Prescription Drug and Medicare Improvement Act of 2003 - Resumed

PRESCRIPTION DRUG AND MEDICARE IMPROVEMENT ACT OF 2003—RESUMED

AMENDMENT NO. 1103 TO AMENDMENT NO. 1092

    Mr. DURBIN. Will the Senator yield?

    Mr. DORGAN. I will be happy to yield.

    Mr. DURBIN. Do I understand that senior citizens, given the choice between traditional Medicare and Medicare HMOs, have already voted and that 88 or 89 percent of them want traditional Medicare; that they do not want to put their medical fate in the hands of these HMO private insurers who are unreliable, who may or may not cover the procedures they need? Haven't the seniors of this country, with their experience, already voted on this issue we are considering?

    Mr. DORGAN. Seniors have already made that judgment. They have already decided that. So we want to take $6 billion and give it to private health insurers at a time when Senators have been coming to the Chamber and saying we cannot improve this plan because we do not have any money. I have quotes of all the Senators, and I shall not name them all. I could read lots of quotes from the last 2 weeks of Senators. Why can't we improve it? Because we are limited by money. So now we have $12 billion more? That is what happens when you go into a room, shut the door, make a little deal, and say this is how we want to use this money: We are going to take $6 billion and try an experiment that we failed at previously. It makes no sense to me. It is a byzantine failure, in my judgment, to do it this way.

    What I am proposing in my amendment is use the money to actually improve the program for senior citizens. We can drive down the cost of the prescription drug policies and improve the coverage.

    Mr. DURBIN. I ask the Senator, if he will yield further, is the Senator aware of a recent survey of seniors—over 600 across the United States—where they were told what this plan, S. 1, is all about? They said the fact that the $35 premium is not mandated in this law but is simply a suggestion; it may go higher; the fact private insurance companies that provide the prescription drug benefit may decide to change the benefit or go out of business every 2 years; the fact there is a $275 deductible and a huge gap in coverage for the sickness of the senior citizens—when they looked at all those items, is the Senator aware of the fact that most of the seniors, when asked, said they did not believe that S. 1 really answered the need in America that seniors are looking for?

    Mr. DORGAN. I know that is the case. I have seen the same survey to which the Senator referred. I think there are some provisions in this bill that have some merit. I prefer we do something rather than do nothing, but when we do something, let's do something right and something that benefits senior citizens. This is the case when you cite the polls, when you cite what our previous experience has been. It is a case, especially with respect to the use of this $6 billion, of the old joke from the movies: What are you going to believe, me or your own eyes?

    The fact is, we have already had these experiments. We understand how much additional costs are involved in the private sector delivery of this benefit, and we also know what Medicare does and how Medicare works. We know the private insurers have about a 14-percent overhead in administrative costs and delivering their service. We know that. We also know Medicare has about a 4-percent cost, a dramatic advantage.

    For that reason alone, you would want to provide this benefit through the traditional Medicare delivery system. Against all odds, we have people in this Chamber who, I guess, although they do not say it, believe along with Congressman THOMAS that this bill ought to be the end of Medicare as we know it. Congressman THOMAS said: Our answer to that is, we certainly hope so.

    Mr. DURBIN. I ask the Senator, is it possible Halliburton is going to pay some of these services with the six—I will withdraw that question. I ask the Senator, if one believes in privatization and competition, why does the private sector need a $6 billion subsidy to compete with Medicare? If they are good, if they are efficient, if they are customer friendly, why do they need this Federal subsidy of $6 billion to offer an attractive health care package to seniors?

    Mr. DORGAN. First, they do not need it, and no subsidy is warranted. The point of my amendment is to say if you have $12 billion, and they say let's take $6 billion and use it for an experiment that we know does not work, let's instead use that money to help seniors. Then the underlying amendment says let's take another $6 billion and test whether focusing on wellness will work, which we know it does work. We do not exactly have to have an experiment on that. Do things that promote wellness and the fact is you save money on the acute care side by not having people go into the hospital because they are taking care of themselves and have the kind of preventive care that is necessary to take care of themselves.

