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S. 1034. A bill to amend title XVIII of the Social Security Act to increase the amount of payment under the Medicare p rogram for pap s mear laboratory tests; to the Committee on Finance.

[Page: S5275]  GPO's PDF


   Mr. AKAKA. Mr. President, today marks the 116th birthday of Dr. George Papanicolaou, who developed one of the most effective cancer screening tests in medical history--the Pap s mear. Cervical cancer was one of the leading causes of cancer deaths in women in the United States 50 years ago and it is still a major killer of women worldwide. I rise today to introduce the Investment in Women's Health Care Act, a bipartisan bill to increase the reimbursement for Pap s mear laboratory tests under the Medicare p rogram. I am pleased to be joined by my colleagues--Senators SNOWE, MURRAY and COLLINS.

   The inadequacy of current lab test reimbursement was brought to my attention by pathologists who alerted me to the significant cost-payment differential for Pap s mear testing in Hawaii. According to the American Pathology Foundation, Hawaii is one of the 23 States where the cost of performing the test greatly exceeds the Medicare p ayment. In Hawaii, the cost ranges between $13.04 and $15.80. Yet the Medicare r eimbursement rate is only $7.15.

   The large disparity between the reimbursement level and the actual cost of performing the test may force labs in Hawaii and around the Nation to discontinue Pap s mear testing. The below-cost reimbursement may compel some labs to process tests faster and in higher volume to improve cost efficiency. This situation increases the risk of inaccurate results and can severely handicap patient outcomes.

   This bill would increase the a reimbursement rate for Pap s mear labwork from its current $7.15 to $14.60--the national average cost of the test. This rate is important because it establishes a benchmark for many private insurers.

   Last year, we were successful in having language included in the omnibus appropriations conference report recognizing the large disparity between the costs incurred to provide the screening tests and the amount paid by Medicare. The conferees noted that data from laboratories nationwide indicates that the cost of providing the test averages $13.00 to $17.00, with the costs in some areas being higher. Accordingly, conferees urged the Health Care Financing Administration to increase Medicare r eimbursement for Pap s mear screening. Although HCFA has indicated a willingness to increase this payment, I am concerned that the adjustment the agency is considering may be significantly less than the costs incurred by most laboratories in providing this service. Therefore, my colleagues and I are compelled to reintroduce legislation that would implement what we believe to be an appropriate increase.

   Mr. President, no other cancer screening procedure is as effective for early detection of cancer as the Pap s mear. Over the last 50 years, the incidence of cervical cancer deaths has declined by 70 percent due in large part to the use of this cancer detection measure. Evidence shows that the likelihood of survival when cervical cancer is detected in its earliest stage is almost 100 percent, if treatment and follow-up is timely. If the Pap s mear is to continue as an effective cancer screening tool, it must remain widely available and reasonably priced for all women. Adequate payment is necessary to ensure women's continued access to quality Pap s mears.

   I urge my colleagues to support this important bipartisan legislation. Mr. President, I also ask consent the text of my bill be included in the RECORD.

   There being no objection, the bill was ordered to be printed in the RECORD as follows:

S. 1034

   Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,


   This Act may be cited as the ``Investment in Women's Health Act of 1999''.


   (a) IN GENERAL.--Section 1833(h) of the Social Security Act (42 U.S.C. 13951(h)) is amended by adding at the end the following:

   ``(7) In no case shall payment under the fee schedule established under paragraph (1) for the laboratory test component of a diagnostic or screening pap s mear be less than $14.60.''.

   (b) EFFECTIVE DATE.--The amendment made by subsection (a) shall apply with respect to laboratory tests furnished on or after January 1, 2000.

   Ms. SNOWE. Mr. President, I rise today to join my colleague from Hawaii, Senator AKAKA, in introducing the Investment in Women's Health Act.

   Today we celebrate the 116th birthday of Dr. George Papanicolaou, the physician who developed the Pap s mear. In the 50 years since Dr. Papanicolaou first began using this test, the cervical cancer mortality rate has declined by an astonishing 70 percent. There is no question that this test is the most effective cancer screening tool yet developed. The Pap s mear can detect abnormalities before they develop into cancer. Having an annual Pap s mear is one of the most important things a woman can do to help prevent cervical cancer.

   Congress has recognized the incomparable contribution of the Pap s mear in preventing cervical cancer and nine years ago directed Medicare t o begin covering preventive Pap s mears. Medicare b eneficiaries are eligible for one test every three years, although a more frequent interval is allowed for women at high risk of developing cervical cancer. And through the Balanced Budget Act of 1997, Congress expanded the Pap s mear benefit to also include a screening pelvic exam once every 3 years.

   But the Medicare r eimbursement rate is artificially low and does not accurately reflect the true cost of providing this vital test. The current Medicare r ate of reimbursement is $7.15, though the mean national cost of the test is twice that amount: $14.60 per test. The bill we introduce today, The Investment in Women's Health Act, will raise the Medicare r eimbursement rate for Pap s mears to at least $14.60 per test.

