Remarks on the Conference Report on H.R. 1
Medicare Prescription Drug Benefit Legislation
U.S. Senator Ron Wyden
November 23, 2003
"M. President, as Congress considers Medicare and prescription
drugs, I keep remembering the older people whose stories spurred
me to choose a career in public service. For seven years before
I came to the Congress, I worked with the elderly and spent many
hours visiting them in their homes. During those visits, seniors
would often bring out shoeboxes full of health insurance policies
that were supposed to fill the gaps in their Medicare coverage.
It was common for a senior to have seven or eight of these policies,
and many of them weren’t worth the paper they were written
on. Slick, fast-talking insurance hucksters kept coming around and
scaring these older folks, and it was heartbreaking to see seniors
ripped off this way. After working all their lives, they went without
every month because they were paying for these junk policies with
the precious funds they really needed to pay the heating bill, or
buy some groceries.
"When I got elected to Congress, I vowed to stop this fleecing
of America’s seniors. I helped to write the first and only
tough law to stop the rip-offs of private health insurance sold
to the elderly. This statute has worked to drain the swamp of fly-by-night
Medigap policies that used to rob seniors blind.
"The days of the shoebox full of policies are long gone. But
skyrocketing drug costs and lack of access to medicine, two of the
problems that plagued seniors even back then, is more of a problem
today.
"During those home visits with seniors, I saw firsthand the
pain they felt when they couldn’t afford life-saving medicines.
Their anguish was physical, and emotional. They lived with pain.
They feared for their futures. They worried that the choices that
financial constraints forced them to make might not be the right
ones.
"Stories like theirs are familiar today. Caseworkers in every
Senate office hear them all the time. A senior is supposed to take
four pills, but because she can’t make ends meet, she takes
two pills for as long as she can afford that. Then she runs short
of money and she takes none. Eventually, she ends up in the hospital
– where the hospital portion of Medicare, known as Part A,
will cover her drug treatment, but sometimes then it’s too
late.
"I’ve worked to rewrite stories like that since I came
to Congress. That’s why I worked with Senator Pryor’s
father so that the states could bargain aggressively, and get more
for their Medicaid dollar when buying prescription drugs that would
help low-income seniors. I’ve tried to expand coverage for
generic drugs. I’ve worked to supplement these efforts by
creating new health care options for seniors, including in-home
care, and increased payments for providers in low-cost areas –
funds that can be used to offer prescription drug benefits.
"Because of my history, I’m acutely aware that there
is so much more to do. The reason the debate on this bill is so
important is that government has an obligation to do right by a
generation that deserves our nation’s respect and care –
not the runaround when it comes to their health.
"My years working with seniors have governed my decision on
this bill. I have tried to keep the focus on determining whether
this Medicare prescription drug legislation could make a genuine,
positive difference for a significant number of America’s
seniors, or whether it would fall short of that objective.
"As part of the process, I’ve developed criteria for
evaluating this legislation. I’d like to describe the questions
I felt were key, and the answers I have found.
"First, does the bill help a significant number of seniors
with low incomes or big prescription bills?
"In their editorial endorsing this legislation, the New York
Times stated that “the bill is strongest when it comes to
the most important target groups: elderly people with low incomes
or very high drug bills.”
"But I didn’t take their word for it – particularly
because they are just one voice in a chorus coming from both sides.
"I have gone to considerable lengths to examine the figures
and data from all angles. The data that’s been available has
been compiled from those strongly in favor of the bill, such as
the federal Center for Medicare and Medicaid Services, as well as
those strongly opposed to the bill, such as the non-profit Center
on Budget and Policy Priorities.
"Critics say this legislation has significant gaps in coverage
for all seniors – particularly those of modest income. Proponents
of the bill claim that millions of seniors will have coverage they
didn’t have before. There seems to be some truth on both counts,
and that’s why I’ve zeroed in on some figures that seem
to be beyond doubt.
"Using data from the 2000 Oregon census, my staff determined
that 78,829 older people in Oregon had health costs that were more
than the catastrophic cap of $5000 and, under this bill, would have
their prescription drug costs reduced by one half. Using 2001 data
from the non-profit Kaiser Family Foundation, my staff determined
that Oregon has 106,765 seniors on Medicare with incomes at or below
$12,123 for an individual or $16,362 for a couple. Under this legislation,
this low-income group would pay no premium for their drug coverage
and would be responsible for a co-pay of no more than $2 for generic
drugs and no more than $5 for brand-name drugs. The least fortunate
would pay only $1 for generics and $3 for brand-name drugs.