    I have another amendment pending. It has been pending for nearly a week. I hope it will be approved by the end of this process. It is a very inexpensive amendment that deals with that very kind of wellness approach.

    If senior citizens have heart disease, Medicare covers cholesterol screening. It makes sense, does it not? But Medicare does not cover cholesterol screening if one does not know they have heart disease. It does not make sense.

    Heart disease is our biggest killer in this country. We ought to cover cholesterol screening across the board. That is the way one can discover who is at risk for heart disease at a point when steps can be taken to prevent it. Yet Medicare does not cover that screening unless a person already has evidence of heart disease.

    There are many things we should do to improve Medicare's preventive coverage. My hope is that perhaps we will have that amendment approved before the end of this process.

    My colleague from Illinois talked about HMOs a moment ago. We are not in the trenches of the HMO debate as it was first envisioned by the White House, which said to senior citizens, here is a Faustian bargain: we will give you a prescription drug benefit but only if you enroll in an HMO. Talk about a goofy proposal; that is it.

    I have been talking about HMOs. There were some HMOs that did some good things, held down some prices. I understand that. But we have all also heard the stories of HMOs not taking good care of people. I guess we do not need to review the HMO stories about what happens to patients when profits were at stake. For instance, a woman falls off a cliff in the Shenandoah Mountains, sustains very serious head injuries and body injuries. She is hauled into an emergency room on a gurney in a coma. After a long convalescence, she finally gets out of the hospital only to be told by her HMO that they will not cover her emergency room treatment because she did not have prior approval to use the emergency room. This is a woman who is hauled in on a gurney in a coma.

    I will not revisit all of those HMO stories because it will take too much time, but I will say this: With Medicare, we know what works. Some of my colleagues make the case that it costs too much. Do my colleagues really know what costs too much in Medicare? It costs too much because people are living too long. What a wonderful set of victories we have in this country. With great health care, people are living longer.

    I probably should not talk about my uncle again, but I have an 81-year-old uncle who runs the 400 meter and 800 meter in the Senior Olympics. He is probably out running today. He runs 3 miles a day at 81 years old. Forty years ago, one reached 81 years old and they had to be in a chair someplace, but not any longer. People live longer, doing things no one ever expected them to do. And that includes my uncle. Good for them. Good for him. But because people live longer, Medicare costs more. That is not a sign of failure; it is a sign of success.

    Now we are trying to add to Medicare that which should have been added some long while ago: The miracle drugs that do provide miracles but only if one can afford them. We are talking about covering the drugs that keep seniors out of the hospital and they do not have to go into an acute care hospital bed. That is what we are dealing with.

    With this amendment, we are dealing with $12 billion. Instead of bifurcating it into two different experiments, one of which failed and one of which we do not need because we know the answer, what I propose we do is use that $12 billion to reduce from $43 to $38 the premium our senior citizens will have to pay for this prescription drug benefit, starting in 2009.

    There are people who live on $350 or $450 a month, their total income from their miserable little Social Security payment, who are living alone in a small town, are struggling to buy food, struggling to buy the necessities of life. There are people who have been told by their doctor: Oh, by the way, you have heart disease and diabetes, and here are the prescription drugs you need; and they sit at home knowing they do not have a penny to pay for those prescription medicines. Talk to those seniors and understand how important this coverage is. The coverage ought to be good and extensive coverage, and it ought to provide what we know we should provide for senior citizens.

    Second, it ought to be done in an affordable way. Unfortunately, another weakness of this plan is that there is no defined benefit, which means the premiums can vary. The monthly premiums will increase year after year because we have not done enough to put downward pressure on prescription drug prices—and as prescription drug prices increase, the monthly premium will increase. The expectation is that the monthly premium starts at $35 and goes to $60 in a 10-year period. My amendment proposes about a $6 reduction in the monthly premium for senior citizens. That is a more effective way to use this $12 billion. Either that, or I would propose we extend the coverage through the $1,300 gap that exists in coverage, which I think would also represent a meritorious way of using this amount of money.