   Women understand the usefulness and life-saving benefit of the Pap s mear. The U.S. Centers for Disease Control and Prevention reported last year that 95 percent of women age 18 years old and over have received a Pap s mear at some point in their lives. And 85 percent of women age 18 years and older across the country have received a Pap s mear within the last 3 years.

   Unfortunately, the artificially low reimbursement rate threatens both our country's local clinical laboratories and the health of women across the country. Pathologists are increasingly concerned that low Medicare r eimbursement for Pap s mears will force them to stop providing the service and to ship the slides to large out-of-state laboratories. Shipping the slides to non-local, large-scale laboratories--``Pap m ills''--reduces quality control, brings up continuity of care issues, and puts women at risk of higher rates of ``false positives'' or ``false negatives.''

   Providing Pap s mears locally facilitates the likelihood of follow-up by a pathologist, comparison of a patient's Pap s mear to cervical biopsy, and facilitates better communication and consultation between the patient's pathologist and attending physician or clinician. When Pap s mears are shipped out of the local community these vital comparisons are much more difficult to complete and are more prone to inconsistencies and error.

   Inadequate reimbursement for Pap s mears provided through Medicare t hreatens not only a woman's health but the financial stability of the laboratory as well. If a lab is forced to continue to subsidize Medicare P ap s mears they will eventually either stop providing the Medicare s ervice or go out of business--and neither option is acceptable. Finally, local laboratories have a proven track record of providing better service for the patients. A Pap s mear is less likely to get lost in a local lab than among the tens of thousands of other tests in a ``Pap m ill'' and cytotechnicians have better supervision by a pathologist in smaller laboratories than in large volume operations.

   The Pap t est has contributed immeasurably to the fight against cervical cancer. We cannot risk erasing our advancements in this fight because of low Medicare r eimbursement. I urge my colleagues to join us.

   By Mr. FEINGOLD (for himself and Mr. BINGAMAN):

   S. 1035. A bill to establish a program to provide grants to expand the availability of public health dentistry programs in medically underserved areas, health professional shortage areas, and other Federally-defined areas that lack

[Page: S5276]  GPO's PDF
primary dental services; to the Committee on Health, Education, Labor, and Pensions.


   Mr. FEINGOLD. Mr. President, I rise today to introduce legislation to address a troubling--but little recognized--public health problem in this country, and that's access to dental health.

   Unlike many public health problems, there are clinically proven techniques to prevent or delay the progression of dental health problems. These proven techniques are not only more cost-effective, but also are relatively simple if done early. I'm specifically referring to the use of fluoride and dental sealants. The combination of fluoride and sealants is so effective against tooth decay that it has been likened to a ``magic potion.'' In fact, an article in Public Health Reports called the ``one-two combination of fluoride and sealants . . . similar to that of vaccinations.''

   With such an effective prevention method in place, one might assume that dental disease is becoming increasingly rare in this country. But that's not the case, Mr. President, because, in order to receive these preventive treatments--this ``magic potion'' against dental disease--you need to see a dentist, and there simply are not enough dentists to provide these basic services to everyone who needs them. As of September 30 of last year, the United States had 1,116 dental health professions shortage areas, or Dental HPSA's according to the Health Resources and Services Administration. The chart I have here shows the counties in Wisconsin that have areas designated as shortage areas, but every single state in our Nation has a portion designated as a dental shortage area.

   There are proven methods for preventing dental disease, yet 1,116 communities across our country--particularly underserved rural and inner-city communties--do not have enough dentists to provide simple preventive services. Barriers to dental care are particularly acute among lower income families, Medicaid enrollees, and the uninsured. Studies indicate that the prevalence of dental disease increases as income decreases. In many areas, there simply are not enough dentists to provide basic treatment to all who need them, and although there is a federal method for designating such areas as dental health professional shortage areas (DHPSA's) to become eligible for additional funding, the designation process can be so tedious that State dental directors simply lack the resources to complete the necessary documentation.

   To illustrate this problem of undercounting shortage areas, as of September 30 of last year, only eight counties in Wisconsin had portions designated as DHPSA's according to the Health Resources and Services Administration (HRSA), but statewide only 23 percent of Medicaid enrollees had received dental care. As you can see from this chart, in 13 Wisconsin counties, fewer than 10 percent of Medicaid enrollees received dental care. According to Wisconsin's state dental director, Dr. Warren LeMay, 80 percent of tooth decay is found in the poorest 25 percent of children. Given the effectiveness of dental health care in preventing dental disease--particularly the combination of check-ups, fluoride, and sealants--the access problems are simply unacceptable.

   And the impact of so many people going without dental care is devastating. Those of us who have ever had a toothache remember how excruciating that pain can be, making it difficult if not impossible to work, go to school or otherwise go about our business. For those Americans who lack access to dental services, however, the toothache is more than a bad memory--it is the here and now.

