Unanimous-Consent Request - S.3656

Floor Speech

UNANIMOUS-CONSENT REQUEST--S. 3656 -- (Senate - November 19, 2008)

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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 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.

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