"Most seniors with low incomes and high drug costs are likely
to be eligible for both Medicaid and Medicare. These people are
commonly known as “dual eligibles.” This bill assures
that they receive a drug benefit through Medicare so they are not
left at the mercy of perennial State budget crises and so they will
not have to compete against other vulnerable groups in State budget
battles.
"Another factor to consider with respect to a drug benefit
is based on what I hear from seniors at town meetings, senior center
and nutrition sites. Many seniors will fear that this bill will
fence them in to a drug benefit they don’t want. Expectations
for this program are sky high. I know that some seniors will find
that this bill does not offer benefits that match their expectations.
But at the very least, because the program is voluntary, no senior
will be forced to accept the terms of this legislation.
"Based on the statistics I’ve cited here, I believe
that a significant number of low-income seniors and those with high
bills will benefit. That strikes me as a step in the right direction.
"My second question: how does the bill affect seniors who
currently get their prescription drug coverage through corporate
retiree benefit packages?
"You can pick up a newspaper almost every day and read about
another employer dropping their retiree benefits or cutting them
back significantly. There has been a dramatic reduction in such
corporate retiree health benefits, and it’s taking place right
now before the enactment or rejection of any legislation.
"From 1988 to 2002, the percentage of large employers offering
retiree health benefits dropped from 66 percent to 34 percent. Consistently,
employers who have kept coverage have required retirees to shell
out for higher co-payments and premiums.
"Employers say they have to make these cuts because of the
rising costs of health care, and the effects of a lousy economy.
Now along comes Congress with a bill that many believe will dramatically
affect retiree plans in the future.
"Employers are already cutting back on retiree benefits –
the Employee Benefit Research Institute says that even the number
of big employers with bargaining power who offer health benefits
to their retirees is going down. Given that this legislation offers
$71 billion tax-free to employers to keep their coverage, I have
concluded this: those funds can only be a plus in developing a strategy
for getting more employers to retain existing coverage. This is
a subsidy those companies will not see, absent this bill. Wouldn’t
companies be less likely, not more likely, to drop coverage if they
get the funds offered tax free under this bill?
"The corporate retiree provisions in this conference report
are better than the provisions in the original Senate bill, which
was approved by more than 75 members of this body. Each employer
will get back 28 percent of what they spend on drug coverage, up
to $5,000 per employee. Corporate retiree plans have significant
flexibility with respect to their design. They can use cost containment
policies such as formularies.
"Bernstein Research says employers spend about $1900 per year,
per senior, on retiree drug benefits. Based on my calculations,
this bill gives corporations a significant tax-free incentive to
cover not just retiree drug benefits, but other senior health care
costs as well.
"Does the bill significantly undermine traditional Medicare?
"Critics have focused on this issue, and I share their view
that seniors believe in Medicare, and want it modernized –
not undermined. The critics seem to believe that any effort to create
choices outside the basic Medicare fee-for-service program is a
mistake. I disagree.
"I believe seniors need good quality choices beyond fee-for-service.
I simply believe those choices must be accompanied by strong consumer
protections, and that you must strike a balance, making sure those
new choices never cut off access to the traditional Medicare that
seniors know so well, and with which they feel so comfortable.
"I have never been opposed to private-sector involvement with
Medicare. In many Oregon communities, upwards of 40 percent of the
elderly get their Medicare through private health plans. My Medigap
law standardized ten private-sector policies to help seniors fill
the holes in Medicare. The key to making private-sector choices
work is a combination of strong consumer protections and a level
playing field between the private-sector choices and health services
offered by the government. I have considerable ambivalence about
how this legislation will affect that balance.
"In the bipartisan prescription drug legislation that I drafted
with Senator Olympia Snowe, we offered private-sector options for
seniors that contained strong consumer safeguards. The Seniors Prescription
Insurance Coverage Equity Act, known as the SPICE bill, did not
tilt the playing field toward the private sector the way the legislation
before Congress does today, with its health savings accounts and
premium support.
"Unfortunately, the health savings accounts in this bill -
which are tax breaks for purchasing health care - are structured
to disproportionately benefit the healthy and wealthy. Seven billion
dollars of tax subsidies are directed to these accounts. This has
gone from a demonstration project to a major expense – that
siphons away money that could beef up the drug benefit.
