[Budget of the U.S. Government]
[V. Creating Opportunity, Demanding Responsibility, and Strengthening Community]
[1. Strengthening Health Care]
[From the U.S. Government Publishing Office, www.gpo.gov]


         V. CREATING OPPORTUNITY, DEMANDING RESPONSIBILITY, AND         
                        STRENGTHENING COMMUNITY                         

[[Page 49]]

 
                      1.  STRENGTHENING HEALTH CARE

  ----------------------------------------------------------------------

                                                                                                                
                                                                                                                
                                                                                                                
  We can, and we must, work together to reform Medicare and Medicaid so they continue to meet the promise to our
parents and our children and continue to expand health care step by step to children in working families who    
don't have it. We can do that and balance the budget, and take advantage of the fact that new models are clearly
making it possible to lower the rate of medical inflation in a way that advances the quality of health care as  
well as the quality of our long-term objectives in balancing the budget and investing in the future of America. 
I know it can be done, and I am determined to get it done.                                                      
                                      President Clinton                                                         
                                      December 11, 1996                                                         
                                                                                                                

  ----------------------------------------------------------------------
  Americans have good reason to be optimistic about the Nation's health 
care as we approach the new millennium.
  Medicare ensures that older Americans receive high quality health care 
and can look forward to a longer life expectancy. Medicaid provides 
vital health services to low-income pregnant women and children, people 
with disabilities, and elderly Americans. Together, Medicare and 
Medicaid serve over 71 million Americans. Meanwhile, the Federal 
Government is investing more in biomedical research and technology, 
furthering our knowledge about the prevention and treatment of diseases 
and providing new insights into the genetic basis of diseases such as 
breast cancer as well as threats from food-borne illnesses newly 
emerging infectious diseases.
  And just in the past year, we have witnessed the rapid development of 
new prescription drugs to help people with AIDS and other debilitating 
diseases. These new developments hold the potential for a vastly 
increased life expectancy for these Americans.
  Our private health system, already the world's most dynamic, is 
undergoing a dramatic transformation--much of it positive. The best 
private sector innovations have helped make our delivery system more 
efficient, and have improved quality by increasing consumer choice, 
stressing accountability, and focusing on medical outcomes.
  In his first term, the President and Congress took important steps to 
improve our Nation's health care system. One of the most significant was 
last year's passage of the Health Insurance Portability and 
Accountability Act of 1996 (HIPAA), also known as the Kassebaum-Kennedy 
bill. Now, as many as 25 million Americans have health benefit 
portability they did not have before; no longer will people who have 
been sick have to fear that they will lose their access to health 
insurance if they lose their job or change jobs. Nor can they be denied 
coverage because they have a preexisting medical condition. Moreover, 
the law requires insurance companies to sell coverage to small employer 
groups and to individuals who lose group coverage without regard to 
their health status. It also made it easier and cheaper for self-
employed people to get health insurance, simplified health care 
paperwork, strengthened Medicare's fraud and abuse efforts, and helped 
make long-term care insurance more affordable.
  Other significant health care initiatives enacted in the last four 
years include laws requiring health plans to allow new mothers and their 
babies to remain in the hospital at least 48 hours following most 
deliveries, and prohibiting health plans from establishing separate 
lifetime and annual limits for mental health coverage.
  With this budget, the President takes the next critical steps toward a 
better health care future:

[[Page 50]]

   Preserving Medicare and Medicaid, while reforming and 
          strengthening both programs in important ways.
   Helping the growing numbers of American children and families 
          who lack health insurance coverage.
   Strengthening the health care infrastructure by investing 
          more in biomedical research, in programs to combat infectious 
          diseases, in the Ryan White AIDS program that provides life-
          extending drug therapies to many people with AIDS, and in 
          programs such as community health centers and Indian Health 
          Service facilities that serve critically underserved 
          populations.

Preserving Medicare

  The budget preserves and improves Medicare, extending the life of the 
Part A Hospital Insurance Trust Fund into 2007. Like the President's 
previous two budgets, it gives beneficiaries more choices among private 
health plans, makes Medicare more efficient and responsive to 
beneficiary needs, slows the growth rate of provider payments, and 
maintains the Part B Supplementary Medical Insurance premium at 25 
percent of program costs. The plan saves $100 billion over five years 
(and $138 billion over six years), according to the Health Care 
Financing Administration's Office of the Actuary.
  The President also wants to work with Congress on a bipartisan basis 
to address the longer-term problem of financing Medicare to support the 
health care needs of the ``baby boom'' generation.

