAC, which advises Congress 

on Medicare payment issues. CMS has 

documented relatively high and continued positive margins for teaching hospitals under the capital IPPS compared 

to nonteaching hospitals. In fact, from 

1998 through 2006, teaching hospitals 

had an aggregate capital IPPS margin 

of 11.2 percent while nonteaching hospitals had an aggregate capital IPPS 

margin of ¥0.8 percent. 

Based on these figures, many, including myself, question the appropriateness of this payment adjustment. This 

is a case in point of why legislative 

proposals such as this must first go 

through the committee process. 

S. 3656 puts a moratorium on a CMS 

rule regarding Medicaid payments for 

hospital outpatient services. Early this 

year, Congress placed moratoriums on 

six other CMS Medicaid regulations. 

Just as I opposed those moratoriums, I 

strongly oppose this one as well. The 

Finance Committee has not held the 

first hearing as to why this action is 

necessary. We have not considered 

whether payments currently being 

made are not consistent with the statute. Medicaid is a critical program for 

children, pregnant women, the disabled, and the elderly. We have a responsibility to the people who depend 

on the program to make sure that 

funds are being appropriately spent. 

This moratorium is not consistent with 

that responsibility. 

This bill also intervenes in a dispute 

by CMS and the State of California. 

The State of California has been seeking approval of an extension of their 

family planning waiver for 6 years. For 

6 years, CMS has been pushing California to improve their collection of 

Social Security numbers and citizenship documentation for women enrolled in the program. This bill essentially requires CMS to approve of the 

extension of California’s waiver without requiring California to do anything 

further to improve their process of ensuring people who receive benefits are 

actually eligible for those benefits. 

I would also like to point out that a 

comprehensive Medicare bill written 

by the Chairman of the Finance Committee was passed by the Senate this 

summer. One can presume that the proposals in this bill were considered and 

rejected for inclusion in that Medicare 

bill. 

I understand that legislation is often 

the art of compromise. We can’t always 

get everything we want in every bill 

and keep everything we dislike out. It 

is a balance. However, I think both in 

terms of process and policy, this bill 

does not sufficiently achieve a balance 

I think is necessary and I must, therefore, object to its consideration. 

The PRESIDING OFFICER. Objection is heard. 

The Senator from New York. 

Mr. SCHUMER. Madam President, I 

introduced this bill in October in response to overwhelming concerns New 

York health care providers have about 

three devastating health regulations 

that the Bush administration is pushing. 

My bill would put a 6-month delay on 

the Medicare Hospital Capital IME 

payment policy to teaching hospitals, a 

6-month delay on the now-final Medicaid Outpatient Clinic regulation, and 

a 6-month delay on the Medicare Hospice rule—three regulations that affect 

the heart and soul of our health care 

system—the facilities and health providers that take care of all Americans, 

rich or poor, rural or urban. 

Given the urgent challenges we face 

in our economic health, now is not the 

time to be cutting hospitals or clinics 

that serve our physical health. We 

should be making health care more effective and efficient—not slashing reimbursement and running these providers out of business. 

The new Medicare Hospital Capital 

Indirect Medical Education, IME, payment policy is a disaster for teaching 

hospitals. It went into effect on October 1 and will be fully implemented in 

2010. 

This new policy runs counter to what 

works in American medicine. The 

Medicare program has long served the 

public good by funding the training of 

new doctors in our academic medical 

centers and teaching hospitals, using 

IME payments. 

Across the Nation in large and small 

communities there is a shortage of 

physicians—from primary care to surgeons. We rely on our Nation’s academic medical centers, 13 of which are 

in my State, and teaching hospitals to 

train new physicians. 

The new policy eliminates critical 

funding that supports teaching. 

The total cost of this new policy to 

New York’s teaching hospitals would 

be $62 million when it is fully implemented in 2010. The total for all U.S. 

hospitals is $380 million. 

