[Budget of the United States Government]
[V. Preparing For the 21st Century]
[3. Strengthening Health Care]
[From the U.S. Government Publishing Office, www.gpo.gov]


 
                      3.  STRENGTHENING HEALTH CARE

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

  [The Balanced Budget Act] strengthens our families by extending health 
insurance coverage to up to five million children . . . [The Act] honors 
our commitment to our parents by extending the life of the Medicare Trust 
Fund for a decade. It also provides structural reforms that will give 
Medicare beneficiaries more informed choices among competing health plans, 
authorizes a number of new anti-fraud provisions, and establishes a wide  
array of new preventative benefits.                                                                          

                                      President Clinton                                                        
                                      August 1997                                                           
  ----------------------------------------------------------------------

   The past year has brought a number of improvements in health care 
that will benefit all Americans.
   The 1997 Balanced Budget Act (BBA) represents a major step forward in 
the President's effort to improve and protect the Nation's health, 
especially for the almost 70 million vulnerable Americans who rely on 
Medicare and Medicaid. It strengthened the guarantee of quality health 
care for nearly 40 million Medicare participants by extending the life 
of the Medicare Trust Fund until at least 2010, investing in preventive 
benefits, introducing more choice of health plans, and strengthening our 
expanding array of activities to combat fraud and abuse. It strengthened 
Medicaid managed care quality standards and allowed States greater 
flexibility in designing their programs. And it provided an 
unprecedented $24 billion, through the State Children's Health Insurance 
Program (CHIP) and new Medicaid options, to cover up to five million 
children in working families--a population in which many have no 
insurance at all.
   These wide-ranging efforts came just a year after the President and 
Congress enacted the Health Insurance Portability and Accountability Act 
(HIPAA), which the Administration is now implementing. HIPAA reformed 
the private insurance market to help people keep their health insurance 
when they change jobs and limited the ability of insurers to deny 
coverage due to pre-existing conditions. It also simplified health care 
paperwork, clarified that certain long-term care insurance policies are 
tax deductible, and, for the first time, created a new stable source of 
funding to control fraud. Also, combined with the 1997 Taxpayer Relief 
Act, HIPAA boosted the tax deduction for the self-employed, making it 
cheaper for self-employed persons to get health insurance. In addition, 
the Administration and Congress enacted legislation that ensured parity 
in annual and lifetime limits between mental and physical health 
benefits and required health plans to allow new mothers and their babies 
to remain in the hospital at least 48 hours following most deliveries.
   To ensure that consumers continue to receive high-quality health 
care, the President created the Advisory Commission on Consumer 
Protection and Quality in the Health Care Industry early last year to 
advise him on changes occurring in the health care system and to 
recommend steps to ensure quality. In the fall, the Commission approved 
and the President endorsed a Health Care Consumer Bill of Rights, which 
includes the right to a choice of health care providers; access to 
emergency room treatments; participation in treatment decisions; 
assurance that patients are respected and not discriminated against; 
internal and external grievance and appeals processes; access to 
accurate, easily understood information; and confidential medical 
records.
   These improvements occurred against a backdrop of dramatic change in 
the private health care marketplace. After rapid inflation in the 1980s 
and early 1990s, national health spending growth dropped to a record low 
of 4.4 percent from 1995 to 1996. A strong

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economy, cost consciousness on the part of employers and consumers, and 
the shift to managed care contributed to this slowdown. In 1995, nearly 
75 percent of workers with employer-based insurance were enrolled in 
managed care, a 22-percent increase since 1993. Nevertheless, the number 
of uninsured has continued to rise. Thus, the Nation's work is not done; 
we must guard against the return of rapidly growing health care costs 
and work to reduce the number of uninsured, while maintaining a high 
standard of quality.
   With this budget, the Administration builds on the recent legislative 
achievements by committing to work with Congress on bipartisan tobacco 
legislation; proposing to expand health care coverage for some of the 
most vulnerable Americans aged 55 to 65; continuing the Administration's 
aggressive anti-fraud and abuse enforcement activities in Medicare and 
Medicaid; launching an aggressive outreach campaign to enroll eligible 
children who are not enrolled in Medicaid; proposing an unprecedented 
investment in health research; expanding access to powerful AIDS 
therapies; expanding access to cancer clinical trials; increasing funds 
for substance abuse treatment and prevention; and helping to reduce 
health-related disparities across racial and ethnic groups.