"Another drawback of the bill is the premium support provisions,
which are designed to test competition between traditional Medicare
and private plans. These could drive seniors out of the fee-for-service
programs they want. Premium support demonstrations could allow insurance
companies to cherry-pick the healthiest seniors, leaving the truly
ill to go to poorly funded government programs sicker than they
are. Even though premium support doesn’t start until 2010,
it shouldn’t be in this bill at all.
"I don’t believe this legislation will wipe out traditional
Medicare. I do believe that Congress would have to be extraordinarily
vigilant with respect to this part of the legislation. Without careful
management, it’s certainly possible that health savings accounts
and premium support could tilt the Medicare program away from providing
traditional fee-for-service Medicare for every senior who wants
it. If this legislation passes, it will be the job of the Congress
to make sure that doesn’t happen.
"The next question is especially important. Virtually every
senior in America wants to know – what will this legislation
do to keep their prescription drug costs down?
"In my mind, the key to effective cost containment is creating
bargaining power for older people in the health care marketplace.
Today, when a seniors gets his prescriptions through a health plan
with many members, that plan has significantly more bargaining power
than that same senior would have walking in by himself to a Walgreen’s
or Fred Meyer to buy his medicine. Getting seniors more purchasing
power by getting them into large buying groups is an absolute prerequisite
for keeping costs at bay.
"That was the principle behind my Medicaid drug rebate law
with the first Senator Pryor. That’s the principle I worked
to follow in 1999, when Olympia Snowe and I proposed the SPICE bill.
SPICE would have allowed large groups of seniors to choose from
a vast array of competing drug benefit plans. It was a market-based
proposal based on private sector competition, offering consumers
a wide range of options for coverage under guidelines similar to
the Federal Employee Health Benefit plan – a program proven
to contain costs well because of the sheer size of the group of
federal employees for which it bargains.
"The conferees clearly rejected a model like the Federal Employees’
Health Benefit Plan, and that’s unfortunate. They did take
some baby steps in the right direction. This bill begins to leverage
the potential bargaining power of 30 million seniors by giving them
the opportunity to join large managed care plans and big fee-for-service
plans that can use their numbers to negotiate discounts. The bill
does remove some of the barriers to getting cheaper generics to
market faster. It also recognizes there is great value in comparing
the effectiveness of similar drugs, so that seniors, providers and
the government can spend funds on the best medicines at the lowest
cost. This is very much in keeping with the way my own state has
approached cost containment.
"But I wish this bill would go further. There should be a
way to bargain for even bigger segments of seniors, not just for
the fractions of the population who end up in various HMOs or other
private health care plans. I’m concerned that while private
plans have the power to bargain under this bill, the Medicare program
is specifically enjoined from bargaining. By prohibiting the Medicare
program from giving seniors the kind of bargaining power members
of Congress have in the FEHBP, the field is being tilted away from
Medicare and toward private plans. I am also concerned that there
is no ongoing monitoring to assure that drug prices are not increased
unfairly before the bill takes effect – or after, for that
matter.
"This bill doesn’t contain costs the way the bipartisan
Snowe-Wyden legislation would have done. It borrows from the principles
of our bill. However, in the end, I believe that more and better
cost-containment measures will have to be taken.
"I also wanted to look at the big picture. Does this legislation
seek to address Medicare’s broader challenges, including the
large number of retirees that will join in the near future?
"A demographic tsunami is about to occur in our country. As
the baby boomers come of age, there will be extraordinary pressures
on the health care system. Health care advances mean that seniors
will live longer, and many of those advances will come in pill form.
What is exciting is that the more researchers learn about the way
medicines affect individuals, the more personalized treatments using
pharmaceuticals will become. Drugs that work one way for Bob, will
work differently for Mary. In the years ahead, I believe a new field
known as “personalized medicine” will help to increase
the quality of patient care, and cut down on wasteful spending.
"As of now, however, baby boomers face the prospect of joining
a Medicare program already short of funds. That’s why the
$400 billion authorized in this legislation is a lifeline for those
baby boomers. Those funds provide some measure of security for future
retirees and some tangible evidence that Congress is laying the
groundwork to support the growing Medicare population – which
will need both prescription drugs and the broader program.
"I’ve already discussed the need for more cost containment
in the drug benefit. One of the controversial provisions of this
bill deals with how Medicare costs should be contained overall.
Because this demographic tsunami is coming, explosive cost increases
are inevitable.
"This legislation contains something called a “budget
trigger.” This means that if at any point Medicare spending
takes up 45 percent or more of the country’s tax dollars,
the President has to submit proposals to contain costs.