Provider Payment Reforms and Program Savings

  Hospitals: The budget reduces the annual inflation increase, 
          or ``update,'' for hospitals; reduces payments for hospital 
          capital; reforms payments for graduate medical education; and 
          begins to reform the payment methodology for outpatient 
          departments while protecting beneficiaries from increasing 
          charges for those services.
  Managed Care: Along with the Administration's previous 
          proposals to reduce the current geographic variation in 
          payments, the budget proposes a new managed care payment 
          methodology in light of substantial evidence that Medicare 
          pays too much for managed care plans and, in fact, loses money 
          for every beneficiary who opts for managed care. The budget 
          would reduce Medicare reimbursement to managed care plans from 
          its current rate of 95 percent of fee-for-service rates to 90 
          percent. To enable the industry to prepare for this change, 
          the Administration would not implement it until the year 2000. 
          The Administration views this reform as a first step and will 
          continue to work with the industry to create a better 
          reimbursement mechanism for Medicare managed care plans.
  Physicians: The budget reforms physician payments by paying a 
          single update for all physician services--based on a single 
          ``conversion factor,'' or base payment amount, and replacing 
          the current three conversion factors, effective January 1, 
          1998. The budget replaces current ``volume performance 
          standards'' with a sustainable growth rate.
  Home Health Agencies/Skilled Nursing Facilities: The budget 
          implements payment reforms, leading to separate prospective 
          payment systems for home health care and skilled nursing 
          facilities. Prospective payments would begin to bring the 
          current double-digit rise in spending on these services under 
          control. The budget also proposes to reform the home health 
          benefit by paying for services following a hospital stay from 
          the Part A Trust Fund and paying for other services from 
          Medicare's Part B Trust Fund. Beneficiaries would not be 
          affected by the change. In addition, the change will not count 
          towards the budget's proposed $100 billion in Medicare savings 
          through 2002, but will help to extend the solvency of the Part 
          A Trust Fund.
  Other Providers: The budget makes payments for durable medical 
          equipment and laboratory services more consistent with private 
          market rates and reduces payment updates to ambulatory 
          surgical centers. The budget also proposes to address 
          Medicare's overpayment for prescription drugs that are 
          provided in a physician's office 

[[Page 51]]

by making payments more competitive with what private purchasers pay.
  Beneficiaries: The budget continues, but does not increase, 
          the requirement that beneficiaries pay 25 percent of Part B 
          costs through the monthly Part B premium. The budget imposes 
          no new cost increases on beneficiaries. The budget also would 
          maintain current law to prevent ``balance billing,'' ensuring 
          that doctors in the new managed care plan options may not 
          charge above Medicare's approved amount and leave the elderly 
          vulnerable to higher costs.
  Private Plan Choices: The budget increases the numbers of 
          plans--including Preferred Provider Organizations and Provider 
          Sponsored Networks--available to seniors and people with 
          disabilities. These new options will meet strong quality 
          standards and include consumer protections. The plans would be 
          required to compete on cost and quality, not on the health 
          status of enrollees.

Beneficiary Improvements

  The budget proposes reforms to improve and increase services to 
beneficiaries, to protect them from the burden of additional costs, and 
to offer them a wider choice of private plans.
  Preventive Health Care: The budget covers new preventive 
          health benefits including: colorectal screening; diabetes 
          management; preventive injections like pneumonia, influenza, 
          and hepatitis B; and annual mammograms without coppayments.
  Alzheimer's Respite Benefit: The budget establishes a new 
          respite benefit for the families of Medicare beneficiaries 
          with Alzheimer's disease. Medicare beneficiaries would be 
          eligible to receive non-medical care, giving family members a 
          much-needed break from the constant demands of caring for 
          them.
  Outpatient Department Payments: Payments to hospitals for 
          outpatient services are one of Medicare's fastest growing 
          components. Due to flaws in the current reimbursement 
          methodology, hospital outpatient departments get a 
          reimbursement higher than their actual costs. In effect, 
          beneficiaries pay about a 50-percent copayment for hospital 
          outpatient services, as opposed to the 20-percent copayment 
          made for other Part B services. Medicare's payments are not 
          always reduced to account fully for these high copayments. The 
          budget corrects these flaws by establishing a prospective 
          payment system for outpatient services and ensuring that, by 
          2007, beneficiaries pay the same 20-percent copayment as they 
          do for other Part B services.
  Medigap Protections: The budget adds protections, such as new 
          open enrollment requirements and prohibitions against the use 
          of pre-existing condition exclusions, to help Medicare 
          beneficiaries who wish to opt for managed care but fear they 
          will be ``locked in'' and unable to access their old Medigap 
          protections if they switch back to a fee-for-service plan.
  The Working Disabled: The budget proposes a Medicare 
          demonstration project to encourage Social Security Disability 
          Insurance (SSDI) beneficiaries to return to work. Under the 
          four-year, Nation-wide demonstration project, SSDI 
          beneficiaries who return to work beginning in 1998 would 
          receive Part A coverage through 2001 without paying the 
          premiums.