Adopting Bipartisan National Tobacco Legislation

   The Administration has focused on improving public health--
particularly children's health--by pursuing efforts to curtail tobacco 
use. In 1998, the Administration will work with Congress to enact 
comprehensive national tobacco legislation to reduce smoking, especially 
by youth. The President has outlined five key principles that must be at 
the heart of any national tobacco legislation:
   A comprehensive plan to reduce youth smoking, including: 
          tough penalties on tobacco firms that continue to market to 
          youths; price increases; public education and counter 
          advertising; and expanded efforts to restrict access and limit 
          appeal.
   Full authority of the Food and Drug Administration (FDA) to 
          regulate tobacco products.
   Changes in how the tobacco industry does business, including 
          an end to marketing and promotion to children and broad 
          document disclosure.
   Progress towards other public goals, including a reduction of 
          secondhand smoke; promotion of cessation programs; public 
          health research; the strengthening of international efforts to 
          control tobacco; and other urgent priorities.
   Protection for tobacco farmers and their communities.
   In its final form, the legislation will result from extensive 
bipartisan negotiations between the Administration and Congress. The 
Administration proposes that the legislation provide for annual lump sum 
payments by tobacco manufacturers, with the amounts paid by each 
determined by formula. The budget assumes net Federal receipts from this 
legislation will total at least $10 billion in 1999, rising each 
subsequent year for a total of $65 billion between 1999 and 2003. These 
amounts are consistent with the President's call for an increase in per-
pack cigarette prices of up to $1.50 (in constant dollars) over 10 years 
as necessary to meet the targets set to reduce youth smoking.
   The budget applies the receipts from tobacco legislation to finance 
research into tobacco-related and other diseases through the National 
Institutes of Health; fund a cancer clinical trial demonstration project 
for Medicare beneficiaries; support smoking prevention efforts by the 
Centers for Disease Control (CDC); strengthen the FDA's enforcement 
programs; fund smoking cessation programs; expand outreach efforts to 
ensure that children eligible for health care coverage are enrolled; 
sponsor counter-advertising; protect tobacco farmers; and support other 
initiatives associated with national tobacco legislation. It proposes 
that States receive a substantial portion of the net receipts, partly 
through block grants that they can use to provide child care and reduce 
class size in schools, and partly through unrestricted funds. (For more 
information on what the budget proposes to finance through national 
tobacco legislation, see Table S-7 in ``Summary Tables.'')

[[Page 71]]

Improving Access to Health Care Coverage

   The budget proposes new initiatives to provide access to health 
insurance for the nearly two million people between 62 and 65 who do not 
have employer-sponsored insurance; those between 55 and 61 who have been 
displaced from their jobs; and retirees who have had their insurance 
terminated by a former employer. The budget also proposes to help States 
and small employers create voluntary health insurance purchasing 
cooperatives that will help individuals buy affordable health insurance.

