```

[Congressional Record Volume 154, Number 176 (Wednesday, November 19, 2008)]
[Senate]
[Pages S10623-S10625]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

                   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

[[Page S10624]]

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.

[[Page 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.

                          ____________________
```