"I share the view of critics who say that this percentage
is arbitrary. But to do nothing is unacceptable, and if this legislation
passes, this cost containment issue absolutely has to be revisited.
"There are several modest benefits in this bill that look
promising to me. One would focus on an approach known as disease
management. This will be attractive in the years ahead, because
it will allow many of the country’s future seniors to have
better, more cost-effective care for their chronic conditions. Medicare
has lacked this benefit to date.
"In addition to these direct benefits for seniors, the legislation
helps to gear Medicare up for the baby boomers with significant
increases to many deserving providers. Over ten years, hospitals
in my state would receive almost $95 million.
"This includes $72 million in additional funding from adjustments
to payment rates. Oregon hospitals would receive almost $2 million
dollars for what’s known as indirect medical education. That
programs helps hospitals account for teaching expenses.
"More funds come to some Oregon hospitals in the form of an
extra million dollars for those who see a smaller number of patients
– and so have trouble covering big expenses. More than $19
million is made available through a program called “Medicare
DISH,” or disproportionate share. This program helps hospitals
who see more than their share of patients who are too poor to pay
for care.
"Right now, doctors across the country are expecting decreases
in their Medicare reimbursements in 2004 and 2005 – at least
4.5 percent effective this January 1. This legislation blocks that
cut in funding. In fact, it increases Medicare provider payments
by 1.5 percent in both of those years. This is important because
government cost shifts have already cut reimbursement to doctors,
many of whom have a large number of low-income patients, to record
lows. Many seniors are finding it hard to get care today –
because many doctors can no longer afford to take Medicare patients.
"This is particularly true in rural areas, where doctors are
often in short supply anyway. Medicare has traditionally paid rural
doctors less for their work. This bill takes steps to make payments
for rural doctors – and for rural hospitals – more equitable.
"Getting Medicare ready for the tidal wave ahead is not going
to be a walk in the park. Fixing all the problems Medicare has today
is a huge task. The additional resources this bill provides, coupled
with a new focus on promising opportunities such as “personalized
medicine,” can make a real difference for millions of seniors
and their families.
"Finally, I considered this: was there any way this legislation
could provide a path to a health care system that works not just
for seniors, but for all Americans?
"There is a provision in this bill that offers health care
hope not only for seniors, but for every American. It’s a
provision I wrote with Senator Hatch - based on our Health Care
that Works for All Americans Act.
"The Health Care that Works for All Americans provision would,
for the first time, involve the American people in the process of
comprehensive health care reform. The result would be a blueprint
for making health care more accessible and affordable than ever
before.
"Two hundred ninety million Americans live and die by the
health care system every day. In my view, they deserve to make the
hard choices of health care for themselves. Senator Hatch and I
have been able to convince those on the Medicare conference committee
that once the public has the facts about the real costs of health
care and the resources available to spend, they will be able to
make sensible decisions about what this nation’s health care
system should provide for every person.
"This provision represents the chance to launch a national
dialogue on health care reform that is long overdue. I believe that
dialogue is the only path to real reform. Let me tell you why.
"In 1993, then-President Bill Clinton announced his intention
to create a health care system that worked for all Americans. The
idea was popular with the American people at first. Yet by the time
a 1,390-page bill was written with no input from the public, sent
to Congress, and torn apart on the airwaves by special interest
advertisements, the people could not distinguish the truth from
the special interest spin, and the effort died. Without public support,
the opportunity for change was lost.
"Senate leaders from that time have told me: had the Clinton
effort begun with even six months of consultation with the public
– had they been enfranchised and encouraged to lead the way
– the Finance Committee could have written and passed bipartisan
legislation with enough of a grassroots push behind it to move through
Congress, and America could already be seeing meaningful health
changes.
"The Wyden-Hatch amendment to the Medicare bill offers a chance
to restart the process in a new way. It creates a Citizens’
Health Care Working Group to first inform the public on the current
state of American health care and possible ways to improve the system,
and then to oversee, online and through town hall meetings and other
forums, opportunities for citizens to describe the kind of health
care system they want. The Working Group will synthesize the public’s
concerns and recommendations – and the public’s views
will be guaranteed, by law, a timely hearing in every committee
of jurisdiction in the U.S. Congress.
"This plan offers the people a chance to drive the process
from the beginning. In so doing, it guarantees a national groundswell
of support. A number of American grassroots organizations believe
public input is the best road to reform, and are ready to pitch
in.