   Expanding Health Insurance Options for People Aged 55 to 65: The 
budget proposes three options to increase access to health insurance for 
people aged 55 to 65, who face special problems of access and 
affordability. They face greater risks of health problems, with twice 
the chances of heart disease, strokes, and cancer, as people aged 45 to 
54. As people approach 65, many retire or shift to part-time work or 
self-employment as a bridge to retirement, sometimes involuntarily. 
Displaced workers aged 55 to 65 are much less likely than younger 
workers to be re-employed or re-insured through a new employer. As a 
result, more of them rely on the individual health insurance market. 
Without the benefits of having their costs averaged with other younger 
people, as with employer-based insurance, these people often face high 
premiums.
   Such access problems will increase, due to two trends: declines in 
retiree health coverage and the aging of the baby boom generation. 
Recently, businesses have cut back on offering health coverage to pre-
65-year-old retirees; only 40 percent of large firms now do so. In 
several small but notable cases, businesses have dropped retirees' 
health benefits after workers have retired. These ``broken promise'' 
retirees lack access to employer continuation coverage and could have 
problems finding affordable individual insurance. Finally, the number of 
people 55 to 65 years old will rise from 22 million to 35 million by 
2010--or by 60 percent.
   The budget proposes three options that will help an estimated 300,000 
members of this vulnerable population:
   Allowing Americans between 62 and 65 to buy Medicare 
          coverage: The budget proposes to allow Americans between 62 
          and 65 to buy Medicare coverage by paying a premium based on 
          an actuarially fair rate for that age group. The proposal is 
          self-financing, because, over time, participants pay the full 
          cost of their coverage. And it will give millions of older 
          Americans the security of knowing that they have a health 
          insurance option.
   Expanding health insurance options for displaced workers: 
          Along with the 62-to-65 age group, the budget offers access to 
          health insurance to displaced workers between 55 and 61--those 
          who have lost or left their jobs due to plant or company 
          closings or moves, slack work, or the abolishment of their 
          positions or shifts. These workers often become uninsured, 
          even if they had insurance on their last job. The budget 
          proposes to allow displaced workers who were insured on their 
          job but are now uninsured to buy Medicare coverage by paying a 
          premium.
   Protecting retirees whose retiree health benefits have been 
          dropped: In addition, retirees 55 to 65 whose employers have 
          dropped their retiree health coverage will be allowed to buy 
          in to employer continuation coverage (known as COBRA) by 
          paying a premium.

  Creating Voluntary Purchasing Cooperatives: The small group health 
insurance market does not function as efficiently as the large group 
market. As a result, small business employees and their families will 
more likely be uninsured and have more expensive premiums. Small 
businesses also have higher administrative costs and pay more for the 
same benefits as larger firms.
   To help small businesses overcome these disadvantages, the budget 
includes $100 million in seed money over five years for selected States 
to establish voluntary purchasing cooperatives that will allow small 
employers

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to pool their purchasing power and negotiate better rates for their 
employees.

Providing Cancer Clinical Trials for Medicare Beneficiaries

   Less than three percent of cancer patients participate in clinical 
trials of new therapies. Many scientists believe that higher 
participation could lead to the faster development of therapies for more 
of those in need.
   Moreover, the elderly, who are most likely to get cancer, often 
cannot participate in such trials because Medicare does not pay for such 
treatments until they are established as standard therapies. Americans 
over 65 make up half of all cancer patients, and are 10 times more 
likely to get cancer than younger Americans.
   The budget would give more Americans access to these cutting-edge 
treatments and encourage higher participation in clinical trials by 
establishing a three-year, $750 million demonstration program, 
specifically for Medicare beneficiaries, to cover the patient care costs 
for those who participate in certain federally-sponsored cancer clinical 
trials. Although the Health Care Financing Administration (which 
administers Medicare) would run the demonstration, it would be funded by 
specified receipts from national tobacco legislation and, thus, would 
not draw upon Medicare's Hospital Insurance (HI) or Supplementary 
Medical Insurance (SMI) trust funds. The proposal includes an evaluation 
after three years to consider whether to expand the demonstration.