Additional High-Priority Initiatives

  The budget contains other reforms to improve the Medicare program as 
well as adjustments to Medicare payments to ensure that rural 
beneficiaries have access to health care services.
  Rural Health Care: The budget would expand access to, and 
          improve the quality of, health care in rural areas. It would 
          extend the Rural Referral Center program; allow direct 
          Medicare reimbursement for nurse practitioners, clinical nurse 
          specialists, and physician assistants; improve the Sole 
          Community Hospital program; expand the Rural Primary Care 
          Hospital program; and provide grants to promote telemedicine 
          and rural health outreach. The proposed changes in managed 
          care payment methodology also would promote access to managed 
          care plans in rural areas.

[[Page 52]]

  Fraud and Abuse: The budget proposes strong fraud and abuse 
          provisions, including measures to eliminate fraud in home 
          health care--such as by ensuring that home health agencies are 
          reimbursed based on the location of the service, not the 
          billing office, and by enabling the Secretary of Health and 
          Human Services to deny payments for excessive home health use. 
          The budget also would repeal several provisions in last year's 
          HIPAA law that weakened anti-fraud enforcement. Together, 
          these initiatives would save about $9 billion.

Strengthening Medicaid

  The budget would reform Medicaid to give States much more flexibility 
to manage their programs, while preserving the guarantee of high-quality 
health care and long-term services for the most vulnerable Americans--
millions of children, pregnant women, people with disabilities, and 
older Americans. The budget would ensure that as we control the costs of 
Medicaid, we do not compromise what is right with the program.
   The growth in Medicaid spending has slowed significantly over the 
past two years. The budget, however, ensures that our success in 
bringing Medicaid spending under control will not be lost in future 
years, when the actuaries project that Medicaid spending will again 
begin to rise. The budget would save $22 billion from a combination of 
policies to impose a per capita limit on spending and reduce 
Disproportionate Share Hospital (DSH) payments and retarget them to 
hospitals that serve large numbers of Medicaid and low-income patients. 
The budget also makes a number of improvements to the Medicaid program, 
including changes to last year's welfare reform law, costing $13 billion 
over the same period.

Program Savings

  Per Capita Cap: Even though the growth in Medicaid spending 
          has fallen in recent years, aggregate Medicaid spending still 
          will grow at an average annual rate of 7.2 percent from 1997 
          to 2002. To ensure that Medicaid's explosive growth of the 
          1980s and early 1990s does not resume, the budget would set a 
          per capita cap on Medicaid spending, based on spending per 
          beneficiary in a base year, increased by an annual growth 
          limit. The cap protects States facing population growth or 
          economic downturns because it ensures that dollars follow 
          people, allowing Medicaid spending to respond to changes in 
          caseload and the economy.
  Disproportionate Share Hospital Payments: Medicaid DSH 
          spending doubled each year from 1988 to 1993. Although this 
          rapid growth has slowed, due to 1993 legislation that modified 
          the program, the DSH program is still large, and the payments 
          could be targeted better. The budget proposes reforms to reach 
          this goal without undermining the important role these funds 
          play for providers who serve a disproportionate number of low-
          income and Medicaid beneficiaries.