    My colleague, Senator Pryor from Arkansas, is in the Chamber and he may wish to address this issue as well. I have offered this amendment on behalf of myself and my colleague Senator Pryor, so I yield the floor in the hope that Senator Pryor will wish to make some comments as well.

    Mr. GRASSLEY. Mr. President, it is unfair for Members of the other side of the aisle to give us statistics that say 89 percent of the seniors are in for fee-for-service Medicare and only 11 percent are in Medicare+Choice and that is a nationwide average. It is an accurate statistic, but it does not speak to the seniors of America who like Medicare+Choice and I have figures from four cities—Miami, New York, San Francisco, and Chicago.

    In Miami, 45 percent of the senior citizens have chosen managed care, the Medicare+Choice option, as opposed to fee-for-service; New York, 22 percent; San Francisco, 29 percent. In Chicago, it was only 6 percent. That may be one reason why Senator Durbin keeps bringing this up quite regularly. This data is from the Congressional Research Service, and it is as recent as March 2003.

    When people, wherever they are in the Senate, want to denigrate Medicare+Choice by saying only 11 percent of the people in this country join in and that is such a small percentage and that these figures are evidence it is not liked, go to Miami and ask 45 percent of the citizens who belong to Medicare+Choice why they like it.

    I yield the floor.

    The PRESIDING OFFICER. The Senator from Arkansas.

    Mr. PRYOR. Mr. President, last night was a difficult night for me because I was lying in bed worrying about the insurance companies and how we were not getting them enough money during this Congress. Of course, I am being facetious because I think we have a very clear choice.

    I commend Senator Dorgan, Senator Durbin, and a number of others who have shown national leadership on this effort to try to make this bill better. I think there is a broad consensus that we want to add a prescription drug benefit to Medicare. We want to help seniors all over this country, but at the same time we have to make sure it is set up the right way. It has to make sense.

    Quite frankly, one of the things that to me does not make sense, and probably to most people around the country does not make sense, is that we might give a pretty healthy sum of money to the insurance industry.

    All over the country—and I know it is certainly true in my State—insurance companies are raising premiums. It may be health care premiums—everybody knows those are going up. It may be property and casualty; it may be homeowners policies, auto policies, medical malpractice, legal malpractice. You name it, across the board, as far as I know, the price of every single kind of insurance in this country is going up.

    Nonetheless, there are some in this Congress who want to actually give them a sizable chunk of money that could go to people who really need the help.

    I take my hat off to Senator Dorgan for his leadership. One thing he has figured out is a way to make the monthly premium less for people. Now, saving $6 a month to someone at my income level, and all of our income levels, that is not a lot of money, but for those senior citizens all over this country who live below the poverty level—the only money they get every month is Social Security, maybe a little help from the family—$6 is a lot of money. Six dollars may make this program affordable for them. It is real money. It is money that at the end of the year, if you add it up, is only $72 a year, but that is real money to so many Americans all over this country.

    The purpose of the bill, not just this amendment but the whole bill, is to help Americans afford their prescription drugs. I know that Senator Durbin, who is in the Chamber, and Senator Dorgan and a number of others in this Chamber have tried to make prescription drugs more affordable in this legislation. There have been different efforts tried in different ways. One of the things I tried was to strengthen reimportation from Canada to try to make prescription drugs more affordable, but certainly making the premiums more affordable makes the program more accessible to more Americans. That is a win/win/win for everybody.

    So I thank the Senator from North Dakota for yielding me some of his time. I know he is frantically talking to colleagues to try to have them adopt this amendment when we vote on it this afternoon.

    Let's run through the numbers very quickly one more time so we understand clearly what we are talking about. This amendment expends $2.4 billion per year to make premiums cheaper. It will reduce the typical premium—this is average—by $6 a month.

    I take my hat off to the folks in this Chamber who worked out compromise after compromise after compromise trying to come up with solutions to make this bill something that will become law, something that the majority of Members can vote for, not just in this Chamber but the House, something the President can sign.