Promoting Program Integrity in Medicare and Medicaid

   The Administration has worked hard to promote competition, reduce 
errors, and eliminate fraud in Medicare and Medicaid. The budget 
proposes efforts to strengthen our commitment to eliminate fraud and 
abuse and promote competitive pricing, including:
   Initiatives to combat Medicare fraud and abuse and, in turn, 
          extend the life of Medicare's trust funds by enabling Medicare 
          to pay market-oriented prices for prescription drugs; 
          eliminating overpayments that facilities receive for drugs 
          used to treat anemia; reforming outpatient mental health 
          benefits; and requiring insurance companies to provide 
          information to enable Medicare to make payments only when it 
          is the primary payer.
   An initiative to expand Medicare's ability to use its market 
          power to competitively negotiate rates with providers for 
          selected Medicare procedures. By creating ``Centers of 
          Excellence,'' Medicare will be able to reduce its average cost 
          while improving quality.
   The Administration is also considering Medicaid incentive projects 
that measure errors and fraud in State Medicaid programs and develop 
performance measures related to such errors and fraud. These projects 
would help States identify problem areas in their Medicaid programs, 
target program integrity resources more effectively, and measure the 
success of their efforts to reduce errors and combat fraud.

Expanding Access to Children's Health Insurance

   The new Children's Health Insurance Program enables States to extend 
health insurance coverage to as many as five million uninsured children. 
It builds on an already strong Medicaid program that the Administration 
has worked hard to protect. But with over three million uninsured 
children eligible for Medicaid, but not enrolled, important work 
remains.
   To achieve the President's goal of working with the States to enroll 
as many children as possible, the budget contains several outreach 
proposals, costing $900 million over five years and financed by receipts 
from tobacco legislation, including:
   Outreach in schools and child care sites: The budget would 
          allow school and child care center staff to enroll children 
          into Medicaid temporarily on the presumption that they are 
          eligible. This proposal would increase enrollment by expanding 
          the network of individuals who can identify and enroll 
          children, and inform families about the potential eligibility 
          of their children. It also would enable Medicaid to cover the 
          costs related to providing this temporary

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          coverage, rather than requiring States to cover the costs from 
          their CHIP allotment.
   Matching funds for outreach: The budget proposes to expand 
          the use of a special $500 million Medicaid fund--now aimed at 
          outreach for children losing welfare--to fund outreach to all 
          children.
  Simpler enrollment: The budget proposes to streamline the 
          Medicaid application process by simplifying eligibility and 
          encouraging the use of mail-in applications.
   The budget contains other proposals to further promote the 
President's goal of reducing the number of uninsured children, 
including:
   Aid for the territories: The budget proposes $153 million in 
          increased funding under CHIP for Puerto Rico and the other 
          four territories, fulfilling the President's promise to 
          provide more equitable funding for children's health care in 
          the insular areas.
  Health insurance for legal immigrant children: The budget 
          would give States the option to provide health coverage to 
          legal immigrant children under Medicaid and CHIP. Currently, 
          States can provide health coverage to legal immigrant children 
          who entered the country before the 1996 welfare reform law was 
          enacted. But immigrant children who entered after the law was 
          enacted cannot get benefits for five years. Under this 
          proposal, States could provide coverage to immigrant children 
          through Medicaid or through their current CHIP allotment.

Promoting Public Health

   The budget continues the Administration's commitment to invest in key 
public health areas. In particular, the budget proposes to expand health 
research; increase access to powerful AIDS therapies; discourage tobacco 
use among young people; enhance food safety; help reduce disparities in 
disease rates across racial and ethnic groups; improve substance abuse 
treatment and prevention; promote childhood immunizations; provide 
voluntary family planning to low-income women; reduce infant mortality; 
and improve health care quality.