Let me illustrate what these cuts 

mean to New York hospitals: Albany 

Medical Center Hospital, $1.2 million; 

Kaleida Health in Buffalo, $1.3 million, 

Montefiore Medical Center, $3.7 million; Strong Memorial Hospital, $1.6 

million; Stony Brook University Hospital, $1.6 million; Bassett Hospital in 

Cooperstown, $426,000; and Coney Island 

Hospital, $565,722. 


rfrederick on PROD1PC67 with SENATE
November 19, 2008 CONGRESSIONAL RECORD — SENATE S10625 

These facilities are the same ones in 

my State who provide the lion’s share 

of uncompensated care to the uninsured. 

One of the hardest hit hospitals in 

my State is Mt. Sinai Medical Center 

in Manhattan. They stand to lose $4.1 

million by 2010. 

This lost funding means Mt. Sinai 

Medical Center will be forced to take 

cost cutting steps: 

First, delay completion of their inpatient electronic medical record rollout; 

second, they won’t be able to expand 

their already crowded emergency room 

that provides over 100,000 patient visits 

a year; and third, they will scale back 

many free medical screenings and 

other programs for patients. 

These are not the actions we want 

hospitals to take. 

Hospitals need our help. The Medicare Payment Advisory Commission, 

MedPAC—which is a nonpartisan 

group—has said that in 2006, hospitals’ 

Medicare margins nationwide were in 

the red at negative 4.8 percent. 

In New York in 2006, rural hospitals 

were hit the hardest by low Medicare 

reimbursements with even lower margins of negative 8.2 percent. 

After 7 consecutive years of overall 

negative margins, the hospitals in my 

State did little better than break even 

in 2006. It doesn’t make sense to me 

that we would gut a source of training 

for high-paying jobs in this country at 

a time when we are bleeding jobs. 

This is not just a New York issue. In 

July, 51 Senators signed a bipartisan 

letter to the Centers for Medicare and 

Medicaid Services, CMS, that opposed 

implementation of the capital IME. We 

need to pass my bill so that these cuts 

don’t hurt all U.S. hospitals. 

Now I want to speak briefly about 

the Medicaid Outpatient Clinic Regulation that my bill places a 6-month moratorium on. 

For months I fought with CMS about 

this regulation. Unfortunately, they finalized it last week. 

But, I am pleased that in the final 

version free-standing health clinics 

were saved from massive cuts. There 

were many clinics in New York that 

were saved from either closing their 

doors or saying no to their patients. 

I want to talk about Ed, a 62-year-old 

Buffalo resident, who can only move 

his head due to his cerebral palsy. With 

the help of a free-standing clinic in 

Buffalo, called Aspire, Ed learned to 

operate his power wheelchair with his 

chin. 

Even more amazing he can operate a 

computer using his chin. Ed spent 5 

years mastering desktop publishing 

and then formed his own successful 

business. 

If free-standing clinics were included 

in the final regulation, Ed could not attend Aspire of WNY’s wheelchair clinic, 

where physical, occupational and 

speech therapists customize all sorts of 

things for him. Without that service, 

Aspire tells me that he would be completely immobile and not as independent. 

Let me discuss another New Yorker 

that the Buffalo-based Aspire Clinic 

helped. In 1998, Aspire wanted a woman 

named Alice to have a colonoscopy. 

When she did, it was revealed that she 

had colon cancer. But luckily they 

found it in time and she had surgery to 

remove the cancer and now, 10 years 

later, she is doing fine. 

Alice is just one of hundreds of individuals who receive primary medical 

care through these essential primary 

care clinics. 

Enable, a Syracuse agency that 

serves children and adults with disabilities, told my office that they would 

have to stop providing physical and occupational therapy to more than 300 

clients on Medicaid if the Rule had included freestanding clinics. 

I wish CMS hadn’t made this regulation final, but at least it isn’t as bad as 

it could be. We will know the extent of 

pain that other clinics and hospital 

outpatient services may face on December 8, when the rule must be implemented. 