    I believe strongly people in this country deserve to have access to these wonderful prescription medications that are in many ways miracle drugs. It is a shame for this country to have these drugs available on the marketplace but so expensive that people cannot afford them. That is what we are trying to accomplish.

    I yield the floor.

    The PRESIDING OFFICER. The Senator from Illinois.

    Mr. DURBIN. I thank my colleague from Arkansas as well as my colleague from North Dakota. They have come to the floor and said to the Members of the Senate, look, we found $12 billion. Imagine $12 billion over a period of time. We are in the middle of debating a prescription drug bill. What would the Senate do with new found money, $12 billion worth?

    We took a look at the underlying bill, the prescription drug bill. There are a lot of problems with it. There is no guaranteed monthly premium. It has a deductible. It has a period of time when there is no coverage. You are paying prescription drug bills and you have no protection, no coverage. There are a lot of uncertainties in this bill.

    You would think the first thing you would do with the $12 billion is make this a stronger bill, try to take care of some of the weaknesses, the deficiencies.

    Wrong. Given $12 billion, an agreement has been reached not to give the money to the seniors to help them pay for prescription drugs but to give $6 billion to HMOs and private insurance companies, a $6 billion Federal subsidy so they can experiment with alternatives to Medicare.

    I am like my colleague from Arkansas; I could not get a moment's rest last night for fear that we just were not going to give enough money to the insurance companies when this was all over with. I lost all my sleep the night before worried about the fact that maybe pharmaceutical companies would not get all the money that we could possibly throw their way. Then along comes this amendment. We can rest easy tonight because we will give $6 billion to HMOs. This industry which manufactures the milk of human kindness for seniors and families across the America by denying basic health care coverage so they can run up profits is going to need a Federal subsidy.

    What a delicious irony that we cannot help poor seniors trying to pay for prescription drugs because, Senator, we just do not have enough money. And we cannot help our schools, we cannot pay for President Bush's No Child Left Behind, this unfunded mandate on everybody's local schools because, Senator, we just do not have enough money. But the $6 billion we just found we are going to give to the HMO insurance industry.

    When they write the history of this debate, this amendment will stand out. This amendment is a tribute to selfishness, a tribute to shortsightedness. Why in the world aren't we helping the people who need it the most? Why are we giving the money to the HMOs so they can experiment with an effort to end Medicare?

    I just ran into BILL THOMAS in the hallway, chairman of the House Ways and Means Committee, most powerful man when it comes to Medicare in the House of Representatives. He said in today's New York Times:

    Some of our friends on the other side of the aisle are saying if this bill becomes law, it will be the end of Medicare as we know it. Our answer to that is, we certainly hope so.

    Well, thank you, Congressman THOMAS, for your candor. And your candor is the reason why so many Senators have now come to the Senate and said the only way to end Medicare is to subsidize HMOs with even more money so they can be more profitable and try to force Medicare out of business. That is what it is all about.

    My colleagues will have two choices. They can join me in voting with Senator Dorgan, Senator Pryor, and others and say if you have $12 billion, for goodness' sake, put it into this bill. Make this bill a little better for seniors. Reduce the cost for seniors. Give them some assurance of what they will pay. Provide more prescription drug coverage. That is one option. I will support it.

    If it does not succeed, I will offer a second option. It reaches a point under the bill we are debating, during the course of a year, when there is a gap in coverage where the Federal Government will not help pay one penny on your prescription drugs, and about $3,700 into the year out-of-pocket expenses for prescription drugs, this plan cuts off. The underlying plan says you are on your own until you get in the range of $5,500. Then we will start paying you again. So there is a gap in coverage where that senior citizen, that widow living by herself, has to pay all of the prescription drug bills until she reaches the catastrophic coverage level.

    This would not be a problem if you did not have over $3,700 in prescription drugs a year. But a lot of seniors do. I have run into them, met them in Illinois, heard their testimony on Capitol Hill from across the country.

    I will offer an alternative to my colleagues in the Senate that says simply this: We want to make sure people who suffer from some of the most expensive diseases that afflict senior citizens can pay for their medication. So we will take the $12 billion and we will put it into the basic bill and cover heart disease, cancer, Alzheimer's, diabetes and its complications.