   Increasing Biomedical Research: Progress in biomedical research has 
ensured that many diseases that Americans faced a generation ago can now 
be prevented or treated. Smallpox has been eradicated from the world and 
polio is gone from the Western Hemisphere. Surgical procedures, such as 
organ transplants or cardiac pacemakers, can restore normal lives for 
those who once had few treatment options.
   The scientific community is now poised to make even more advances 
that, with sufficient investment, could dramatically alter and improve 
the way we treat diseases. Several new technologies in medical research 
show great promise. Specifically, important strides in imaging 
technologies make it possible to visualize living cells and entire 
organs, providing new insights into the structure of disease; computer-
based systems give scientists new tools to rapidly analyze vast amounts 
of new data; and the scientific community stands on the cusp of a host 
of breakthroughs in genetics that will enable scientists to map the 
entire human genome and revolutionize how we understand, treat, and 
prevent some of our most devastating diseases.
   The budget proposes an unprecedented commitment in biomedical 
research that will lay the foundation for new innovations to improve 
health and prevent disease. It invests $1.15 billion in the National 
Institutes of Health (NIH)--the largest increase in history. Moreover, 
to ensure that the Nation continues to make important investments in 
biomedical research, the budget proposes--for the first time ever--
sustained increases in the NIH over five years. By the year 2003, 
funding for biomedical research will increase to over $20 billion, or by 
nearly half.
   Within the NIH increase, the budget provides for increased funding on 
cancer-related research. In 1999, NIH's cancer-related research will 
grow by 10 percent and, over the next five years, by almost two thirds. 
Though the Nation's death rate from cancer fell between 1991 and 1995--
the first sustained decline since record-keeping began in the 1930s--
nearly one in five people in the United States dies from cancer. The 
proposed investment in cancer-related research over

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the next five years will enable NIH to make further advances in cancer 
prevention, detection, and treatment.

   Making Quality Direct Services and Preventive Care Accessible to 
Special Populations: Direct health services and prevention activities 
translate the ground-breaking medical advances often produced by 
biomedical research into benefits such as disease prevention, medical 
cost reductions, and public health education. The budget proposes 
funding increases for the following health service and prevention 
activities, many of which help serve low-income and other vulnerable 
populations:
   Ensuring access to powerful AIDS therapies through Ryan White 
          HIV/AIDS Treatment Grants in partnership with the States: The 
          budget proposes a $100 million increase in Ryan White 
          treatment grants to help States provide AIDS treatment, 
          especially the powerful ``combination therapy'' AIDS drugs. 
          While combination therapy offers tremendous hope to people 
          with HIV, it also presents a tremendous challenge to AIDS 
          services programs to make this hope available to all Americans 
          living with HIV/AIDS. Many States spend a considerable amount 
          of money on the AIDS Drug Assistance Program; others 
          contribute little or nothing. The Federal Government, States, 
          and the private sector all must rise to the challenge of 
          meeting the future needs of people with AIDS. The 
          Administration will work with Congress to develop revised 
          matching requirements or other means of encouraging more State 
          participation on behalf of people living with HIV/AIDS. The 
          budget also includes a $65 million increase for grants to 
          cities, States, and clinics for medical care, critical support 
          services, and new ways to help people who are HIV-positive. In 
          total, the budget proposes $1.3 billion in Federal spending 
          for activities authorized by the Ryan White CARE Act, a 14-
          percent increase over 1998 levels and a 241-percent increase 
          over comparable 1993 levels.
   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, a million 
          young people become regular smokers, 300,000 of whom will die 
          earlier as a result. In August 1996, the Administration 
          approved an FDA regulation to cut tobacco use among young 
          people in half over seven years. The budget includes $146 
          million of additional funds for tobacco-related activities in 
          the CDC and the FDA--$46 million of which will pay for 
          expanding CDC's existing State-based tobacco prevention 
          activities, and $100 million of which will support FDA's 
          outreach and enforcement activities.
   Improving substance abuse prevention and treatment: The 
          budget continues to expand substance abuse prevention and 
          treatment activities, enabling hundreds of thousands of 
          pregnant women, high-risk youth, and other under-served 
          Americans to get drug treatment and prevention services. The 
          Substance Abuse and Mental Health Services Administration's 
          Substance Abuse Block Grant (SABG) funds 40 percent of all the 
          Nation's publicly-provided substance abuse treatment. To 
          narrow the gap between those who are seeking treatment and 
          those who can be accommodated by the public treatment system, 
          the budget proposes a $200 million increase for the SABG. 
          Along with continued support from the States, this increase 
          would allow another 50,000 individuals a year to receive 
          substance abuse treatment. This proposal also would help 
          reduce the spread of AIDS by giving intravenous drug users 
          increased access to substance abuse treatment programs.
   Enhancing food safety: American consumers enjoy the world's 
          safest food supply, but too many Americans get sick from 
          preventable food-borne diseases. The budget increases funding 
          by $101 million, or 12 percent, over the 1998 level for the 
          Administration's inter-agency food safety initiative, which 
          created a national early warning system for food-borne 
          illnesses and improved Federal-State coordination when food-
          borne disease outbreaks occur. The budget increase also 
          expands food safety research, risk assessment capabilities, 
          education, and surveillance activities, as well as food import 
          inspections. Furthermore, the budget proposes to expand FDA's 
          international inspection force to en