Therefore, I hope that the Senate 

will pass the PATH Act. As we have 

heard, there are just too many terrible 

cuts underway in health care, and we 

need to be doing all we can right now 

to stop the bleeding. 

I understand my colleague has objected. That is unfortunate. To wait 

another 3 months or 6 months at a time 

when our economy is in such dire shape 

will do severe damage to health care 

throughout the country. In my State of 

New York, for instance, the new Medicare Hospital Capital Indirect Medical 

Education payment policy is a disaster 

for teaching hospitals. It runs counter 

to what works in American medicine. 

It affects large and small communities. 

We have a desperate shortage of physicians, from primary care to surgeons. 

The country relies on academic medical centers. This clobbers them at a 

time when it should not have happened. Many of us believe this regulation was not within the purview of 

CMS to enact. They went ahead and did 

it. I would hope that maybe my colleague will reconsider. We will return 

to this issue when we come back in 

January, but some damage, unfortunately, will be done. 

I understand why my colleague has 

objected. I regret it. There was no time 

to move in the Finance Committee because this regulation didn’t take effect 

until very recently, having many bad 

affects. I will work hard and not rest 

until we overturn the regulation. 

I yield the floor and suggest the absence of a quorum. 

The PRESIDING OFFICER. The 

clerk will call the roll. 

The legislative clerk proceeded to 

call the roll. 

Mr. REID. I ask unanimous consent 

that the order for the quorum call be 

rescinded. 

The PRESIDING OFFICER. Without 

objection, it is so ordered. 

UNANIMOUS-CONSENT REQUEST— 

S. 3689 

Mr. REID. Madam President, with 

the daunting challenges we face on our 

road to economic recovery—and that 

will come; it is a question of when— 

there is no reason to wait for a new 

year, a new Congress and a new President. We could vote now. We could take 

action now. We can’t solve our economic challenges with one vote, but we 

could get started. So I say, why wait. 

Every day that goes by, thousands of 

Americans lose their jobs. Thousands 

of homes are lost. Scores of companies 

file for bankruptcy. So why don’t we 

staunch the bleeding, stop some of the 

pain, and begin to turn things around? 

We have before the Senate a comprehensive economic stimulus plan 

worked out with the Appropriations 

Committee, the Finance Committee, 

and the Agriculture Committee, that 

we could pass and we should pass. I 

wish to express my appreciation to the 

members of the Appropriations, Finance, and Agriculture Committees. 

They have worked very hard to put this 

package together under the leadership 

of Senators BYRD, BAUCUS, and HARKIN. 

What do I mean by ‘‘comprehensive’’? 

Instead of addressing just one part of 

our economic crisis, this legislation 

takes many steps that economists 

agree we need. 

I ask unanimous consent that the 

Senate proceed to the consideration of 

Calendar No. 1122, S. 3689; that the bill 

be read a third time, passed, and the 

motion to reconsider be laid on the 

table, and there be no intervening action or debate. 

The PRESIDING OFFICER. Is there 

objection? 

The Senator from Arizona. 

Mr. KYL. I object. 

The PRESIDING OFFICER. Objection is heard. 

Mr. REID. Madam President, we have 

a matter on which the objection was 

made. I did not cover it all, of course, 

in that matter. We have significant 

things in that piece of legislation that 

were objected to dealing with infrastructure; unemployment benefits; 

FMAP, which is the matter to give 

some fiscal relief to our States; and it 

would give help to the auto industry. 

So this is the type of issue on which I 

wish we could move forward. I understand my colleagues. They are not 

going to accept this. 

I think the provision we have dealing 

with taking the money out of the financial bailout that we have, that the 

White House has, the Treasury Department has—I have talked on the floor 

over the last 2 days about that. There 

is no need to belabor that point. But it 

is too bad we could not move forward 

on that basis. 

It is my understanding Senators 

LEVIN and BOND are going to try to 

come up with some alternative proposal. When they come up with that, I 

would be happy to see if there is any 

way we can move procedurally. That is 

not going to be easy with what is going 


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