    We are not going to leave you high and dry. At the end of $3,700 of subsidy from the Government, we are going to take the $12 billion and put them back in there to try to keep helping you if you are afflicted with one of these diseases.

    I will readily concede to my colleagues that I can think of a half a dozen other diseases where people have horrendous prescription drug bills and need help but I will try to appeal to my colleagues. Here is your choice. You have a parent or a grandparent, suffering from cancer, who has to buy expensive drugs to stay alive. The Government program that we are proposing stops paying for those drugs halfway through the year because they have reached a point where they spent $3,700 and now they have to wait and spend another $1,500 to $1,800 of their own money before they have coverage. You can help them pay for those cancer therapies or you can send $6 billion in Federal subsidies to HMO insurance companies.

    That is the choice. It is a fairly straightforward choice.

    According to a July 2002 study, heart disease and hypertension are the most expensive conditions to treat. Millions of Medicare beneficiaries are suffering from them and struggling to pay for their medications. That is one of the conditions we would help pay for with the $12 billion, $6 billion of which is headed for these private insurance companies' subsidy.

    The majority of America's cancer patients are on Medicare. They are your parents and grandparents. They are struggling with all forms of cancer. Nearly 60 percent of new cancer diagnoses and 50 percent of all cancer-related deaths occur in people 65 years and older.

    I am not identifying a problem that does not exist. It exists. Ask any family about cancer, my family included. We all have stories to tell. And you know how expensive it is now to keep that loved one alive to try to give them a chance to survive. This bill cuts them off and leaves them high and dry. My amendment gives them a chance.

    More than 2 million of all Medicare beneficiaries will have cancer in 2003. Let me give an example of a couple who wrote to my office. They wrote a couple years ago from a downstate community, a small community. It is one of the letters that Senators get every day, one that we saved. It was sent to us in September of 2002.

    Dear Senator Durbin:

    My wife has multiple myeloma, which is a cancer of the bone marrow. This disease, while controllable, is not curable. As a result, she has to take a great deal of drugs for physical as well as mental anxiety.

    Last year our combined prescription drug bill [and this is the year 2000] was $4,500. This year our regular prescription drug bills will be more.

    Now my wife Marion has been put on Thalidomide. A great many multiple myeloma patients are now on Thalidomide. Said drug is very expensive. With a low dose [and this is in the year 2000] it is $455.99 a month.

    Incidentally, we checked. That same low dose now costs $645 a month. So in 3 years it has gone up over 40 percent. It costs them $5,500 a year just for that drug. This is an elderly couple in their retirement on a fixed income, fighting cancer, putting every dollar in their savings into keeping one of them alive. Think about $644 a month. Think about seniors trying to survive on $1,100 a month on Social Security. And think about this bill which says to this family from Illinois and others just like them: I am sorry, but at some point we are going to stop paying.

    Doesn't it make more sense for us to take the $6 billion and not give it in a subsidy to these private insurance companies but instead give it to these seniors to help them pay these bills? I think it does.

    I don't have to tell you the story of Alzheimer's. Is there a family in America that does not have a loved one or a friend who is struggling with some form of Alzheimer's? God bless us; we are living longer, but as we do life gets more complicated. Let me give an example of a gentleman in Maplewood, MN. His annual out-of-pocket drug costs for Alzheimer's are $7,000—annual cost. This man is 78 years old. He pays as much out of pocket for prescription drugs as he does for all of his other household expenses combined. He is a World War II vet, father of three. He is a full-time caregiver for his wife. He hasn't had a vacation in 5 years. He has given up what he loves to do because he just can't afford them.

    "I am managing the cost, but I'm pretty nervous about it," he says. Medicare can do something to help. Yes, it can. That is our choice. Are we going to do something to help these seniors facing the most expensive medical conditions or are we going to give $6 billion to private HMOs in a Federal subsidy?

    The last one I include is diabetes and its complications. I am sad to report to you, those who are following this debate, diabetes is reaching epidemic proportions in America. Over 6 percent of the American population suffers from some form of diabetes. In the late stages of diabetes, the complications become horrible: Amputations, blindness, severe problems.