Provisions to Increase State Flexibility

  The budget continues the President's strong commitment to giving 
States the flexibility to design their own Medicaid program. The budget 
would ensure accountability for high-quality health care while enabling 
States to develop programs that meet the special needs of their 
populations.
   Coverage for Children: The budget would let States provide 
          continuous coverage for one year after eligibility is 
          determined, guaranteeing more stable coverage for children and 
          more continuity of health care services. In addition, it will 
          reduce the administrative burden on Medicaid officials, health 
          care providers, and families required to refile paperwork to 
          determine their children's eligibility.
  Coverage Without Waivers: The budget would let States, without 
          a waiver, expand coverage to any person whose income is under 
          150 percent of the poverty line, within their per-capita 
          spending limits.
  Managed Care: The budget would allow States to enroll people 
          in managed care without Federal waivers.
  Home- and Community-based Care: The budget would allow States 
          to serve people needing long-term care in home- and com-

[[Page 53]]

          munity-based settings without Federal waivers.
  Boren Amendment: The budget would repeal the ``Boren 
          amendment'' for hospitals and nursing homes, giving States 
          more flexibility to negotiate provider payment rates.
  The Working Disabled: The budget would let States establish an 
          income-related premium buy-in program under Medicaid for 
          people with disabilities who work. It would let eligible 
          Supplemental Security Income beneficiaries who earn more than 
          certain amounts purchase Medicaid coverage by paying a premium 
          that States would set on an income-related sliding scale.

Maintaining and Expanding Coverage for Working Families

  The President's budget plan would help an estimated 3.2 million 
families, including 700,000 children, keep their health care coverage 
for to six months up until their breadwinners find new jobs. The budget 
also would help provide health coverage for millions of children who do 
not now have it. Finally, the budget proposes to help States to create 
voluntary health insurance purchasing cooperatives.

Health Insurance for the Families of Workers Who are In-Between Jobs

  While unemployment remains low and job creation remains high, the 
fast-moving economy creates rapid job turnover and job elimination. An 
estimated one in four workers will make an unemployment claim at least 
once in four years.
  With health care coverage in this country usually linked to 
employment, many workers lose their health care coverage during these 
brief periods of unemployment. Nearly half of workers with one or more 
job interruptions experienced at least a month without health insurance 
between 1992 and 1995. Nearly half of children who lose their health 
insurance do so because of a change in their parent's employment status. 
A family experiencing a catastrophic illness during this transition 
loses the benefit of years' worth of premiums. Worse, for families with 
an ill child or a worker with a chronic condition, the loss of health 
insurance while their breadwinner is between jobs can make it 
financially impossible for them to regain coverage.
  The budget proposes a national demonstration program to help States 
finance up to six months of coverage for the unemployed and their 
families. The program would be available to recipients, based on need, 
who had employer-based coverage in their prior jobs. Eligible 
individuals and their families would have access to a policy generally 
equivalent to the Blue Cross/Blue Shield Standard Option plan available 
through the Federal Employees Health Benefits program. The plan gives 
States flexibility to administer their own programs (e.g., through 
Medicaid, COBRA, or an independent program). It would cost $1.7 billion 
in 1998, $9.8 billion from 1998 to 2002.

Health Coverage for Children

  The budget proposes several measures to expand health care coverage to 
more children. Combined with the proposal to help the families of 
unemployed workers (discussed above), and the ongoing phase-in of 
Medicaid coverage for a million older children, these additional 
proposals could add coverage for as many as five million children. The 
President is pleased with the widespread congressional interest in 
expanding health care coverage for children, and he looks forward to 
working with both Democrats and Republicans to develop and implement 
proposals to reach that goal.
  State Grants to Develop Innovative Programs: The budget 
          provides $750 million a year in grants to States ($3.8 billion 
          from 1998 to 2002) to build on recent State successes in 
          working with insurers, providers, employers, schools, and 
          others to develop innovative ways to provide coverage to 
          children. This proposal would cover an estimated one million 
          children.
  Continuous Medicaid Coverage to Children: The budget provides 
          funds to let States extend one year of continuous Medicaid 
          coverage to children, potentially helping one million children 
          who would otherwise have lost coverage to keep it. The 
          proposal would reduce administrative bur-
          

[[Page 54]]

          dens on States, families, and health care plans 
          who now must determine eligibility 
          at least every six months.
  Medicaid Outreach: About three million children are now 
          eligible for Medicaid, but not enrolled. The Administration 
          will ask the Nation's Governors to work with us to find ways 
          to reach and sign up such children.
  School Health Centers and Consolidated Health Centers (CHCs): 
          The budget provides more funds for CHCs to expand and enhance 
          services to working families and their children through 
          school-based health clinics.