"There are tough calls to be made in today’s health
care system, including in the Medicare program. But it’s time
to make them together. And it’s time to look at the whole
picture. Health care is like an ecosystem. Senators should be reminded
in this debate about medicine and Medicare that what happens in
one part of the health care system affects health care across the
board. The Wyden-Hatch provision takes the whole ecosystem into
account. Nothing is taken off the table. Not even Medicare.
"I think folks will have concerns about this Medicare drug
benefit, as I do. And I feel a lot better knowing there is a mechanism
in this bill, in the Wyden-Hatch provision, to revisit these drug
benefit issues in the context of the health care system as a whole.
"In crafting this provision, Senator Hatch and I sought to
find common ground in order to make a real difference in America’s
health care system. I would humbly encourage my colleagues to consider
the importance of bipartisanship today.
"Collegiality hasn’t exactly been one of the watchwords
of the debate over this bill. There are some very cold considerations
entering into this discussion. Perhaps at my some peril, I want
to speak frankly for just a moment about the political aspect of
the debate.
"Some Democrats believe that the passage of this bill hands
the majority party a huge victory on the threshold of a presidential
election year, and that will be an enormous benefit on the political
trail. Some Republicans have fed these concerns by talking about
how Democrats will pay if they dare raise questions about this legislation.
"Are these really the concerns that ought to drive the debate
on Medicare, at a time when America has to get ready for the demographic
tsunami? Can polarization and division possibly do our seniors –
or any Americans – any good when it comes to fixing the health
care system they need? In my mind, the answer is no.
"There will be a Democratic president some day. Some day soon,
I hope. How would Democrats feel if Republicans denied the nation
needed legislation because they simply wanted to deny that Democratic
president a victory?
"Actually, we know how we would feel – they did it to
President Clinton. But at some point, we need to get off this carousel.
It’s not fun. It’s not good for the nation. It’s
not even good politics.
"And yet it isn’t difficult to understand the passion
on the Democratic side over this legislation. The majority has worked
behind closed doors and shut out key Democratic voices that would
have made this a far better bill. Their partisan approach has probably
guaranteed them a decade of battles over the benefits offered in
this bill – battles they will eventually lose on both the
politics and the substance.
"M. President, it’s not Casablanca on the Senate floor,
where I’m shocked, I tell you, shocked to find out about politics
being part of this debate. But excuse my pre-Thanksgiving wish that
at this time, in this place, politics should be secondary to what’s
good for seniors.
"I say to my colleagues, cast whatever vote you choose on
this legislation. But I hope the Senate will do what I’ve
tried to do in 30 years of working for seniors. I’ve always
looked for people of goodwill, ideas and energy who are willing
to work together to make a positive difference.
"I will be the first to admit that uncertainties abound with
regard to this bill. I have discussed at length the aspects of this
legislation about which I still have questions.
"I can tell you: this vote is a really tough call.
"In the final analysis, M. President, I am concerned that
Congress could make a mistake by believing that the $400 billion
on the table for a Medicare prescription drug benefit today, will
still be there in February of 2005.
"As a member of the Budget Committee, I know how hard it has
been to get funding for a benefit in the budget. For example, when
Senator Snowe and I began in 1999 to work for funding for a drug
benefit, we thought we had lassoed the moon when we successfully
got $40 billion in the budget. How, then, do you argue that Congress
should walk away from $400 billion?
"Every year of delay has made this benefit cost more. No senator
will ever get to go off and write every idea they have into a Medicare
bill. Waiting simply costs dollars that could be used to create
a better drug benefit.
"I have long said that there are tough choices to be made
about the kind of health care system Americans deserve. I have called
on my fellow citizens to make those tough choices for themselves.
I wrote a provision in this bill to give them the power to make
those tough calls and to get them heard by their government. In
view of that, I cannot shrink from this decision, no matter how
hard it may be.
"I wish this were a better bill. There are a number of legitimate
procedural considerations that may come before the Senate during
this debate, and I will have to weigh every procedural vote carefully
to decide how each might affect the quality of this legislation.
If it finally becomes clear that the bill, as is, represents the
Senate’s sole opportunity to inject $400 billion and a long-sought
prescription drug benefit into Medicare, I will vote yes.
"And should this bill pass this year without the improvements
I would like to see, I will come back to this when dawn rises on
the new session. I will fight to put more and better cost containment
measures into the drug benefit and Medicare overall. I will fight
to assure coverage to those who slip through the cracks of this
benefit. I will fight to create stronger consumer protections for
every senior. I will fight to preserve the option of traditional
Medicare. And I will continue to fight for better health care for
all. M. President, I yield the floor."
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