    Faced with this in your senior retirement years, depending on a prescription drug plan, do you really want to say to these people and these families battling diabetes and its complications: We are going to cut you off. We would love to give you more but frankly we have to help the HMO insurance companies. Those are the ones who really need a helping hand.

    You couldn't take that argument to any town in America. You couldn't take it to any public meeting. You couldn't take it to any senior citizens. You couldn't take it to any family with a loved one struggling with one of these diseases.

    So my friends on the floor of the Senate are going to have a choice: $6 billion in Federal subsidies for HMOs or $6 billion to help seniors struggling with these terrible, life-threatening, expensive conditions, to pay their prescription drug bills. I think that choice is easy. I hope the majority of the Senate agrees.

    I reserve the remainder of my time.

AMENDMENT NO. 1108

    Mr. DURBIN. Mr. President, I will speak briefly because I have to go to another meeting and return for the vote.

    I have great respect for the Senators from Iowa and Montana, but I struggle to understand why we are giving a $6 billion subsidy to the HMOs in America. If they are so good, if they are so efficient, if the free market is truly better than the Government-run Medicare system, why in the world do they need $6 billion worth of the taxpayers' money? You know that of that $6 billion hundreds of millions of dollars are going to go to them in profits. We are literally subsidizing the profits of these companies. We are creating this artificial environment that suggests these companies can do just as good a job or better than Medicare with the $6 billion Federal subsidy to make it work.

    I can't understand why my colleagues on the conservative side who are hidebound apostles of the free market system don't even wince when it comes to sending $6 billion to the HMOs and the private insurance industry in order to let them play on the field for health care for seniors in America. I don't get it. I certainly don't understand why you wouldn't take that same money to protect the most vulnerable people in America—our senior citizens who are struggling with heart disease, cancer, Alzheimer's, and diabetes and its complications. Why is the money for the boardrooms of the HMOs a good expenditure of tax dollars and the money for the family rooms of senior citizens struggling with these deadly diseases not a good investment with taxpayer dollars?

    The underlying bill is the biggest breakthrough for the American pharmaceutical industry since the establishment of patents in the Constitution. This amendment with $6 billion in flatout tax subsidies to HMOs is the answer to the prayers of the insurance companies in America.

    Is that what the Senate is all about? Are we supposed to come here to make certain that the wealthiest corporations in America get wealthier? I don't think so. They are doing quite well. The rate of return for pharmaceutical companies across America is 18 percent. The average for the S&P companies is 3 percent. These companies are immensely wealthy and profitable. We help them even more with this bill. We know how well the insurance companies are doing. We know the bonuses they give their executives and we are going to plow in $6 billion to make it even wealthier.

    There is something else wrong. We know that a lot of average citizens in America—particularly senior citizens—are struggling. Pick up the morning papers. Whether it is the Washington Post or the New York Times, they go to speak to seniors in their real-life environment and talk to them about how they survive. Some of them are well off. Some are lucky. They have saved a lot of money or they have a good and generous retirement but a lot of them do not. A lot of them are literally struggling month to month, some even week to week, just to get by.

    This morning in the Washington Post there was a story about a widow lady who said: At the end of the month, I'm lucky if I have a dollar left over. At the end of the article she said: I wonder how many Senators have ever thought about trying to live on $1,100 a month.

    I don't know how she does it. I don't know how a lot of people do it in my State. Why wouldn't we want to help these people? Why is it the pharmaceutical companies and the HMOs are more important than the most vulnerable people in society? I don't get it.

    Frankly, I think a lot of our colleagues, as I said earlier, ought to take these arguments, which sound so good on the floor of the Senate, back to the real world of the State they represent, take them into the town of their choice, the public meeting of their choice, and explain to people why HMOs need a subsidy but seniors do not need a helping hand. It just does not work.

    So I will be offering an amendment that says we will take this $12 billion and focus it on the elderly people who suffer from some of the worst and most demanding diseases.

    I reserve the remainder of my time.