Voluntary Purchasing Cooperatives

  Employees in small businesses and their families are far likelier to 
be uninsured than other Americans. Small businesses have more difficulty 
providing health care coverage for their workers because they have 
higher per capita costs due to increased risk and extraordinarily high 
administrative costs.
  The budget would make it easier for small businesses to provide health 
care coverage for their employees, by helping them to band together to 
reduce their risks, lower their administrative costs, and improve their 
purchasing power with insurance companies. The budget proposes to 
empower small businesses to access and purchase more affordable health 
insurance through voluntary health purchasing cooperatives--providing 
$25 million a year in grants that States can use for technical 
assistance, and setting up voluntary purchasing cooperatives and 
allowing them to access Federal Employees Health Benefit Plans.

Promoting Public Health

  The budget invests in preventive steps that show the greatest promise 
of ameliorating pain and suffering while controlling future costs. In 
particular, the budget focuses on preventing teen smoking; substance 
abuse; teen pregnancy; the spread of AIDS and HIV infections; food-borne 
diseases; the spread of infectious diseases; and infant mortality. The 
budget also invests in health care services for low-income and other 
vulnerable populations, such as American Indians and Alaska Natives.

Expanding Biomedical and Behavioral Research

  The budget continues the Administration's longstanding commitment to 
biomedical and behavioral research, which advances the health and well-
being of all Americans. For the National Institutes of Health (NIH), it 
proposes $13.1 billion for biomedical research that would lay the 
foundation for future innovations that improve health and prevent 
disease. The budget includes funding for high-priority research areas 
such as HIV/AIDS (including efforts to develop an AIDS vaccine), breast 
cancer, spinal cord injury, high performance computing, prevention and 
genetic medicine.
  The Office of AIDS Research will continue to coordinate all of NIH's 
AIDS research. The budget also includes the second year of funding for a 
new NIH Clinical Research Center, which would give NIH a state-of-the-
art research facility in which researchers would bring the latest 
discoveries directly to patients' bedsides. NIH's top priority continues 
to be financing investigator-initiated research project grants.

Providing Direct Services and Preventive Care to Special Populations

  While basic biomedical research lays the foundation for medical 
advances, direct health services and prevention activities reduce the 
cost of medical care, and directly benefit Americans by preventing 
disease outbreaks and promoting the population's health. The budget 
proposes funding increases for the following health service and 
prevention activities:
  Preventing and Treating AIDS through Ryan White HIV/AIDS 
          Treatment Grants/HIV Prevention: The budget proposes just over 
          $1 billion for activities authorized by the Ryan White CARE 
          Act, $40 million more than in 1997, to help our most hard-hit 
          cities, States, and local clinics provide medical and support 
          services to individuals with HIV/AIDS. Under this 
          Administration, funding for Ryan White grants has risen by 158 
          percent. The proposed level 

[[Page 55]]