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          sure that imported fruits and vegetables are as safe as those 
          produced in the United States.
   Helping to reduce racial disparities in health status: 
          Despite improvements in the Nation's overall health, 
          continuing disparities remain in the burden of death and 
          illness that certain minority groups experience. For example, 
          the infant mortality rate for African-Americans is twice that 
          of Caucasians. American Indian and Alaska Natives are about 
          three times as likely to die from diabetes as other Americans. 
          To address these and other disparities, the budget includes 
          $80 million for health education, prevention, and treatment 
          services for minority populations. Working with minority 
          public health providers, advocates, and other consumer 
          representatives, CDC will begin a new $30 million 
          demonstration program to enable selected communities to 
          develop innovative and effective approaches to address these 
          disparities. Each community, chosen through a competitive 
          grant process, would begin an intensive program to address one 
          or more health areas with major disparities, such as infant 
          mortality. The remaining $50 million will go to various public 
          health programs that serve mostly minority and low-income 
          populations.
   Enhancing family planning: The budget provides a $15 million 
          increase, to $218 million, to support over 4,000 family 
          planning clinics, a primary source of voluntary family 
          planning services for low-income women Nation-wide. The 
          increase would expand services to adolescents and enable 
          grantees to better meet the rising demand for comprehensive 
          services, such as screening, prevention, and education and 
          counseling. Publicly subsidized family planning services help 
          American women prevent over a million unintended pregnancies 
          each year. The budget also includes $50 million in mandatory 
          funding for States to conduct abstinence education projects to 
          help reduce out-of-wedlock pregnancies.
   Promoting full participation in the Women, Infants, and 
          Children (WIC) program: WIC reaches nearly 7.5 million women, 
          infants, and children a year, providing nutrition assistance, 
          nutrition education and counseling, and health and 
          immunization referrals. WIC provides for prenatal care to 
          those who would not otherwise get it, 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. Largely because of funding 
          increases in the last five years, WIC participation has grown 
          by 30 percent, and the program now helps half of America's 
          infants. The budget proposes $4.1 billion to serve 7.5 million 
          people through 1999, fulfilling the President's goal of full 
          participation in WIC.
   Promoting childhood immunizations: The budget proposes $973 
          million for the Childhood Immunizations Initiative, including 
          the Vaccines for Children program and CDC's discretionary 
          immunization program. As a result of the Administration's 
          Childhood Immunization Initiative, the Nation exceeded its 
          childhood vaccination goals for 1996, with 90 percent or more 
          of America's toddlers receiving 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 immunization throughout the world.
   Improving health care quality: The budget would double, to 
          $30 million, the Department of Health and Human Services' 
          health care quality activities to expand research on quality 
          and put into practice the recommendations of the President's 
          Advisory Commission on Consumer Protection and Quality in the 
          Health Care Industry. The research will increase knowledge 
          about how best to measure and improve the outcomes and quality 
          of medical services, and reveal ways to encourage health care 
          providers to use this information in their work.

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   Caring for veterans health needs through veterans medical 
          care: Continuing its commitment to veterans programs, the 
          Administration proposes $17.7 billion for the Department of 
          Veterans Affairs' (VA) health system. The funds will enable 
          the VA to continue to restructure its health care system by 
          increasing access and delivering quality care to our Nation's 
          veterans.