   Mr. President, imagine you had a child, a daughter, in need of dental services. But you lack insurance, and cannot afford to pay out-of-pocket to see a dentist. Or you may have Medicaid, but the nearest dentist is more than 2 hours away, and you don't own a car. Since your child hasn't received the preventive care treatments, she has a lot of untreated tooth decay--decay that

   leads to infection, fevers, stomach aches, and, worst of all, debilitating pain, making it almost impossible for her to concentrate in school. She may also develop speech difficulties, since she may lack the teeth necessary to form certain words and sounds. When you try to get her emergency dental services, you find that the few dentists in the area have waiting lists of two months or more.

   Mr. President, one mother, from Rhinelander, WI--which is in Oneida County in the northern part of my state--called me to tell me about her 8-year-old daughter in just that situation. He daughter was in excruciating pain because of a severe toothache, but the one dental provider in the area had a waiting list of several weeks, so that mother had no choice but to take her child to the nearest hospital emergency room, where the child was given painkillers to use until she could be seen by a dentist. Whereas routine primary dental care could have prevented this decay altogether, this mother had to take her young child to the hospital emergency room for prescription painkillers in order to make the wait before seeing the dentist bearable.

   Mr. President, the unfortunate reality is that I hear such stories from my constituents on a regular basis, and I have heard enough to know that it's time to stop this needless suffering from dental disease by increasing access to dental care.

   The legislation I am introducing today, the Dental Health Access Expansion Act, will establish take three important steps to promote access to dental health services:

   First, the bill creates a federal grant program to be administered by the Health Resources and Services Administration through which community health centers and local health departments in designated dental health professionals shortage areas can apply for funding to assist in the hiring of primary care dentists. Strengthening locally run dental access programs ensures a safety net for these vitally important services.

   The bill also creates a grant program to give bonus payments to dentists in shortage areas who devote at least 25 percent of their practice to Medicaid patients. More than 90 percent of America's dentists are in private practice, and incentive payments for dentists to increase their Medicaid practice helps to bring needy patients into the dental care mainstream.

   Finally, the bill requires that HRSA work with the Association of State and Territorial Dental Directors and other organizations interested in expanding dental health access to simplify the process for designating dental shortage areas. Right now the system is so complicated that states simply don't have the resources to fill out the paperwork needed to get the designation.

   Mr. President, the Dental Health Access Expansion Act is meant to complement existing initiatives--such as Health Professions Training Program expansions of general dentistry residencies, and the National Health Service Corps scholarship program--to increase access to primary care dental services in underserved communities. I have supported these and other programs in the past, and will continue to do so. My legislation is also meant to complement the excellent oral health initiatives proposed by my colleague, Senator BINGAMAN of New Mexico. I am thankful for the good work he has done in increasing awareness about this issue, and look forward to working with him to increase access to dental health services.

   Through the legislation I am proposing, we can increase the number of dentists providing care to underserved communities, and in doing so strengthen our nation's existing network of Community Health Centers and local health departments.

   Advances in dentistry have given us the tools to eradicate most dental diseases--what we need now is to provide people with access to dental care so that they can receive the simple preventive treatments they need, and that's what my legislation can help us achieve.

   By Mr. KOHL (for himself, Mr. DODD, and Mr. ROCKEFELLER):

   S. 1036. A bill to amend parts A and D of title IV of the Social Security Act to give States the option to pass through directly to a family receiving assistance under the temporary assistance to needy families program all child support collected by the State and the option to disregard any child support that the family receives in determining a family's eligibility for, or

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amount of, assistance under that program; to the Committee on Finance.


   Mr. KOHL. Mr. President, I rise today to introduce legislation, along with my colleagues Senator DODD of Connecticut and Senator ROCKEFELLER of West Virginia, to provide more resources to America's children and families by encouraging more parents to live up to their child support obligations. My legislation, the Children First Child Support Reform Act, would enhance the options and incentives available to states to allow more child support to be paid directly to the families to whom it is owed and not be counted against public assistance benefits. My legislation will help assure more noncustodial parents that the child support they pay will actually contribute to the wellbeing of their child, rather than the government, and also help reduce administrative burdens on the state.

   As my colleagues know, since its inception in 1975, our Federal-State Child Support Enforcement Program has been tasked with collecting child support for families receiving public assistance and other families that request help in enforcing child support. Toward this end, the program works to establish paternity and legally binding support orders, while collecting and disbursing funds on behalf of families so that children receive the support they need to grow up in healthy, nurturing surroundings.

   But on one crucial point, the current program does not truly work on behalf of families and, perhaps more importantly, actually works against families.

   Under current law, if a family is not on public assistance, support collected by the Child Support Enforcement Program is generally sent directly to the family. However, and this is the crux of the problem, support collected on behalf of families receiving public assistance is kept by the State and Federal Governments as reimbursement for welfare expenditures. Thus, for families on public assistance, the child support program ends up benefiting the financial interests of the government, rather than their children.

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