          would fund grants to cities and 
          States to help finance medical and support services for 
          individuals infected with the HIV virus; to community-based 
          clinics to provide HIV early intervention services; to 
          pediatric AIDS and HIV dental activities; and to HIV education 
          and training programs for health care providers. The budget 
          also includes $167 million dedicated to State AIDS drug 
          assistance programs funded under Title II of the Ryan White 
          Care act, to improve access to protease inhibitors and other 
          life-extending AIDS medications. The budget also proposes $637 
          million for the Centers for Disease Control's (CDC) HIV 
          prevention activities, $20 million more than in 1997. The 
          increased funding will help prevent HIV among drug users, who 
          face the greatest risk of HIV infection.
   Reducing Tobacco Use Among Young People: Tobacco is linked to 
          over 400,000 deaths a year from cancer, respiratory illness, 
          heart disease, and other health problems. Each year, another 
          million young people become regular smokers, and over 300,000 
          of them will die earlier as a result. Consequently, in August 
          1996, the Administration approved an FDA regulation that aims 
          to cut tobacco use among young people by half over seven 
          years; the budget includes $34 million to implement the 
          regulation. The budget also provides $36 million for the CDC 
          and $50 million for NIH for State grants and technical support 
          for tobacco control and cancer prevention activities.
   Enhancing Food Safety: Too many Americans get sick from 
          preventable food-borne diseases. The Nation faces new 
          challenges in this area as we enter the 21st Century. New 
          pathogens are emerging and familiar pathogens have grown 
          resistant to treatment. We consume record levels of imported 
          foods, some of which moves across the globe overnight. The 
          budget proposes $42 million for a new interagency food safety 
          initiative to establish a national early warning system for 
          food-borne illnesses Nation-wide, and to improve Federal-State 
          coordination when food-borne disease outbreaks occur. The 
          budget also proposes to continue implementing a new food 
          safety system in the meat, poultry, and seafood industries.
   Promoting Full Participation in Women, Infants, and Children 
          (WIC): WIC reaches over seven million women, infants, and 
          children a year, providing nutrition assistance, nutrition 
          education and counseling, and health and immunization 
          referrals. WIC provides prenatal care to those who would not 
          otherwise get it, while reducing the incidence of premature 
          birth and infant death. As a result, Medicaid saves 
          significant sums that it would otherwise spend in the first 60 
          days after childbirth. Because of funding increases in the 
          last four years, WIC participation has grown by over 25 
          percent. The budget proposes $4.1 billion to serve 7.5 million 
          people by the end of 1998, fulfilling the President's goal of 
          full participation in WIC.
   Promoting Childhood Immunizations: The budget proposes $794 
          million for the Childhood Immunization Initiative, including 
          the Vaccines for Children program and CDC's discretionary 
          immunization program. The Nation is ahead of schedule to meet 
          the Administration's goal of raising immunization rates to 90 
          percent for two-year old children for each basic childhood 
          vaccine. The incidence of vaccine-preventable diseases among 
          children, such as diphtheria, tetanus, measles, and polio, are 
          at all-time lows. The budget also includes $47 million to 
          eradicate polio--preventable through immunizations--throughout 
          the world.
   Improving Substance Abuse Treatment and Prevention: The 
          budget proposes to increase support for the Substance Abuse 
          and Mental Health Services Administration's substance abuse 
          treatment and prevention activities by $33 million, to $1.7 
          billion, enabling hundreds of thousands of pregnant women, 
          high-risk youth, and other under-served Americans to get drug 
          treatment and prevention services. The budget proposes a 
          coordinated approach to combating substance abuse among youth 
          with a comprehensive prevention initiative, focusing on State-
          level data documenting trends in drug use. The Administration 
          again calls on Congress to enact 

[[Page 56]]

          Performance Partnerships, 
          which would give States more flexibility to better target 
          Federal resources to priorities.
   Enhancing Abstinence Education and Family Planning: For each 
          of the next five years, the budget includes $50 million in 
          mandatory funding for States to conduct abstinence education 
          projects to help reduce out-of-wedlock pregnancies. The budget 
          also includes a $5 million increase, to $203 million, to 
          support voluntary family planning services.
   Preventing and Containing Infectious Diseases: The budget 
          includes $103 million, $15 million more than in 1997, for 
          CDC's cooperative efforts with States to address infectious 
          disease. It would support training and applied research, and 
          the States' disease surveillance capability. All Americans 
          face threats from infectious disease problems, such as drug 
          resistant bacteria, and from emerging viruses, such as the 
          hantavirus. CDC works with State health departments to monitor 
          and prevent such problems and to contain outbreaks.
   Promoting Better Health Care for Native Americans through 
          Indian Health Service (IHS): The budget proposes $2.4 billion 
          for the IHS, $70 million over 1997. IHS clinical services are 
          often the only source of medical care on remote reservation 
          lands, and this increase maintains our commitment to American 
          Indians and Alaska Natives.
   Caring for Veteran's Health Needs through Veterans Medical 
          Care: Continuing its longstanding commitment to veterans 
          programs, the Administration proposes $17.5 billion for the 
          Department of Veterans Affairs' (VA) health system, $0.5 
          billion more than in 1997. The budget would enable the VA 
          health system to retain, and spend for itself, all first- and 
          third-party medical collections. In the past, these 
          collections have gone to the Treasury; in 1998, they would 
          support health services for veterans. The budget would enable 
          the VA to implement eligibility reform legislation that the 
          President signed in October 1996, and pursue ambitious plans 
          to restructure the health system to better deliver care.